Deck 6: Nursing Process: Planning Interventions

Question 1

The nurse is selecting nursing interventions for her patient with diabetes.The nurse will select interventions using which resources available to her? Select all that apply.

A) A standardized list of interventions
B) Interventions generated based on her knowledge base and past experiences
C) Traditional interventions that seem to have worked in the past
D) Only those interventions that agree with patient preferences

Answer 1

A standardized list of interventions
Interventions generated based on her knowledge base and past experiences

Question 2

The nurse is using electronic care planning.He enters the patient's nursing diagnosis into the computer and chooses desired outcomes.He has validated his data,diagnosis,and goals.When he considers the list of interventions that the program generates,he sees that none of them fits this patient's individual needs.What should the nurse do?

A) Reject them all and type in appropriate interventions.
B) Select the interventions from the program that are most suitable.
C) Ask another nurse to assess the patient and give her recommendation.
D) Restart the computer; it is probably a program malfunction.

Answer 2

Reject them all and type in appropriate interventions.

Question 3

A 55-year-old patient returned to the medical-surgical unit after undergoing a right hemicolectomy (abdominal surgery)for colon cancer.Which of the following is an appropriate,correctly written nursing order for this patient?

A) 7/12/15 Encourage use of the incentive spirometer every hour while the client is awake-D. Goodman, RN
B) By 7/12/15, uses incentive spirometer 10 times every hour while awake to 1,000 mL
C) Incentive spirometer hourly while awake
D) Offer incentive spirometer to the client-J. Smith, RN

Answer 3

7/12/15 Encourage use of the incentive spirometer every hour while the client is awake-D. Goodman, RN

Question 4

A client newly diagnosed with diabetes is admitted to the hospital because her diabetes is out of control.Which of the following is an appropriate direct-care intervention for this client during her stay?

A) Consulting the diabetic nurse educator for help with a teaching plan
B) Making arrangements for the client to join a diabetic support group
C) Demonstrating blood glucose monitoring and insulin administration to the client
D) Consulting with the dietician about the client's dietary concerns

Question 5

Which of the following best describes evidence-based practice?

A) Tool developed by a healthcare organization for its own use to guide best nursing practice
B) An approach that uses the best scientific data to guide nursing practice
C) Nurses who uses clinical judgment and expertise to guide nursing practice
D) A method of practice that uses tradition and folklore interventions to guide practice

Question 6

Nurses use a five-step process in selecting the best nursing interventions for their patients.Using the five-step process in selecting the best nursing interventions,arrange the list on the left in the correct order of completion on the right.(Enter the number of each step in the proper sequence,do not use commas.)

A)Review the desired outcomes/goals.
B)Identify several actions or interventions.
C)Individualize standardized interventions.
D)Review the nursing diagnosis.
E)Choose the best interventions for the patient.

Question 7

Which statement(s)about nursing interventions is/are true? Select all that apply.

A) The responsibility of writing nursing orders cannot be delegated to the LPN/LVN.
B) The best nursing interventions are based on tradition.
C) Nursing interventions should be individualized and culturally sensitive.
D) Standardized nursing interventions improve care for a specific client.

Question 8

Which definition best describes a critical pathway?

A) Standardized plan of care for frequently occurring conditions
B) Systematically developed statement to assist practitioners and patients in decision making
C) Systematic review of clinical evidence for an intervention
D) Set of interrelated concepts that describes or explains something

Question 9

A client is admitted to the hospital with an acute respiratory problem resulting from lung disease.The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations.Which nursing intervention should be listed first on the care plan?

A) Determine airway adequacy hourly and as needed.
B) Administer oxygen as needed.
C) Monitor arterial blood gas values.
D) Place the client in a high Fowler's position.

Question 10

The nurse has completed the plan of care for her patient with a medical diagnosis of Gall Bladder Disease.In selecting nursing interventions that will best serve to help the patient achieve the desired goals,the nurse will consider which of the following? Select all that apply.

A) Age of the patient
B) Patient abilities and preferences
C) Education levels of the nursing staff
D) Medical orders
E) None of the above

Question 11

The nurse is completing her plan of care for a patient with congestive heart failure.In performing a direct-care nursing intervention the nurse will:

A) Collaborate with the physician for further medication orders
B) Instruct the patient about low sodium and low fat diets
C) Refer the patient to the cardiac rehabilitation program for a home-care exercise program
D) Consult with physical therapist for cardiac rehabilitation exercises

Question 12

Which of the following nursing interventions is an indirect-care intervention?

A) Emotional support
B) Teaching
C) Consulting
D) Physical care

Question 13

Which of the following is the best example of a well-written nursing order?

A) Administer pain medication 30 minutes prior to physical therapy exercises.
B) Teach patient how to give insulin injections prior to discharge.
C) The nurse will assess vital signs and report changes as needed.
D) Consider patient and family cultural preferences in diet order.

Question 14

A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung)disease.The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan.When selecting nursing interventions,what should the nurse do first?

A) Identify several interventions likely to achieve the desired outcomes.
B) Review the problem and etiology of the nursing diagnosis.
C) Choose the best interventions for the patient.
D) Review the goals she has written.

Question 15

Which of the following is the best example of a well-written nursing order?

A) Provide emotional support to patient and family as needed.
B) Bathe patient every day.
C) Follow fluid restriction of 1,500 mL per day.
D) Insert Foley catheter if patient has not voided within 8 hours.

Question 16

The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning.The client does not at present have any respiratory problems.The nurse's teaching plan includes coughing and deep-breathing exercises.Which type of nursing intervention is the nurse performing?

A) Health promotion
B) Treatment
C) Prevention
D) Assessment

Question 17

Who is the primary decision maker when caring for healthy adult clients?

A) Provider
B) Family
C) Client
D) Nurse

Question 18

A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision.She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas.What type of nursing intervention did the nurse write?

A) Collaborative
B) Interdependent
C) Dependent
D) Independent

Question 19

Which of the following best describe the primary goal(s)of evidence-based practice? Select all that apply.

A) Identify the most effective treatments for disease processes, conditions, or problems
B) Identify the most cost-effective treatments for disease processes, conditions, or problems
C) Include all patient and family preferences in guiding nursing practice
D) Create standardized clinical pathways for healthcare organizations

Question 20

The nurse is caring for a 55-year-old male smoker on the medical-surgical unit.The patient states,"I'd really like some help in quitting smoking." As part of her intervention plan she includes a smoking cessation class.What type of intervention is the nurse performing?

A) Wellness
B) Prevention
C) Assessment
D) Treatment