Question 1

During which aspect of the nursing process will the nurse most likely consult with other health professionals?
A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation

Accepted Answer

During the implementation phase, nurses often consult with other health professionals to coordinate and carry out the care plan effectively.

Question 2

Which of the following processes is an example of indirect care?
A) Documentation
B) Medication administration
C) Catheterization
D) Grief counselling

Accepted Answer

Documentation is considered an example of indirect care because it involves recording information about a patient's care and treatment, rather than directly providing hands-on care. Medication administration and catheterization are both examples of direct care because they involve physically interacting with the patient's body. Grief counselling could be considered indirect care or direct care, depending on the specific situation and approach of the counselor.

Question 3

What is the first step in the implementation process?
A) Providing care
B) Reassessing the client
C) Reviewing and revising the existing nursing care plan
D) Organizing resources and care delivery before delivering an intervention

Accepted Answer

Reassessing the client is the first step in the implementation process to ensure that the planned interventions are still appropriate and relevant to the client's current condition.

Question 4

Which of the following is often missing when writing nursing interventions and is acknowledged as a frequent error?
A) Etiology
B) Frequency
C) Action verbs
D) Purpose of the intervention

Accepted Answer

Frequency is often missing in nursing interventions, which can lead to ambiguity about how often an intervention should be performed.

Question 5

The nurse is working with a client who is being prepared for a diagnostic test this afternoon.The client tells the nurse that she wants to have her hair shampooed.Which of the following is the most appropriate label with regard to assigning a priority for the client's request?
A) Low priority
B) An unmet need
C) Intermediate priority
D) A safety and security need

Accepted Answer

The request to have hair shampooed is a personal preference and does not impact the client's health or safety, making it a low priority.

Question 6

Nursing interventions may be categorized based on the degree of nursing autonomy.Which one of the following is an example of a nurse-initiated intervention?
A) Providing client teaching
B) Administering medication
C) Ordering a computed tomography scan
D) Referring a client to physiotherapy

Accepted Answer

Nurse-initiated interventions are those that nurses can initiate without any orders or supervision from a physician or other healthcare provider. Providing client teaching is an example of a nurse-initiated intervention, as it falls within the scope of practice for registered nurses. Administering medication, ordering diagnostic tests, and referring a client to physiotherapy are examples of interventions that require physician orders or collaboration with other healthcare providers.

Question 7

Which of the following is measurable along a continuum in response to a nursing intervention?
A) Client goal
B) Nursing diagnosis
C) Time-limited nursing intervention
D) Nursing-sensitive client outcome

Accepted Answer

A nursing-sensitive client outcome is measurable along a continuum in response to a nursing intervention. Client goals and nursing diagnoses are not necessarily measurable along a continuum, and time-limited nursing interventions refer to the duration of the intervention rather than the measurable outcome.

Question 8

A number of different types of nursing interventions may be incorporated into the plan of care.Which of the following interventions is an example of a specific life-saving measure that the nurse may implement?
A) Restraining a violent client
B) Administering analgesics
C) Initiating stress-reduction therapy
D) Teaching the client how to take his or her pulse

Accepted Answer

Restraining a violent client may be a life-saving measure for both the client and those around them, and is therefore an example of a specific life-saving measure that a nurse may implement. Administering analgesics, initiating stress-reduction therapy, and teaching the client how to take his or her pulse are important interventions, but they may not necessarily be life-saving measures.

Question 9

In documentation of nursing care plans,how do critical pathways differ from traditional nursing care plans?
A) Multidisciplinary approach
B) Nursing interventions
C) Client outcomes
D) Client assessment

Accepted Answer

Critical pathways involve a multidisciplinary approach, whereas traditional nursing care plans focus primarily on nursing interventions, client outcomes, and client assessments. Critical pathways involve input and coordination from all members of the healthcare team, including physicians, nurses, therapists, and other professionals.

