Chapter 18: Implementing Nursing Care Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. The nurse is working with postoperative clients on a surgical unit. One aspect of care is manipulation of the clients environment. This involves the nurse:

a.

Delegating ambulation of clients to the nursing assistant

b.

Providing pain medication to the client before a dressing change

c.

Removing clutter from the clients room

d.

Repositioning the client q2h

ANS: c

c. Making rooms free of clutter is an example of manipulating the environment to create safe surroundings.

a. Delegating ambulation of clients to the nursing assistant is an example of organizing personnel (resources) for care delivery.

b. Providing pain medication before a dressing change is an example of organizing care delivery specific to the client. Before beginning to perform interventions, the nurse should make the client as physically and psychologically comfortable as possible.

d. Repositioning the client q2h is an example of organizing care delivery to promote client comfort and prepare the client for nursing intervention.

REF: Text Reference: p. 345

2. The client is given an injection of an antibiotic. Shortly afterward she says that she has hives and is itchy. The nurse administers an antihistamine to counteract the effect of the antibiotic. The nurse is using which one of the following intervention methods?

a.

Preventive measures

b.

Assisting with activities of daily living (ADLs)

c.

Preparing for special procedures

d.

Compensation for adverse reactions

ANS: d

d. Nursing actions that control adverse reactions reduce or counteract the reaction, such as administering an antihistamine after an allergic reaction to a medication.

a. Preventive measures, such as immunizations, health teaching and risk appraisal, promote health and prevent illness to avoid the need for acute or rehabilitative care..

b. Assisting with activities of daily living (ADLs) is a direct care measure with which the nurse provides the client with assistance in activities that are usually performed in the course of a normal day, such as eating, bathing, dressing, grooming, and ambulating.

c. Preparing for special procedures is a direct care measure involving physical care techniques and possible teaching.

REF: Text Reference: p. 349

3. The client is scheduled to receive warfarin (Coumadin, an anticoagulant) at 9:00 AM. His morning laboratory results show him to have a high partial thromboplastin time (PTT). His nurse decides to withhold the warfarin. Which step of the implementation process is she using?

a.

Reassessing the client

b.

Modifying the nursing care plan

c.

Revising the nursing diagnosis

d.

Stating an expected outcome

ANS: b

b. The nurse is modifying the nursing care plan. Data have been updated to reflect the clients current status of an elevated partial thromboplastin time (PTT), and nursing diagnoses and specific interventions are revised. In this case, the revised intervention is withholding the warfarin (Coumadin).

a. The nurse is doing more than reassessing the client. The nurse modifies the nursing care plan based on new data obtained.

c. Withholding the warfarin reflects modification of the nursing care plan. The client may require a new or additional nursing diagnosis to address the problem of a risk for deficient fluid volume.

d. By gathering further assessment data and revising nursing interventions, the nurse is modifying the nursing care plan. Withholding the warfarin is not an example of stating an expected outcome.

REF: Text Reference: p. 344

4. The nurse notes that a narcotic is to be administered per epidural cath. The nurse, however, does not know how to perform this procedure. Which aspect of the implementation process should be followed?

a.

Seek assistance

b.

Reassess the client

c.

Use interpersonal skills

d.

Critical decision making

ANS: a

a. If a nurse does not know how to perform a procedure, he or she should seek assistance. Information about the procedure is obtained from the literature and the agencys procedure book. All equipment necessary for the procedure is collected. Finally, another nurse who has completed the procedure correctly and safely provides assistance and guidance.

b. Reassessing the client is a partial assessment that may focus on one dimension of the client or on one system. It provides a way to determine whether the proposed nursing action is still appropriate for the clients level of wellness.

c. Interpersonal skills are used to develop a trusting relationship, express a level of caring, and communicate clearly with the client, family, and health care team.

d. Critical decision making is used when the nurse implements the care plan by using the knowledge bases necessary for care planning and for then completing the planned interventions most effectively. In this case, the nurse lacks the necessary knowledge and experience and should seek assistance.

