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A student is ambulating a patient for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome?
- A. Take the patients vital signs after ambulation.
- B. Ask the patients wife to assist with ambulation.
- C. Delay ambulation until the following shift.
- D. Ask another student to help with ambulation.
Correct Answer: D
Rationale: Asking another student to help anticipates potential complications (e.g., falls) by ensuring additional support is available during ambulation.
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What activity is carried out during the implementing step of the nursing process?
- A. Assessments are made to identify human responses to health problems.
- B. Mutual goals are established and desired patient outcomes are determined.
- C. Planned nursing actions (interventions) are carried out.
- D. Desired outcomes are evaluated and, if necessary, the plan is modified.
Correct Answer: C
Rationale: The implementing step involves carrying out planned nursing interventions to address the patient's needs, as outlined in the nursing care plan.
A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The patient has visitors in the room. What should the nurse do?
- A. Ask the visitors to leave the room.
- B. Ask the patient if visitors should remain in the room.
- C. Tell the patient to ask the visitors to leave the room.
- D. Wait until the visitors leave to begin the procedure.
Correct Answer: B
Rationale: The nurse should ask the patient if visitors should remain, respecting patient autonomy and privacy preferences during the procedure.
What phrase best describes nurse-initiated interventions?
- A. nurse-prescribed interventions
- B. physician-prescribed interventions
- C. healthcare team interventions
- D. interventions based on medical orders
Correct Answer: A
Rationale: Nurse-initiated interventions are best described as nurse-prescribed, as they are independently ordered by nurses based on their scope of practice and patient needs.
A nurse documents the following diagnosis for a hospitalized patient: Risk for Imbalanced Nutrition: More Than Body Requirements. What is the major goal of interventions for a risk diagnosis?
- A. reduce or eliminate contributing factors
- B. prevent the problem
- C. collect additional data
- D. promote higher-level wellness
Correct Answer: B
Rationale: The major goal for a risk diagnosis is to prevent the problem from occurring by addressing risk factors and implementing preventive measures.
What core value of nursing care is missing when a nursing intervention is delegated to a UAP?
- A. communication
- B. patient teaching
- C. nurse/patient dynamic
- D. competent care
Correct Answer: C
Rationale: Delegating to a UAP may miss the nurse/patient dynamic, as the professional relationship and holistic assessment provided by the nurse are not fully replicated.