Question 10

When an etiological factor cannot change,at which of the following should interventions be directed?
A) Eliminating risk factors
B) Treating signs and symptoms
C) Creating a safe environment for the client
D) Understanding the scientific rationale for the interventions

Accepted Answer

Since the etiological factor cannot be changed, interventions should be aimed at treating signs and symptoms to improve the client's quality of life despite the presence of the underlying factor. Eliminating risk factors may not be possible, creating a safe environment may not directly improve the client's symptoms, and understanding the scientific rationale for interventions is important but not a direct intervention in itself.

Question 11

Which one of the following interventions selected by the nurse is classified as Level 2,Domain 2 (Physiological: Complex Care)?
A) Maintaining regular bowel elimination
B) Promoting the health of the family
C) Managing restricted body movement
D) Restoring tissue integrity

Accepted Answer

The answer of Which one of the following interventions selected...

Question 12

The nurse may use a concept map when implementing a plan of care.What is the purpose and distinction of a concept map?
A) Quality assurance in the health care facility
B) Multidisciplinary communication
C) Provision of a standardized format for client problems
D) Identification of the relation of client problems and interventions

Accepted Answer

A concept map is a visual representation of the relationships among client problems and interventions. It helps the nurse to identify the most effective interventions for the client's specific problems. The purpose of a concept map is to provide a comprehensive and organized approach to care planning, which in turn can improve client outcomes. While communication and standardization may be benefits of using a concept map, they are not the primary purpose or distinction. Quality assurance is a separate aspect of healthcare that involves monitoring and evaluating the delivery of care.

Question 13

The nurse is working with postoperative clients on a surgical unit.One aspect of care is manipulation of the client's environment.What does this involve on the part of the nurse?
A) Delegating ambulation of clients to the unregulated care provider
B) Providing pain medication to the client before a dressing change
C) Maintaining client privacy during procedures
D) Repositioning the client every two hours

Accepted Answer

Manipulating the client's environment involves maintaining privacy during procedures, as it pertains to the physical and social setting around the client.

Question 14

Which of the following is a specific and measurable behavioural response that reflects independence in function?
A) Client goal
B) Priority setting
C) Nursing diagnosis
D) Concept mapping

Accepted Answer

Client goal is a specific and measurable behavioural response that reflects independence in function, as it outlines what the client aims to achieve on their own. Priority setting, nursing diagnosis, and concept mapping may all contribute to developing client goals, but they do not specifically reflect independence in function.

Question 15

What is the primary reason for establishing standing orders?
A) To provide appropriate nursing autonomy in settings where client needs can change rapidly
B) To facilitate adequate care when direct contact with a primary health care provider is not immediately possible
C) To allow the nurse to provide certain routine therapies without first notifying the primary health care provider
D) To afford the client interventions that reflect the appropriate standard of care in the absence of a primary health care provider

Accepted Answer

The answer of What is the primary reason for establishing...

Quiz 13: Planning and Implementing Nursing Care

During which aspect of the nursing process will the nurse most likely consult with other health professionals?

Which of the following processes is an example of indirect care?

What is the first step in the implementation process?

Which of the following is often missing when writing nursing interventions and is acknowledged as a frequent error?

The nurse is working with a client who is being prepared for a diagnostic test this afternoon.The client tells the nurse that she wants to have her hair shampooed.Which of the following is the most appropriate label with regard to assigning a priority for the client's request?

Nursing interventions may be categorized based on the degree of nursing autonomy.Which one of the following is an example of a nurse-initiated intervention?

Which of the following is measurable along a continuum in response to a nursing intervention?

A number of different types of nursing interventions may be incorporated into the plan of care.Which of the following interventions is an example of a specific life-saving measure that the nurse may implement?

In documentation of nursing care plans,how do critical pathways differ from traditional nursing care plans?

When an etiological factor cannot change,at which of the following should interventions be directed?

Which one of the following interventions selected by the nurse is classified as Level 2,Domain 2 (Physiological: Complex Care) ?

The nurse may use a concept map when implementing a plan of care.What is the purpose and distinction of a concept map?

The nurse is working with postoperative clients on a surgical unit.One aspect of care is manipulation of the client's environment.What does this involve on the part of the nurse?

Which of the following is a specific and measurable behavioural response that reflects independence in function?

What is the primary reason for establishing standing orders?