C HAPTER 19: I MPLEMENTING N URSING
C ARE
Potter: Fundamentals of Nursing, 11th Edition
MULTIPLE CHOICE
1. A novice nurse is working in a unit that uses interdisciplinary
collaboration. Which action will the nurse take to help assure
effectiveness as a team member?
a. Act as a leader of the health care team.
b. Develop good communication skills.
c. Work solel y with experienced nurses.
d. Avoid conflict.
ANS: B
Good communication between other health care providers builds trust
and is related to the acceptance of your role in the health care team. As
a beginning nurse, you will not be considered a leader of the health
care team, but your input as an interdisciplinary team member is
critical. Interdisciplinary involves other health care providers, not just
nurses. Organizational culture includes leadership, communication
processes, shared beliefs about the quality of clinical guidelines, and
conflict resolution.
, DIF: Appl y (application) OBJ: Discuss how to effectivel y
communicate nursing interventions. TOP: Implementation
MSC: Management of Care
2. Which action should the nurse take first during the initial phase of
implementation?
a. Determine patient outcomes and goals.
b. Prioritize patient’s nursing diagnoses.
c. Evaluate interventions.
d. Reassess the patient.
ANS: D
Assessment is a continuous process that occurs each time the nurse
interacts with a patient. During the initial phase of implementation,
reassess the patient. Determining the patient’s goals and prioritizing
diagnoses take place in the planning phase before c hoosing
interventions. Evaluation is the last step of the nursing process.
DIF: Understand (comprehension) OBJ: Explain how nursing
interventions are related to nursing’s scope of practice.
TOP: Implementation MSC: Management of Care
3. Vital signs for a patient reveal a blood pressure of 187/100. Orders state
to notify the health care provider for diastolic blood pressure greater than
90. What is the nurse’s first action?
a. Follow the clinical protocol for a stroke.
b. Review the most recent lab results for th e patient’s potassium level.
c. Assess the patient for other symptoms or problems, and then notify
the health care provider.
, d. Administer an antihypertensive medication from the stock suppl y,
and then notify the health care provider.
ANS: C
Communication to other health care professionals must be timel y,
accurate, and relevant to a patient’s clinical situation. The best answer
is to reassess the patient for other symptoms or problems, and then
notify the health care provider according to the orders. Reviewing the
potassium level does not address the problem of high blood pressure.
The nurse does not follow the protocol since the order says to notify
the health care provider. The orders read to notify the health care
provider, not administer medications.
DIF: Appl y (application) OBJ: Discuss how to effectivel y
communicate nursing interventions. TOP: Implementation
MSC: Management of Care
4. Which initial intervention is most appropriate for a patient who has a new
onset of chest pain?
a. Reassess the patient.
b. Notify the health care provider.
c. Administer a prn medication for pain.
d. Call radiology for a portable chest x -ray.
ANS: A
Preparation for implementation ensures efficient, safe, and effective
nursing care; the first activit y is reassessment. The cause of the
patient’s chest pain is unknown, so the patient needs to be reassessed
C ARE
Potter: Fundamentals of Nursing, 11th Edition
MULTIPLE CHOICE
1. A novice nurse is working in a unit that uses interdisciplinary
collaboration. Which action will the nurse take to help assure
effectiveness as a team member?
a. Act as a leader of the health care team.
b. Develop good communication skills.
c. Work solel y with experienced nurses.
d. Avoid conflict.
ANS: B
Good communication between other health care providers builds trust
and is related to the acceptance of your role in the health care team. As
a beginning nurse, you will not be considered a leader of the health
care team, but your input as an interdisciplinary team member is
critical. Interdisciplinary involves other health care providers, not just
nurses. Organizational culture includes leadership, communication
processes, shared beliefs about the quality of clinical guidelines, and
conflict resolution.
, DIF: Appl y (application) OBJ: Discuss how to effectivel y
communicate nursing interventions. TOP: Implementation
MSC: Management of Care
2. Which action should the nurse take first during the initial phase of
implementation?
a. Determine patient outcomes and goals.
b. Prioritize patient’s nursing diagnoses.
c. Evaluate interventions.
d. Reassess the patient.
ANS: D
Assessment is a continuous process that occurs each time the nurse
interacts with a patient. During the initial phase of implementation,
reassess the patient. Determining the patient’s goals and prioritizing
diagnoses take place in the planning phase before c hoosing
interventions. Evaluation is the last step of the nursing process.
DIF: Understand (comprehension) OBJ: Explain how nursing
interventions are related to nursing’s scope of practice.
TOP: Implementation MSC: Management of Care
3. Vital signs for a patient reveal a blood pressure of 187/100. Orders state
to notify the health care provider for diastolic blood pressure greater than
90. What is the nurse’s first action?
a. Follow the clinical protocol for a stroke.
b. Review the most recent lab results for th e patient’s potassium level.
c. Assess the patient for other symptoms or problems, and then notify
the health care provider.
, d. Administer an antihypertensive medication from the stock suppl y,
and then notify the health care provider.
ANS: C
Communication to other health care professionals must be timel y,
accurate, and relevant to a patient’s clinical situation. The best answer
is to reassess the patient for other symptoms or problems, and then
notify the health care provider according to the orders. Reviewing the
potassium level does not address the problem of high blood pressure.
The nurse does not follow the protocol since the order says to notify
the health care provider. The orders read to notify the health care
provider, not administer medications.
DIF: Appl y (application) OBJ: Discuss how to effectivel y
communicate nursing interventions. TOP: Implementation
MSC: Management of Care
4. Which initial intervention is most appropriate for a patient who has a new
onset of chest pain?
a. Reassess the patient.
b. Notify the health care provider.
c. Administer a prn medication for pain.
d. Call radiology for a portable chest x -ray.
ANS: A
Preparation for implementation ensures efficient, safe, and effective
nursing care; the first activit y is reassessment. The cause of the
patient’s chest pain is unknown, so the patient needs to be reassessed