REF: Text Reference: p. 346

5. The nurse recognizes the discharge needs of a client after a hip replacement. This is an example of which type of nursing skill?

a.

Cognitive

b.

Interactive

c.

Psychomotor

d.

Communication

ANS: a

a. Cognitive skills involve the application of nursing knowledge. Being able to identify a clients discharge needs is a cognitive skill.

b. Interactive skills are interpersonal skills such as developing a trusting relationship and communicating effectively.

c. Psychomotor skills involve the integration of cognitive and motor skills such as in administering an injection.

d. Effective communication is an interpersonal skill. The nurse communicates with the client and family when providing client teaching and emotional support. The nurse communicates with the health care team to achieve client outcomes.

REF: Text Reference: p. 346

6. The nurse uses a variety of skills in the application of the nursing process. An example of a cognitive nursing skill is:

a.

Providing a soothing bed bath

b.

Communicating with the client and family

c.

Giving an injection to the client per the physicians orders

d.

Recognizing the potential complications of a blood transfusion

ANS: d

d. Cognitive skills involve the application of nursing knowledge. Understanding normal and abnormal physiological and psychological responses is a cognitive skill, as in recognizing the potential complications of a blood transfusion.

a. Providing a soothing bed bath involves both interpersonal skills and psychomotor skills. The nurse who provides a soothing bed bath is expressing a level of caring, which is an interpersonal skill. The nurse who provides a soothing bed bath also is using a psychomotor skill in performing the bed bath correctly.

b. Communicating with the client and family is an example of an interpersonal skill.

c. Giving an injection to the client is a psychomotor skill.

REF: Text Reference: p. 346

7. An enterostomal nurse shows a clients significant other how to assist with the supplies for and manipulation of the ostomy equipment. The nurse in demonstrating the technique to the client is using what type of nursing skill?

a.

Cognitive

b.

Interactive

c.

Affective

d.

Psychomotor

ANS: d

d. Psychomotor skills involve the integration of cognitive and motor activities, such as in providing ostomy care.

a. Cognitive skills involve the application of nursing knowledge. Knowing the rationale for therapeutic interventions, understanding normal and abnormal physiological and psychological responses, and being able to identify client learning and discharge needs all require cognitive skills.

b. Interpersonal skills are used when the nurse interacts with clients, their families, and other health care team members. Effective communication is an example of an interpersonal skill.

c. Affective means pertaining to an emotion or mental state.

REF: Text Reference: p. 346

8. For a client with a nursing diagnosis of Impaired physical mobility related to bilateral arm casts, the nurse should select which of the following methods of nursing intervention?

a.

Counseling

b.

Teaching

c.

Compensating for adverse reactions

d.

Assisting with ADLs

ANS: d

d. A client with bilateral arm casts has a temporary need for assistance with ADLs.

a. Counseling is a direct care method that helps the client use a problem-solving process to develop new attitudes and feelings. It does not meet the physical need for assistance with ADLs.

b. Teaching is an implementation method used to present correct principles, procedures, and techniques of health care to clients and to inform clients about their health status.

c. Compensating for adverse reactions means the nurse takes action to reduce or counteract the reaction, such as with administering an antihistamine when a client has an allergic reaction to a medication. Assisting with ADLs would be compensating for the clients impaired mobility.

REF: Text Reference: p. 347

9. There are a number of different types of nursing interventions that may be incorporated into the plan of care. An example of a specific lifesaving measure that the nurse may implement is:

a.

Restraining a violent client

b.

Administering analgesics

c.

Initiating stress-reduction therapy

d.

Teaching the client how to take his or her pulse

ANS: a

a. Restraining a violent client is an example of a lifesaving measure to protect the client. The purpose of a lifesaving measure is to restore physiological or psychological equilibrium.

b. Administering analgesics is an example of physical care techniques. It is not a lifesaving measure.

c. Initiating stress-reduction therapy is an example of a counseling technique.

d. Teaching the client how to take his or her pulse is an example of the nursing intervention of teaching. The focus is for the client to obtain new knowledge or psychomotor skills.

REF: Text Reference: p. 348

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