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A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean?
- A. The nurse is using critical thinking to implement the dressing change.
- B. The patient has specified how the dressing should be changed.
- C. Written plans are developed that specify nursing activities for this skill.
- D. The physician verbally requested specific steps of the dressing change.
Correct Answer: C
Rationale: An established protocol means written plans specify the nursing activities for the procedure, ensuring standardized and evidence-based practice.
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Which of the following examples of nursing actions involve direct care of the patient? Select all that apply.
- A. A nurse counsels a young family who is interested in natural family planning.
- B. A nurse massages the back of a patient while performing a skin assessment.
- C. A nurse arranges for a consultation for a patient who has no health insurance.
- D. A nurse helps a patient in hospice fill out a living will form.
- E. A nurse arranges for physical therapy for a patient who had a stroke.
- F. A nurse comforts a distraught patient whose baby was stillborn.
Correct Answer: A,B,D,F
Rationale: Direct care involves hands-on or face-to-face interaction with the patient. Counseling (A), massaging (B), assisting with a living will (D), and comforting (F) involve direct patient interaction, whereas arranging consultations (C) and physical therapy (E) are indirect care activities.
What must occur before physician-initiated interventions can be carried out?
- A. They must be written on the nursing plan of care.
- B. The nurse relinquishes all responsibility for them.
- C. Any healthcare provider may order them.
- D. The physician gives a verbal or written order.
Correct Answer: D
Rationale: Physician-initiated interventions require a verbal or written order from the physician, as they are prescribed based on medical authority.
A nurse is catheterizing a patient. What action illustrates respect for the patients privacy?
- A. explaining the procedure to the family
- B. leaving the patients pajamas on
- C. closing the door to the room
- D. asking another nurse if he wants to watch
Correct Answer: C
Rationale: Closing the door to the room ensures privacy by limiting exposure to others, a key aspect of respecting patient dignity during invasive procedures.
What is one advantage of having a standard classification of nursing interventions?
- A. to standardize nomenclature (names or terms)
- B. to legitimize the use of the nursing process
- C. to classify indicators of patient outcomes
- D. to facilitate documentation of expected goals
Correct Answer: A
Rationale: A standard classification of nursing interventions standardizes nomenclature, ensuring consistent terminology across healthcare settings, which improves communication and documentation.
A patient who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?
- A. to implement evidence-based practice
- B. to ensure the order follows hospital policy
- C. to be sure interventions are individualized
- D. to be sure the intervention is safe
Correct Answer: D
Rationale: The nurse reviews the plan to ensure the intervention (increasing oral intake) is safe, as an unconscious patient cannot safely consume oral intake, risking aspiration.