Chapter 7 Nursing Process: Implementation & Evaluation

Chapter 7  Nursing Process: Implementation & Evaluation

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, and she cannot find it in the hospital formulary or other references. How should she proceed?
a)
Administer the medication as ordered.
b)
Hold the medication and notify the prescriber.
c)
Consult with a pharmacist before administering it.
d)
Ask the patient’s RN for information about the medication.

ANS: C
The nurse must recognize when she does not have the knowledge or skill needed to implement an order. Because the nurse is unfamiliar with the medication, that does not mean she should hold it and delay patient treatment. It is wisest to first consult with the pharmacist for information before administering the medication to ensure safe practice. Administering the medication as ordered, without knowing its expected actions and side effects, at the least prevents adequate reassessment; at the most, it is dangerous. Holding the medication and notifying the prescriber prevents the client from receiving timely treatment—many drugs are less effective if a consistent schedule is not maintained. Asking another nurse to administer the medication is also unsafe because it cannot be assumed that the other nurse has the correct knowledge. In addition, the nurse caring for the client must assess for adverse reactions to the medication.

Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Analysis

PTS: 1

2. Which task can be delegated to nursing assistive personnel (NAP)?
a)
Turn and reposition the patient every 2 hours.
b)
Assess the patient’s skin condition.
c)
Change pressure ulcer dressings every shift.
d)
Apply hydrocolloid dressing to the pressure ulcer.

ANS: A
The nurse can delegate turning the client every 2 hours to the nursing assistive personnel. Assessing the client’s skin condition, changing pressure ulcer dressings, and applying a hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge and judgment.

Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Application

PTS: 1

3. A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed?
a)
Ask a colleague for help, because the nurse cannot safely perform the procedure alone.
b)
Gather the equipment and prepare it before informing the client about the procedure.
c)
Obtain an order to restrain the client before inserting the urinary catheter.
d)
Inform the primary provider that the nurse cannot perform the procedure because the client is confused.

ANS: A
Before the nurse begins a procedure, she should review the care plan and look at the orders critically. Because this client is confused, she should ask a colleague to assist with the procedure to prevent undue stress for the client and nurse. The client should be informed about the procedure before the nurse gathers the equipment. Gathering the equipment and bringing it into the room before explaining the procedure might cause the client anxiety. Restraining the client should be done only as a last resort and to prevent client injury. Informing the primary provider that the procedure cannot be performed because the client is confused is inappropriate because the procedure can very likely be done with assistance.

Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Analysis

PTS: 1

4. Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill?
a)
Psychomotor
b)
Interpersonal
c)
Cognitive
d)
Critical thinking

ANS: B
Reassuring the client is an interpersonal skill. Inserting the nasogastric tube requires psychomotor skills. Checking catheter placement after insertion requires cognitive and psychomotor skills. Assessing whether there is an indication for the nasogastric tube requires critical thinking skills.

Difficulty: Moderate
Nursing Process: Implementation
Client Need: PHI
Cognitive Level: Comprehension

PTS: 1

5. The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan?
a)
Teaching the client that he must lose weight to control his blood sugar
b)
Informing the client that he must exercise at least three times per week
c)
Explaining to the client that he must come to the diabetic clinic weekly
d)
Determining the client’s main concerns about his diabetes

ANS: D
Determining the client’s main concerns promotes cooperation with the treatment regimen. For example, if the client is concerned about paying for diabetic monitoring equipment, he may disregard any teaching about the procedure. Although it is often important for a diabetic client to exercise and lose weight to control blood sugar levels, the client must want to do both. He will not exercise or lose weight simply because he is told to do so. The nurse must assess the client’s support systems and resources, not merely tell him he must come to the diabetic clinic weekly. Some clients do not have access to transportation and, therefore, could not come to the clinic without social service intervention. Remember that knowledge does not necessarily change behavior.

Difficulty: Moderate
Nursing Process: Planning Interventions
Client Need: PHSI
Cognitive Level: Analysis

PTS: 1