Chapter 19: Implementing Nursing Care
ra ra ra ra r
MULTIPLE CHOICE ra
1. A nursing attendant is providing nursing care to hospital client s after completing a
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
care plan from nursing diagnoses. In which step of the nursing process is the nursing
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
attendant ? ra
a. Assessment
b. Planning
c. Implementation
d. Evaluation
ACCURATE ar
ANSWER:-C
Implementation, the fourth step of the nursing process, formally begins after a nursing attend ra ra ra ra ra ra ra ra ra ra ra ra ra
ant develops a plan of care. With a care plan based on clear and relevant nursing diagnoses, a
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
nursing attendant initiates interventions that are designed to assist the hospital client in ac
ra ra ra ra ra ra ra ra ra ra ra r a ra
hieving the goals and expected outcomes needed to support or improve the hospital client ’s h
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ealth status. The nursing attendant gathers data during the assessment phase and mutually set
ra ra ra ra ra ra ra ra ra ra ar ra ra
s goals and prioritizes care during the planning phase. During the evaluation phase, the nursi
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ng attendant determines the achievement of goals and effectiveness of interventions.
ra ra ra ra ra ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Explain how critical thinking influences a nursing attendant ’s role in the i
ra ra ra ra ra ra ra ra ra ra ra ra
mplementation process. TOP:Implementation MSC: Basic Care and Comfort ra ra ra ra ra
2. The nursing attendant is teaching a novice nursing attendant about protocols. Which
ra ra ra ra ra ra ra ra ra ra ra
information from the novice nursing attendant indicates a correct understanding of t
ra ra ra ra ra ra ra ra ra ra ra ra
he teaching? ar
a. Protocols are guidelines to follow that replace the nursing care plan. ra ra ra ra ra ra ra ra ra ra
b. Protocols assist the clinician in making decisions and choosing interventions for ra ra ra ra ra ra ra ra ra ra ar
specific health care problems or conditions. ra ra ra ra ra
c. Protocols are policies designating each nursing attendant ’s duty according to ra ra ra ra ra ra ra ra ra ra ar
standards of care and a code of ethics. ra ra ra ra ra ra ra
d. Protocols are prescriptive order forms that help individualize the plan of care. ra ra ra ra ra ra ra ra ra ra ra
ACCURATE ar
ANSWER:-B
A clinical practice guideline or protocol is a systematically developed set of statements that h
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
elps nursing attendant s, physicians, and other health care providers make decisions about ap
ra ra ra ra ra ra ra ra ra ra ra ra ra
propriate health care for specific clinical situations. This guideline establishes interventions fo
ra ra ra ra ra ra ra ra ra ra ar
r specific health care problems or conditions. The protocol does not replace the nursing care pl
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
an.
Evidence-
based guidelines from protocols can be incorporated into an individualized plan of care. A cli
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
nical guideline is not the same as a hospital policy. Standing orders contain orders for the car
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
e of a specific group of hospital client s. A protocol is not a prescriptive order form like a stan
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra ra
ding order. ra
, DIF:Understand (comprehension)
ra
OBJ:Explain the factors to consider in determining if nursing interventions are hospital client centered.
ra ra ra ra ra ra ra ra ra ra ra ra ra
, TOP:Teaching/Learning MSC: Management of Care ra ra ra
3. The standing orders for a hospital client include acetaminophen 650 mg every 4 hours prn f
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
or headache. After assessing the hospital client , the nursing attendant identifies the need f
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
or headache relief and determines that the hospital client has not had acetaminophen in th
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
e ar past 4 hours. Which action will the nursing attendant take next? a. ra ra ra ra ra ra ra ra ra ra
Administer the acetaminophen. ra ra
b. Notify the health care provider to obtain a verbal order. ra ra ra ra ra ra ra ra ra
c. Direct the nursing assistive personnel to give the acetaminophen. ra ra ra ra ra ra ra ra
d. Perform a pain assessment only after administering the acetaminophen. ra ra ra ra ra ra ra ra
ACCURATE ANSWER:-A ra
A standing order is a preprinted document containing orders for the conduct of routine th
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
erapies, monitoring guidelines, and/or diagnostic procedures for specific hospital client s
ra ra ra ra ra ra ra ra ra ra ar
with identified clinical problems. The nursing attendant will administer the medication.
ra ra ra ra ra ra ra ra ra ra
Notifying the health care provider is not necessary if a standing order exists. The nursing assis
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
tive personnel are not licensed to administer medications; therefore, medication administrat
ra ra ra ra ra ra ra ra ra ra
ion should not be delegated to this person. A pain assessment should be performed before an
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
d after pain medication administration to assess the need for and effectiveness of the medica tion.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Explain the factors to consider in determining if nursing interventions are hospital client
ra ra ra ra ra ra ra ra ra ra ra ra ar
centered. TOP:Implementation MSC: Basic Care and Comfort
ra ra ra ra
4. Which action indicates a nursing attendant is using critical thinking for implementation o
ra ra ra ra ra ra ra ra ra ra ra ra
f nursing care to hospital client s?
