Exam 67: Implementing Nursing Care

The nurse establishes trust and talks with a school-aged patient before administering injections.This nurse is demonstrating which type of implementation skill?

A patient visiting with family members in the waiting area tells the nurse that his stomach is not feeling good.Before intervening,what should the nurse do?

The nurse is intervening for an identified nursing diagnosis of Caregiver role strain.Which direct care nursing intervention is most appropriate?

The nurse is intervening for an identified nursing diagnosis of Risk for infection.Which direct care nursing intervention is most appropriate?

Before implementing any intervention,the nurse uses critical thinking to

A patient recovering from a leg fracture after a fall states that he has dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale.The patient is not able to walk around in the room with crutches because of leg discomfort.What is the priority nursing intervention for this patient?

What is the first intervention included on any patient's plan of care?

Which of these interventions,to be included in the plan of care,is appropriate for the patient outcome that states,"The patient will verbalize a pain level at 3 or below on a 0 to 10 scale throughout this shift."?

Which is the appropriate initial intervention for the nursing diagnostic statement Impaired skin integrity related to poor wound healing?

The standing orders for a patient include acetaminophen (Tylenol)650 mg every 4 hours prn for headache.After assessing the patient,identifying the need for headache relief,and determining that the patient has not had Tylenol in the past 4 hours,the nurse

The nurse inserts an intravenous catheter using the correct technique and following the recommended steps according to standards of care and hospital policy.This is demonstrating which type of implementation skill?

Before implementing care,the nurse needs to ensure that which resources are available?

Vital signs for a patient reveal a high blood pressure of 187/100.Orders state to notify the health care provider for diastolic blood pressure greater than 90.What is the nurse's first action?

A newly admitted patient who is morbidly obese asks the nurse to assist her to the bathroom for the first time.What should the nurse do first?

A nurse employed in a staff development department is providing an in-service for other nurses to educate them about the Nursing Interventions Classification (NIC)system.During the in-service,which of the following statements made by one of the nurses in the room requires the staff nurse to clarify the information provided?

The nurse defines a clinical guideline or protocol as a

Which of the following are nursing interventions?

In which step of the nursing process does the nurse provide nursing care interventions to patients?

Which intervention is most appropriate for a patient who has a new onset of chest pain?

Which interventions are appropriate for the nursing diagnosis Impaired tissue integrity related to poor wound healing secondary to diabetes?