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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.
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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.
Which of the following statements accurately describe a recommended guideline for implementation? Select all that apply.
- A. When implementing nursing care, remember to act independently, regardless of the wishes of the patient/family.
- B. Before implementing any nursing action, reassess the patient to determine whether the action is still needed.
- C. Assume that the nursing intervention selected is the best of all possible alternatives.
- D. Consult colleagues and the nursing and related literature to see if other approaches might be more successful.
- E. Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success.
- F. Check to make sure that the nursing interventions selected are consistent with standards of care.
Correct Answer: B,D,F
Rationale: Recommended guidelines include reassessing the patient (B), consulting colleagues and literature for better approaches (D), and ensuring interventions align with standards of care (F). Acting independently without patient input (A), assuming interventions are the best (C), or reducing skills (E) are not recommended.
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.
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.
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.