Chapter 6 Nursing Process: Planning Interventions

Chapter 6  Nursing Process: Planning Interventions

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. Which of the following nursing interventions is an indirect-care intervention?
a)
Emotional support
b)
Teaching
c)
Consulting
d)
Physical care

ANS: C
An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include consulting with other healthcare team members, making referrals, advocating, and managing the environment. Direct-care interventions include emotional support, patient teaching, and physical care.

Difficulty: Easy
Nursing Process: Implementation
Client Need: Safe and Effective Nursing Care
Cognitive Level: Comprehension

PTS: 1

2. A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write?
a)
Collaborative
b)
Interdependent
c)
Dependent
d)
Independent

ANS: D
Writing an order to reposition the client in a comfortable position is an example of an independent nursing intervention, one that does not require a physician’s order. The nurse is licensed to prescribe, perform, or delegate the intervention based on her knowledge and skills. A collaborative or interdependent intervention is one that is carried out in collaboration with other health team members, such as providing the client with a sodium-restricted diet. A dependent intervention is prescribed by a physician or advanced practice nurse, for example, “Administer oxygen at 2 L/min via nasal cannula.”

Difficulty: Moderate
Nursing Process: Implementation
Client Need: PHY
Cognitive Level: Application

PTS: 1

3. The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not at present have any respiratory problems. The nurse’s teaching plan includes coughing and deep-breathing exercises. Which type of nursing intervention is the nurse performing?
a)
Health promotion
b)
Treatment
c)
Prevention
d)
Assessment

ANS: C
The nurse is teaching the client coughing and deep-breathing exercises, which help prevent postoperative pneumonia. Therefore, the nurse is employing a prevention intervention. Prevention interventions are used to help prevent complications, such as postoperative pneumonia. Health promotion interventions promote a client’s efforts to achieve a higher level of wellness. Treatment interventions treat disorders, relieve symptoms, and carry out medical orders. Assessment interventions detect changes in the client’s condition and detect potential problems.

Difficulty: Moderate
Nursing Process: Interventions
Client Need: PHSI
Cognitive Level: Application

PTS: 1

4. A 55-year-old patient returned to the medical-surgical unit after undergoing a right hemicolectomy (abdominal surgery) for colon cancer. Which of the following is an appropriate, correctly written nursing order for this patient?
a)
7/12/15 Encourage use of the incentive spirometer every hour while the client is awake—D. Goodman, RN
b)
By 7/12/15, uses incentive spirometer 10 times every hour while awake to 1,000 mL
c)
Incentive spirometer hourly while awake
d)
Offer incentive spirometer to the client—J. Smith, RN

ANS: A
The option beginning with a date and ending with the RN’s signature contains necessary information. It contains the date the order was written along with specific instruction for the nurse that is written in terms of nursing behavior. “Uses incentive spirometer 10 times . . .” is an example of an expected outcome. “Incentive spirometer hourly . . .” is an example of a medical order. In this case, the date and nurse’s signature are missing. “Offer incentive spirometer . . .” does not provide the nurse with enough detailed instruction. Therefore, it is a poorly written nursing order.

Difficulty: Moderate
Nursing Process: Planning
Client Need: PHSI
Cognitive Level: Application

PTS: 1

5. A client newly diagnosed with diabetes is admitted to the hospital because her diabetes is out of control. Which of the following is an appropriate direct-care intervention for this client during her stay?
a)
Consulting the diabetic nurse educator for help with a teaching plan
b)
Making arrangements for the client to join a diabetic support group
c)
Demonstrating blood glucose monitoring and insulin administration to the client
d)
Consulting with the dietician about the client’s dietary concerns

ANS: C
Demonstrating blood glucose monitoring and insulin administration is an appropriate direct-care intervention for this client. Direct-care interventions are performed through intervention with the client and include interventions such as physical care, emotional support, and client teaching. Indirect-care activities include consulting the diabetic nurse educator, making arrangements for the client to join a diabetic support group, and consulting with the dietitian about the client’s dietary concerns. Indirect-care activities are performed away from the client but on behalf of the client.

Difficulty: Moderate
Nursing Process: Interventions
Client Need: Physiological Integrity
Cognitive Level: Application

PTS: 1