Chapter 19 Implementing Nursing Care Fundamentals of Nursing 11th Edition (Potter & Perry) 50 NCLEX-Style Exam Questions with Detailed Rationales

1. What is the primary focus during the implementation phase of the nursing process? A) Evaluating outcomes B) Formulating nursing diagnoses C) Carrying out planned nursing interventions D) Collecting patient data Answer: C Rationale: Implementation involves putting the nursing care plan into action by executing interventions that address the patient’s health problems. ________________________________________ 2. Which of the following is a direct care intervention? A) Administering a medication B) Documenting care C) Arranging transportation D) Coordinating referrals Answer: A Rationale: Direct care interventions involve face-to-face interaction with the patient, such as administering medications or assisting with hygiene. ________________________________________ 3. Which nursing action demonstrates indirect care? A) Turning a patient in bed B) Administering oxygen C) Consulting with a dietitian D) Assisting with ambulation Answer: C Rationale: Indirect care interventions are performed away from the patient but on their behalf, such as collaboration or advocacy. ________________________________________ 4. Before implementing a nursing intervention, the nurse must: A) Determine if the physician ordered it B) Evaluate the cost C) Review the care plan and ensure the intervention is evidence-based and appropriate D) Get patient permission every time Answer: C Rationale: The nurse must verify that each intervention aligns with the individualized care plan and current best practices. ________________________________________ 5. Which of the following best reflects a nurse-initiated intervention? A) Administering IV antibiotics B) Inserting a urinary catheter C) Repositioning a patient every 2 hours D) Starting a blood transfusion Answer: C Rationale: Nurse-initiated (autonomous) interventions are based on nursing judgment, like repositioning to prevent pressure injuries. ________________________________________ 6. A patient refuses a prescribed physical therapy session. What is the nurse’s best response? A) Reschedule the session without documenting B) Inform the therapist the patient is noncompliant C) Document the refusal and notify the provider D) Insist the patient participate for safety Answer: C Rationale: The nurse must respect patient autonomy, document the refusal, and report it to ensure proper follow-up. ________________________________________ 7. What is the best example of collaborative nursing intervention? A) Providing hygiene care B) Administering oxygen per protocol C) Initiating a consult with a physical therapist D) Educating a patient on nutrition Answer: C Rationale: Collaborative interventions involve other health team members, such as PT, OT, or nutritionists. ________________________________________ 8. Which of the following nursing actions reflects a standing order? A) Consulting the physician for every medication B) Administering acetaminophen for fever per protocol C) Waiting for direct orders before acting D) Calling the provider for all non-emergent symptoms Answer: B Rationale: Standing orders are pre-authorized protocols nurses can follow without direct approval for each instance. ________________________________________ 9. What is the purpose of clinical practice guidelines in nursing care? A) To eliminate individualized care B) To reduce nurse responsibility C) To guide evidence-based interventions D) To replace nursing diagnoses Answer: C Rationale: Guidelines help standardize care based on current evidence, ensuring safe and effective practices. ________________________________________ 10. The nurse must modify an intervention due to a change in the patient’s condition. What should be done first? A) Notify the charge nurse B) Update the physician C) Reassess the patient and revise the plan of care D) Skip the intervention Answer: C Rationale: If a patient’s condition changes, reassessment is critical to determine whether the planned intervention is still appropriate. ________________________________________ 11. What documentation is essential immediately after implementing a nursing intervention? A) Physician’s rationale B) Care plan goals C) Specific details of the intervention and patient response D) Name of supervising nurse Answer: C Rationale: Accurate documentation of the intervention and patient response ensures continuity and legal accountability. ________________________________________ 12. Which is the most appropriate response to a patient who refuses a prescribed medication? A) Notify the provider and document the reason for refusal B) Disguise the medication in food C) Omit the dose without documentation D) Persuade the patient aggressively Answer: A Rationale: Patient refusal must be respected, documented, and communicated to the provider for further guidance. ________________________________________ 13. A nurse delegates a bed bath to a nursing assistant. What action is required? A) Supervise the entire task B) Ensure the task is completed safely and review outcomes C) Assign another nurse to verify D) Perform the task again to double-check Answer: B Rationale: Delegation requires follow-up. The nurse remains responsible for evaluating the outcome. ________________________________________ 14. Which principle should guide delegation of nursing tasks? A) Cost efficiency B) Patient preference C) The skill level of the staff and complexity of the task D) Hospital policy only Answer: C Rationale: Delegation must be based on the staff’s scope of practice and patient acuity to ensure safe outcomes. ________________________________________ 15. When implementing care, what is the nurse’s primary goal? A) Minimize workload B) Carry out provider’s orders C) Promote patient well-being and meet expected outcomes D) Avoid responsibility Answer: C Rationale: Implementation focuses on helping the patient achieve the goals and outcomes established in the plan of care. ________________________________________