Chapter 6 Nursing Process: Planning Interventions

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Chapter 6  Nursing Process: Planning Interventions

 

 

Complete Chapter Questions And Answers
 

Sample Questions

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. Which of the following nursing interventions is an indirect-care intervention?
1)
Emotional support

2)
Teaching
3) Consulting 4)
Physical care

TTB06-1

ANS: 3
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, advocacy, and managing the environment. Direct-care interventions include emotional support, patient teaching, and physical care.

PTS: 1 DIF: Easy REF: pp. 103
KEY: Nursing process: Implementation | Client need: SASE | Cognitive level: Recall

____ 2. Which nursing intervention is considered an independent intervention? 1)
Administering 1 L of dextrose 5% in normal saline solution at 100 mL/hour
2)

Encouraging the postoperative client to perform coughing and deep breathing exercises 3)
Explaining his diet to the client; then communicating the teaching with the dietitian
4)

Administering morphine sulfate 2 mg IV to the client with postoperative pain

ANS: 2
Encouraging the postoperative client to perform coughing and deep breathing exercises is an independent nursing intervention. An independent intervention is one that nurses are licensed to prescribe, perform, or delegate based on their skills and knowledge. Administering IV fluid or morphine sulfate are dependent interventions; they require an order from a physician or advanced practice nurse but are carried out by the nurse. Explaining to the client how sodium intake affects his heart failure and then

Treas Fundamentals TTB06-2 Test Bank, Chapter 06

communicating the teaching with the dietitian is an interdependent intervention, one that is carried out in collaboration with other healthcare team members.

PTS: 1 DIF: Moderate REF: p. 103
KEY: Nursing process: Interventions | Client need: SASE | Cognitive level: Application

____ 3. 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?
1)
Collaborative
2)
Interdependent
3)
Dependent
4)
Independent

ANS: 4
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.

PTS: 1 DIF: Moderate REF: p. 103
KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive level: Application

____ 4. The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not currently have any respiratory problems. The nurse’s teaching plan includes coughing and deep breathing exercises. Which type of nursing intervention is the nurse performing?
1)
Health promotion
2)
Treatment
3)
Prevention

Treas Fundamentals TTB06-3 Test Bank, Chapter 06

4) Assessment

ANS: 3
The nurse is teaching the client coughing and deep breathing exercises, which help prevent postoperative pneumonia. Therefore, the nurse is utilizing 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.

PTS: 1 DIF: Moderate REF: p. 106
KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive level: Application

____ 5. Which standardized intervention vocabulary was designed specifically for community health nurses?
1)
Omaha System

2)
Clinical Care Classification
3)
Nursing Interventions Classification
4)
International Classification for Nursing Practice

ANS: 1
The Omaha System was designed specifically for community health nurses to use in caring for individuals, families, community groups, or entire communities. The Clinical Care Classification was developed for home healthcare. The Nursing Interventions Classification system is applicable in all settings, including home health and community nursing. The International Classification for Nursing Practice system was designed to describe nursing practice of individuals, families, and communities worldwide.

PTS: 1 DIF: Easy REF: p. 110
KEY: Nursing process: Planning | Client need: SASE | Cognitive level: Recall

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