Question 1

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

Accepted Answer

A)   Cognitive
B)   Interpersonal
C)   Psychomotor
D)   Judgmental B

Question 2

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?

Accepted Answer

A)   Ask the patient to return to his room so the nurse can inspect his abdomen.
B)   Request that the family leave, so the patient can rest.
C)   Ask the patient when his last bowel movement was and to lie down on the sofa.
D)   Tell the patient that his dinner tray will be ready in 15 minutes. A

Question 3

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

Accepted Answer

A)   Assisting with activities of daily living
B)   Counseling about respite care options
C)   Teaching range-of-motion exercises
D)   Emphasizing the importance of exercise B

Question 4

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

Accepted Answer

A)   Teaching the family proper handwashing technique
B)   Leaving side rails up at all times
C)   Teaching the patient how to use crutches
D)   Counseling the family on stress reduction techniques

Question 5

Before implementing any intervention,the nurse uses critical thinking to

Accepted Answer

A)   Determine whether an intervention is correct and appropriate for the given situation.
B)   Evaluate the effectiveness of interventions.
C)   Establish goals for a particular patient without the need for reassessment.
D)   Read over the steps and perform a procedure despite lack of clinical competency.

Question 6

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?

Accepted Answer

A)   Assist the patient to walk in the room with crutches.
B)   Obtain a walker for the patient.
C)   Consult physical therapy.
D)   Administer pain medication.

Question 7

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

Accepted Answer

A)   Determine patient outcomes and goals.
B)   Prioritize the patient's nursing diagnoses.
C)   Reassess the patient.
D)   Assess for a patent airway.

Question 8

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."?

Accepted Answer

A)   Medicate the patient immediately after all procedures.
B)   Discuss only nonpharmacological methods of pain relief.
C)   Teach the patient about side effects of pain medications.
D)   Medicate the patient based on previous shift assessment findings.

Question 9

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

Accepted Answer

A)   Reinforce the wound dressing as needed with 4 ´ 4 gauze.
B)   Perform the ordered dressing change twice daily.
C)   Document wound characteristics.
D)   Assess wound appearance each shift.

Question 10

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

Accepted Answer

A)   Notifies the health care provider to obtain a verbal order.
B)   Directs the nursing assistant to give the Tylenol.
C)   Administers the Tylenol.
D)   Performs a pain assessment only after administering the Tylenol.

Question 11

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?

Accepted Answer

A)   Cognitive
B)   Interpersonal
C)   Psychomotor
D)   Judgmental

Question 12

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

Accepted Answer

A)   Equipment
B)   Safe environment
C)   Patient readiness
D)   Assistive personnel
E)   Creativity

Question 13

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?

Accepted Answer

A)   Assess the patient for other symptoms or problems, and then notify the health care provider.
B)   Review the most recent lab results for the patient's potassium level.
C)   Follow the clinical protocol for a stroke.
D)   Administer an antihypertensive medication from the stock supply, and then notify the health care provider.

Question 14

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?

Accepted Answer

A)   Ask for at least two other assistive personnel to come to the room.
B)   Medicate the patient to alleviate discomfort while ambulating.
C)   Offer the patient a walker.
D)   Review the patient's activity orders.

Question 15

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?

Accepted Answer

A)   "This system can help medical students determine the cost of the care they provide."
B)   "If the nursing department uses this system, communication among nurses who work throughout the hospital may be enhanced."
C)   "We could use this system to help us better organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our unit."
D)   "The NIC system provides one way to improve safe and effective documentation in the hospital's electronic health record."

Question 16

The nurse defines a clinical guideline or protocol as a

Accepted Answer

A)   Guideline to follow that replaces the nursing care plan.
B)   Document that assists the clinician in making decisions and choosing interventions for specific health care problems or conditions.
C)   Hospital policy designating each nurse's duty according to standards of care and a code of ethics.
D)   Prescriptive order form that individualizes the plan of care.

Question 17

Which of the following are nursing interventions?

Accepted Answer

A)   Order chest x-ray for suspected humerus fracture.
B)   Order antibiotics for a respiratory infection.
C)   Reposition a patient who is on bed rest.
D)   Remind a patient to cough and deep breathe after surgery.
E)   Write transfer orders to move a patient to another hospital unit.

Question 18

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

Accepted Answer

A)   Assessment
B)   Planning
C)   Implementation
D)   Evaluation

Question 19

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

Accepted Answer

A)   Administer a prn medication for pain.
B)   Reassess the patient because of the change in condition.
C)   Notify the health care provider.
D)   Call radiology for a portable chest x-ray.

Question 20

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

Accepted Answer

A)   Teach the patient about signs and symptoms of infection.
B)   Help the patient cope with changes in body image that result from the wound.
C)   Perform dressing changes twice a day as ordered.
D)   Administer medications to control the patient's blood sugar as ordered.
E)   Teach the family how to perform dressing changes.

Exam 67: Implementing Nursing Care