Which of the following nursing interventions is an indirect-care intervention?
1) Emotional support
2) Teaching
3) Consulting
4) Physical care
ANS:
3) Consulting
An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include consulting with other healthcare team members, making referrals, advocacy, and managing the environ
An 80-year-old resident in a long-term-care facility comes to the emergency department with dehydration. The nurse writes a diagnosis of Deficient Fluid Volume related to excessive fluid loss. An individualized nursing goal identified for this client is T
ANS:
1) Measure and record urine output every hour; report an output of less than 30 mL/hour.
3) Administer IV fluids as prescribed.
4) Keep oral fluids within the patients reach, and encourage the patient to drink.
Measuring and recording urine output al
Which nursing intervention is considered an independent intervention?
1) Administering 1 L of dextrose 5% in normal saline solution at 100 mL/hour
2) Encouraging the postoperative client to perform coughing and deep breathing exercises
3) Explaining his d
ANS:
2) Encouraging the postoperative client to perform coughing and deep breathing exercises
Encouraging the postoperative client to perform coughing and deep breathing exercises is an independent nursing intervention. An independent intervention is one
Which statement(s) about nursing interventions is/are true? Select all that apply.
1) The responsibility of writing nursing orders cannot be delegated to the LPN/LVN.
2) The best nursing interventions are based on tradition.
3) Nursing interventions shoul
ANS:
1) The responsibility of writing nursing orders cannot be delegated to the LPN/LVN.
3) Nursing interventions should be individualized and culturally sensitive.
Some nursing interventions and activities can be delegated to the LPN/LVN or nursing assis
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 inter
ANS:
4) Independent
Writing an order to reposition the client in a comfortable position is an example of an independent nursing intervention, one that does not require a physicians order. The nurse is licensed to prescribe, perform, or delegate the interv
The nurse is using electronic care planning. He enters the patients nursing diagnosis into the computer and chooses desired outcomes. He has validated his data, diagnosis, and goals. When he considers the list of interventions the program generates, he se
ANS:
1) Reject them all and type in appropriate interventions.
The nurse can reject all the suggested interventions if they do not address patient needs. Nearly all computer programs have a screen that allows you to type in interventions and nursing order
The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not currently have any respiratory problems. The nurses teaching plan includes coughing and deep breathing exercises. Which type of nur
ANS:
3) Prevention
The nurse is teaching the client coughing and deep breathing exercises, which help prevent postoperative pneumonia. Therefore, the nurse is utilizing a prevention intervention. Prevention interventions are used to help prevent complicat
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 recor
ANS:
2) Review the problem and etiology of the nursing diagnosis.
The process of choosing interventions is review the nursing diagnosis, review the desired outcomes, identify several interventions or actions, choose the best interventions for the patient,
Which standardized intervention vocabulary was designed specifically for community health nurses?
1) Omaha System
2) Clinical Care Classification
3) Nursing Interventions Classification
4) International Classification for Nursing Practice
ANS:
1) Omaha System
The Omaha System was designed specifically for community health nurses to use in caring for individuals, families, community groups, or entire communities. The Clinical Care Classification was developed for home healthcare. The Nursin
Who is the primary decision maker when caring for healthy adult clients?
1) Physician
2) Family
3) Client
4) Nurse
ANS:
3) Client
The client is the primary decision maker in the care of healthy clients. The nurse functions as a teacher and health counselor. The physician plays a role in health promotion and screening. The family may give input, but the client is the d
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?
1) 7/12/13 Encourage use o
ANS:
1) 7/12/13 Encourage use of the incentive spirometer every hour while the client is awakeD. Goodman, RN
The option beginning with a date and ending with the RNs signature contains necessary information. It contains the date the order was written alon
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 interv
ANS:
1) Determine airway adequacy hourly and as needed.
For any acute respiratory problem, prior to implementing interventions, the nurse would assess breathing status of the patient by checking the respiratory rate and depth. When devising a plan of care
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?
1) Consulting the diabetic nurse educator for hel
ANS:
3) Demonstrating blood glucose monitoring and insulin administration to the client
Demonstrating blood glucose monitoring and insulin administration is an appropriate direct-care intervention for this client. Direct-care interventions are performed t
Which definition best describes a critical pathway?
1) Standardized plan of care for frequently occurring conditions
2) Systematically developed statement to assist practitioners and patients in making decisions
3) Systematic review of clinical evidence f
ANS:
1) Standardized plan of care for frequently occurring conditions
Critical pathways are standardized plans of care for commonly occurring health conditions (e.g., myocardial infarction) for which similar outcomes and interventions are appropriate for