ar ra ra ra ra ra
a. Determines whether an intervention is correct and appropriate for the given situation. ra ra ra ra ra ra ra ra ra ra ar
b. Reads over the steps and performs a procedure despite lack of clinical competency.
ra ra ra ra ra ra ra ra ra ra ra ra
c. Establishes goals for a particular hospital client without assessment. ra ra ra ra ra ra ra ra
d. Evaluates the effectiveness of interventions. ra ra ra ra
ACCURATE ANSWER:-A ra
As you implement interventions, use critical thinking to confirm whether the interventions are c
ra ra ra ra ra ra ra ra ra ra ra ra ar
or
rect and still appropriate for a hospital client ’s clinical situation. You are responsible for having t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
he necessary knowledge and clinical competency to perform interventions for your hospital clien
ra ra ra ra ra ra ra ra ra ra ra ra
t s safely and effectively. The nursing attendant needs to recognize the safety hazards of performi
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ng an intervention without clinical competency and seek assistance from another nursing attend
ra ra ra ra ra ra ra ra ra ra ra ra
ant . The nursing attendant cannot evaluate interventions until they are implemented. Hospital c
ra ra ra ra ra ra ra ra ra ra ra ra ra
lient s need ongoing assessment before establishing goals because hospital client conditions can
ra ra ra ra ra ra ra ra ra ra ra ra ra
change very rapidly. ra ra
DIF:Understand (comprehension) ra
OBJ:Explain the factors to consider in determining if nursing interventions are hospital client
ra ra ra ra ra ra ra ra ra ra ra ra ra
centered. TOP:Implementation MSC: Basic Care and Comfort
ra ra ra ra
5. A nursing attendant is reviewing a hospital client ’s care plan. Which information will
ra ra ra ra ra ra ra ra ra ra ra ra ra ar
the nursing attendant identify as a nursing intervention?
ra ra ra ra ra ra ra
a. The hospital client will ambulate in the hallway twice this shift using crutches correctly.
ra ra ra ra ra ra ra ra ra ra ra ra ra
b. Impaired physical mobility related to inability to bear weight on right leg. ra ra ra ra ra ra ra ra ra ra ra
c. Provide assistance while the hospital client walks in the hallway twice thi ra ra ra ra ra ra ra ra ra ra ra
s shift with crutches. ar ra ra
ra ra ra ra r
MULTIPLE CHOICE ra
1. A nursing attendant is providing nursing care to hospital client s after completing a
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
care plan from nursing diagnoses. In which step of the nursing process is the nursing
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
attendant ? ra
a. Assessment
b. Planning
c. Implementation
d. Evaluation
ACCURATE ar
ANSWER:-C
Implementation, the fourth step of the nursing process, formally begins after a nursing attend ra ra ra ra ra ra ra ra ra ra ra ra ra
ant develops a plan of care. With a care plan based on clear and relevant nursing diagnoses, a
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
nursing attendant initiates interventions that are designed to assist the hospital client in ac
ra ra ra ra ra ra ra ra ra ra ra r a ra
hieving the goals and expected outcomes needed to support or improve the hospital client ’s h
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ealth status. The nursing attendant gathers data during the assessment phase and mutually set
ra ra ra ra ra ra ra ra ra ra ar ra ra
s goals and prioritizes care during the planning phase. During the evaluation phase, the nursi
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ng attendant determines the achievement of goals and effectiveness of interventions.
ra ra ra ra ra ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Explain how critical thinking influences a nursing attendant ’s role in the i
ra ra ra ra ra ra ra ra ra ra ra ra
mplementation process. TOP:Implementation MSC: Basic Care and Comfort ra ra ra ra ra
2. The nursing attendant is teaching a novice nursing attendant about protocols. Which
ra ra ra ra ra ra ra ra ra ra ra
information from the novice nursing attendant indicates a correct understanding of t
ra ra ra ra ra ra ra ra ra ra ra ra
he teaching? ar
a. Protocols are guidelines to follow that replace the nursing care plan. ra ra ra ra ra ra ra ra ra ra
b. Protocols assist the clinician in making decisions and choosing interventions for ra ra ra ra ra ra ra ra ra ra ar
specific health care problems or conditions. ra ra ra ra ra
c. Protocols are policies designating each nursing attendant ’s duty according to ra ra ra ra ra ra ra ra ra ra ar
standards of care and a code of ethics. ra ra ra ra ra ra ra
d. Protocols are prescriptive order forms that help individualize the plan of care. ra ra ra ra ra ra ra ra ra ra ra
ACCURATE ar
ANSWER:-B
A clinical practice guideline or protocol is a systematically developed set of statements that h
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
elps nursing attendant s, physicians, and other health care providers make decisions about ap
ra ra ra ra ra ra ra ra ra ra ra ra ra
propriate health care for specific clinical situations. This guideline establishes interventions fo
ra ra ra ra ra ra ra ra ra ra ar
r specific health care problems or conditions. The protocol does not replace the nursing care pl
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
an.
