Nokea
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.
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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.
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 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.
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.
What is the unique focus of nursing implementation?
- A. patient response to health and illness
- B. patient response to nursing diagnosis
- C. patient compliance with treatment regimen
- D. patient interview and physical assessment
Correct Answer: A
Rationale: The unique focus of nursing implementation is addressing the patient's response to health and illness, as it involves carrying out interventions to promote health, prevent illness, or manage health problems.