Question 1

Which of the following is the best example of the implementation phase of the nursing process?

Accepted Answer

A)  Patient verbalizes pain is reduced from an 8 to a 3 after receiving pain medication. 
B)  Nurse observes that patient has a small, quarter-sized skin tear over coccyx area. 
C)  Nurse writes in the care plan: Patient requires 2 person assist with ambulation to bathroom. 
D)  Nurse inserts Foley catheter after reporting to physician patient's inability to void. 
A)  Patient verbalizes pain is reduced from an 8 to a 3 after receiving pain medication. 
B)  Nurse observes that patient has a small, quarter-sized skin tear over coccyx area. 
C)  Nurse writes in the care plan: Patient requires 2 person assist with ambulation to bathroom. 
D)  Nurse inserts Foley catheter after reporting to physician patient's inability to void.

Question 2

The nurse reviews a nursing order for a patient who is 4 days post-operative after hip surgery.It reads: Assist patient in bathing each morning.The nurse assesses the patient and notes that the patient is independent in bathing.What should the nurse do next?

Accepted Answer

A)  Assist with the bath as ordered 
B)  Delegate the bath to the nursing assistant 
C)  Discontinue the nursing order on the plan of care 
D)  Collaborate with the nurse who originally wrote the order 
A)  Assist with the bath as ordered 
B)  Delegate the bath to the nursing assistant 
C)  Discontinue the nursing order on the plan of care 
D)  Collaborate with the nurse who originally wrote the order

Question 3

The nurse and nursing assistive personnel (NAP)are caring for a group of patients on the medical-surgical floor.For which of the following patients can the nurse delegate to the NAP the task of bathing? Select all that apply.

Accepted Answer

A)  75-year-old patient newly admitted with dehydration 
B)  65-year-old patient hospitalized for a stroke, whose blood pressure reading is 189/90 mm Hg 
C)  92-year-old patient with stable vital signs who was admitted with a urinary tract infection 
D)  56-year-old patient with chronic renal failure who has vital signs within his normal range 
A)  75-year-old patient newly admitted with dehydration 
B)  65-year-old patient hospitalized for a stroke, whose blood pressure reading is 189/90 mm Hg 
C)  92-year-old patient with stable vital signs who was admitted with a urinary tract infection 
D)  56-year-old patient with chronic renal failure who has vital signs within his normal range

Question 4

A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative.How should the nurse proceed?

Accepted Answer

A)  Ask a colleague for help, because the nurse cannot safely perform the procedure alone. 
B)  Gather the equipment and prepare it before informing the client about the procedure. 
C)  Obtain an order to restrain the client before inserting the urinary catheter. 
D)  Inform the primary provider that the nurse cannot perform the procedure because the client is confused. 
A)  Ask a colleague for help, because the nurse cannot safely perform the procedure alone. 
B)  Gather the equipment and prepare it before informing the client about the procedure. 
C)  Obtain an order to restrain the client before inserting the urinary catheter. 
D)  Inform the primary provider that the nurse cannot perform the procedure because the client is confused.

Exam 7: Nursing Process: Implementation Evaluation

Which of the following is the best example of the implementation phase of the nursing process?

The nurse reviews a nursing order for a patient who is 4 days post-operative after hip surgery.It reads: Assist patient in bathing each morning.The nurse assesses the patient and notes that the patient is independent in bathing.What should the nurse do next?

The nurse and nursing assistive personnel (NAP)are caring for a group of patients on the medical-surgical floor.For which of the following patients can the nurse delegate to the NAP the task of bathing? Select all that apply.

A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative.How should the nurse proceed?

Evolution of Nursing Thought Action

Critical Thinking: Nursing Process

Nursing Process: Assessment

Nursing Process: Diagnosis

Nursing Process: Planning Outcomes

Nursing Process: Planning Interventions

Evidence-Based Practice: Theory Research

Life Span: Infancy Through Middle Adulthood

Life Span: Older Adults

Experiencing Health Illness

Stress Adaptation

Psychosocial Health Illness

The Family

Culture Ethnicity

Spirituality

Loss,Grief, Dying

Documenting Reporting

Teaching Learning

Measuring Vital Signs

Communication Therapeutic Relationships

Health Assessment

Promoting Asepsis Preventing Infection

Promoting Safety

Facilitating Hygiene

Administering Medications

Nutrition

Urinary Elimination

Bowel Elimination

Sensation,Perception, Cognition

Pain

Physical Activity Mobility

Sexual Health

Sleep and Rest

Skin Integrity-Wound Healing

Oxygenation

Circulation

Fluids,Electrolytes, Acidbase Balance

Perioperative Care

Leading Managing

Nursing Informatics

Promoting Health

Community-Home Health Nursing

Ethics Values

Legal Accountability

Holistic Healing

Filters