C HAPTER 19: I MPLEMENTING N URSING
C ARE
Fundamentals of Nursing 10th Ed ition; Potter Perry
MULTIPLE CHOICE
1. Which of the following interventions is the bes t example of an indirect
intervention directed towards client safety?
A. Checking on a restrained client every 15 minutes
B. Performing hand hygiene between client contacts
C. Including the diagnosis at risk for injury related to falls to a clients
care plan
D. Turning on a night light to illuminate the path to the bathroom
ANS: D
Indirect care interventions are treatments performed away from the
client but on behalf of the client or group of clients. For example,
indirect care measures include actions for managing t he clients
environment (e.g., safet y and infection control), documentation, and
interdisciplinary collaboration. Directl y impacting the light level in a
clients room to minimize the risk for falls is the best example of a
safet y-oriented indirect care inte rvention. Including a nursing
diagnosis regarding falls would also be an example of an indirect care
intervention but it is not as activel y affecting the clients safety.
Checking a restrained client is a direct care intervention because it
involves actual client contact, while performing hand hygiene is
directed more towards infection control than safet y.
, DIF: C dm 287 OBJ: Anal ysis TOP: Nursing Process:
Implementation MSC: NC LEX test plan designation: Safe,
Effective Care Environment
2. Which of the follo wing interventions best reflects the nurses
understanding of direct care interventions regarding a cognitivel y
impaired clients need for social interaction?
A. Arranging for the client to attend a sing along in the dayroom
B. Helping the client place a long dist ance telephone call to his
daughter
C. Turning the clients television on when his or her favorite program is
playing
D. Talking about the clients favorite sports team while redressing his
or her wound
ANS: D
Direct care interventions are treatments performed t hrough interactions
with clients. Actively engaging in a conversation with the client is the
best direct care intervention and so demonstrates the best
understanding of the concept. Facilitating interaction does not have as
much impact as being activel y in volved. Turning on the TV is an
example of an indirect care intervention.
DIF: C dm 285 OBJ: Anal ysis TOP: Nursing Process:
Implementation MSC: NC LEX test plan designation: Safe,
Effective Care Environment
3. The primary reason for the establishment of st anding orders is to:
, A. Provide appropriate nursing autonom y in settings where client needs
can change rapidl y
B. Facilitate adequate care when direct contact with a primary health
care provider is not immediatel y possible
C. Allow nurses to provide certain routi ne therapies without first
notifying the primary health care provider
D. Afford the client interventions that reflect the appropriate standard
of care in the absence of a primary health care provider
ANS: A
Licensed prescribing physicians or health care pro viders in charge of
care at the time of implementation approve and sign standing orders.
These orders are common in critical care settings and other specialized
practice settings where clients needs change rapidl y and require
immediate attention, thus prov iding for nursing autonom y to assess and
implement appropriate care.
DIF: C dm 281 OBJ: Anal ysis TOP: Nursing Process:
Implementation MSC: NC LEX test plan designation: Safe,
Effective Care Environment
4. Which of the following statements best reflects the nurses understanding
of the function of client reassessment?
A. The clients blood pressure is lower this morning than it was
yesterday morning.
B. 30 minutes after receiving his pain medication, the client evaluated
his pain at 3 out of 10.
C. Turning the client every 2 hours has helped in the healing of the
pressure ulcer on his coccyx.
C ARE
Fundamentals of Nursing 10th Ed ition; Potter Perry
MULTIPLE CHOICE
1. Which of the following interventions is the bes t example of an indirect
intervention directed towards client safety?
A. Checking on a restrained client every 15 minutes
B. Performing hand hygiene between client contacts
C. Including the diagnosis at risk for injury related to falls to a clients
care plan
D. Turning on a night light to illuminate the path to the bathroom
ANS: D
Indirect care interventions are treatments performed away from the
client but on behalf of the client or group of clients. For example,
indirect care measures include actions for managing t he clients
environment (e.g., safet y and infection control), documentation, and
interdisciplinary collaboration. Directl y impacting the light level in a
clients room to minimize the risk for falls is the best example of a
safet y-oriented indirect care inte rvention. Including a nursing
diagnosis regarding falls would also be an example of an indirect care
intervention but it is not as activel y affecting the clients safety.
Checking a restrained client is a direct care intervention because it
involves actual client contact, while performing hand hygiene is
directed more towards infection control than safet y.
, DIF: C dm 287 OBJ: Anal ysis TOP: Nursing Process:
Implementation MSC: NC LEX test plan designation: Safe,
Effective Care Environment
2. Which of the follo wing interventions best reflects the nurses
understanding of direct care interventions regarding a cognitivel y
impaired clients need for social interaction?
A. Arranging for the client to attend a sing along in the dayroom
B. Helping the client place a long dist ance telephone call to his
daughter
C. Turning the clients television on when his or her favorite program is
playing
D. Talking about the clients favorite sports team while redressing his
or her wound
ANS: D
Direct care interventions are treatments performed t hrough interactions
with clients. Actively engaging in a conversation with the client is the
best direct care intervention and so demonstrates the best
understanding of the concept. Facilitating interaction does not have as
much impact as being activel y in volved. Turning on the TV is an
example of an indirect care intervention.
DIF: C dm 285 OBJ: Anal ysis TOP: Nursing Process:
Implementation MSC: NC LEX test plan designation: Safe,
Effective Care Environment
3. The primary reason for the establishment of st anding orders is to:
, A. Provide appropriate nursing autonom y in settings where client needs
can change rapidl y
B. Facilitate adequate care when direct contact with a primary health
care provider is not immediatel y possible
C. Allow nurses to provide certain routi ne therapies without first
notifying the primary health care provider
D. Afford the client interventions that reflect the appropriate standard
of care in the absence of a primary health care provider
ANS: A
Licensed prescribing physicians or health care pro viders in charge of
care at the time of implementation approve and sign standing orders.
These orders are common in critical care settings and other specialized
practice settings where clients needs change rapidl y and require
immediate attention, thus prov iding for nursing autonom y to assess and
implement appropriate care.
DIF: C dm 281 OBJ: Anal ysis TOP: Nursing Process:
Implementation MSC: NC LEX test plan designation: Safe,
Effective Care Environment
4. Which of the following statements best reflects the nurses understanding
of the function of client reassessment?
A. The clients blood pressure is lower this morning than it was
yesterday morning.
B. 30 minutes after receiving his pain medication, the client evaluated
his pain at 3 out of 10.
C. Turning the client every 2 hours has helped in the healing of the
pressure ulcer on his coccyx.