Evidence-
based guidelines from protocols can be incorporated into an individualized plan of care. A cli
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
nical guideline is not the same as a hospital policy. Standing orders contain orders for the car
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
e of a specific group of hospital client s. A protocol is not a prescriptive order form like a stan
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra ra
ding order. ra
, DIF:Understand (comprehension)
ra
OBJ:Explain the factors to consider in determining if nursing interventions are hospital client centered.
ra ra ra ra ra ra ra ra ra ra ra ra ra
, TOP:Teaching/Learning MSC: Management of Care ra ra ra
3. The standing orders for a hospital client include acetaminophen 650 mg every 4 hours prn f
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
or headache. After assessing the hospital client , the nursing attendant identifies the need f
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
or headache relief and determines that the hospital client has not had acetaminophen in th
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
e ar past 4 hours. Which action will the nursing attendant take next? a. ra ra ra ra ra ra ra ra ra ra
Administer the acetaminophen. ra ra
b. Notify the health care provider to obtain a verbal order. ra ra ra ra ra ra ra ra ra
c. Direct the nursing assistive personnel to give the acetaminophen. ra ra ra ra ra ra ra ra
d. Perform a pain assessment only after administering the acetaminophen. ra ra ra ra ra ra ra ra
ACCURATE ANSWER:-A ra
A standing order is a preprinted document containing orders for the conduct of routine th
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
erapies, monitoring guidelines, and/or diagnostic procedures for specific hospital client s
ra ra ra ra ra ra ra ra ra ra ar
with identified clinical problems. The nursing attendant will administer the medication.
ra ra ra ra ra ra ra ra ra ra
Notifying the health care provider is not necessary if a standing order exists. The nursing assis
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
tive personnel are not licensed to administer medications; therefore, medication administrat
ra ra ra ra ra ra ra ra ra ra
ion should not be delegated to this person. A pain assessment should be performed before an
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
d after pain medication administration to assess the need for and effectiveness of the medica tion.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Explain the factors to consider in determining if nursing interventions are hospital client
ra ra ra ra ra ra ra ra ra ra ra ra ar
centered. TOP:Implementation MSC: Basic Care and Comfort
ra ra ra ra
4. Which action indicates a nursing attendant is using critical thinking for implementation o
ra ra ra ra ra ra ra ra ra ra ra ra
f nursing care to hospital client s?
ar ra ra ra ra ra
a. Determines whether an intervention is correct and appropriate for the given situation. ra ra ra ra ra ra ra ra ra ra ar
b. Reads over the steps and performs a procedure despite lack of clinical competency.
ra ra ra ra ra ra ra ra ra ra ra ra
c. Establishes goals for a particular hospital client without assessment. ra ra ra ra ra ra ra ra
d. Evaluates the effectiveness of interventions. ra ra ra ra
ACCURATE ANSWER:-A ra
As you implement interventions, use critical thinking to confirm whether the interventions are c
ra ra ra ra ra ra ra ra ra ra ra ra ar
or
rect and still appropriate for a hospital client ’s clinical situation. You are responsible for having t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
he necessary knowledge and clinical competency to perform interventions for your hospital clien
ra ra ra ra ra ra ra ra ra ra ra ra
t s safely and effectively. The nursing attendant needs to recognize the safety hazards of performi
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ng an intervention without clinical competency and seek assistance from another nursing attend
ra ra ra ra ra ra ra ra ra ra ra ra
ant . The nursing attendant cannot evaluate interventions until they are implemented. Hospital c
ra ra ra ra ra ra ra ra ra ra ra ra ra
lient s need ongoing assessment before establishing goals because hospital client conditions can
ra ra ra ra ra ra ra ra ra ra ra ra ra
change very rapidly. ra ra
DIF:Understand (comprehension) ra
OBJ:Explain the factors to consider in determining if nursing interventions are hospital client
ra ra ra ra ra ra ra ra ra ra ra ra ra
centered. TOP:Implementation MSC: Basic Care and Comfort
ra ra ra ra
5. A nursing attendant is reviewing a hospital client ’s care plan. Which information will
ra ra ra ra ra ra ra ra ra ra ra ra ra ar
the nursing attendant identify as a nursing intervention?
ra ra ra ra ra ra ra
a. The hospital client will ambulate in the hallway twice this shift using crutches correctly.
ra ra ra ra ra ra ra ra ra ra ra ra ra
b. Impaired physical mobility related to inability to bear weight on right leg. ra ra ra ra ra ra ra ra ra ra ra
c. Provide assistance while the hospital client walks in the hallway twice thi ra ra ra ra ra ra ra ra ra ra ra
s shift with crutches. ar ra ra
