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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.
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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.
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.
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.
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.