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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.
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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.
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.
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.
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 role of the nurse is crucial to the prevention of fragmentation of care?
- A. advocate
- B. teacher
- C. counselor
- D. coordinator
Correct Answer: D
Rationale: The coordinator role is crucial to prevent fragmentation of care, as it involves organizing and integrating services from multiple healthcare providers to ensure continuity.