Chapter 19.docx - Chapter 19 Implementing Nursing Care MULTIPLE CHOICE 1 In which step of the nursing process does the nurse provide nursing care

Chapter 19.docx - Chapter 19 Implementing Nursing Care...

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Chapter 19: Implementing Nursing Care MULTIPLE CHOICE 1. In which step of the nursing process does the nurse provide nursing care interventions to patients? 1. Assessment 2. Planning 3. Implementation 4. Evaluation ANS: C In the five-step nursing process, the implementation phase involves providing direct and indirect nursing care interventions to patients. The nurse gathers data during the assessment phase and mutually sets goals and prioritizes care during the planning phase. During the evaluation phase, the nurse determines the effectiveness of interventions. DIF: Remember REF: 257 OBJ: Explain the relationship of implementation to the nursing diagnostic process. TOP: Implementation MSC: Safe and Effective Care Environment 2. The nurse defines a clinical guideline or protocol as a 1. Guideline to follow that replaces the nursing care plan. 2. Document that assists the clinician in making decisions and choosing interventions for specific health care problems or conditions. 3. Hospital policy designating each nurses duty according to standards of care and a code of ethics. 4. Prescriptive order form that individualizes the plan of care. ANS: B A clinical guideline or protocol is a document that assists the clinician in making decisions and choosing interventions for specific health care problems or conditions. The protocol does not replace the nursing care plan. Evidence-based guidelines from protocols can be incorporated into an individualized plan of care. A clinical guideline is not the same as a hospital policy. Standing orders contain orders for the care of a specific group of patients. A protocol is not a prescriptive order form like a standing order. DIF: Remember REF: 259 OBJ: Describe the association between critical thinking and selecting nursing interventions. TOP: Implementation MSC: Safe and Effective Care Environment 3. The standing orders for a patient include acetaminophen (Tylenol) 650 mg every 4 hours prn for headache. After assessing the patient, identifying the need for headache relief, and determining that the patient has not had Tylenol in the past 4 hours, the nurse
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1. Notifies the health care provider to obtain a verbal order. 2. Directs the nursing assistant to give the Tylenol. 3. Administers the Tylenol. 4. Performs a pain assessment only after administering the Tylenol. ANS: C A standing order is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. Notifying the health care provider is not necessary if a standing order exists. The nursing assistant is not licensed to administer medications; therefore, medication administration should not be delegated to this person. A pain assessment should be performed before and after pain medication administration to assess the need for and effectiveness of the medication.
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  • Fall '19
  • Ruth Bundy

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