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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.
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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 characteristic of a competent nurse practitioner enables nurses to be role models for patients?
- A. sense of humor
- B. writing ability
- C. organizational skills
- D. good personal health
Correct Answer: D
Rationale: Good personal health enables nurses to model healthy behaviors, serving as role models for patients in promoting wellness.
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.
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.
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.