When initiating the implementation phase of the nursing process, the nurse performs which of the following phases first?
1. Carrying out nursing interventions
2. Determining the need for assistance
3. Reassessing the client
4. Documenting interventions
Answer 3
Rationale: The first step of implementing is reassessing the client to determine that the activity is still indicated and safe. The next action would be to
determine if assistance is required, and then implement the intervention (delegating if appropriate), and last document the intervention.
Under what circumstances is it considered acceptable practice for the nurse to document a nursing activity before it is carried out?
1. When the activity is routine (e.g., raising the bed rails)
2. When the activity occurs at regular intervals (e.g., turning the client in bed)
3. When the activity is to
be carried out immediately (e.g., a stat medication)
4. It is never acceptable
Answer 4
Rationale: It is never acceptable practice for the nurse to document a nursing activity before it is carried out. This would be very unsafe because many things can cause an activity to be postponed or canceled and prior charting would be inaccurate, misleading, and potentially dangerous. In a few situations, it may be permissible to chart frequent or routine activities some time following the activities such as at the end of a shift or after a particular interval (e.g., every 4 hours) rather than immediately following the activity.
The primary purpose of the evaluating phase of the care planning process is to determine whether
1. Desired outcomes have been met.
2. Nursing activities were carried out.
3. Nursing activities were effective.
4. Client's condition has changed.
Answer 1
Rationale: The desired outcomes and indicator statements reflect the parameters by which success will be measured. The goal can be met even if the nursing activities were not carried out or were ineffective. Although the desired outcome, by definition, indicates a change in the client's condition (behavior, knowledge, or attitude), only specific changes (desired outcomes) reflect the success of the care plan.
The client has a high-priority nursing diagnosis of Risk for Impaired Skin Integrity related to the need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and finds the skin integrity is not impaired. When the care plan is reviewed, the nurse should perform which of the following?
1. Delete the diagnosis since the problem has not occurred.
2. Keep the diagnosis since the risk factors are still present.
3. Modify the nursing diagnosis to Impaired
Mobility.
4. Demote the nursing diagnosis to a lower priority.
Answer 2
Rationale: There is no reason to delete or modify the nursing diagnosis or demote its priority because the risk factors that prompted it are still present.
If the nurse planned to evaluate the length of time clients must wait for a nurse to respond to a client need reported over the intercom system on each shift which process does this reflect?
1. Structure evaluation
2. Process evaluation
3. Outcome evaluation
4. Audit
Answer 2
Rationale: Because this assessment focuses on how care is provided, it is a process evaluation. A structure evaluation would focus on the setting (e.g., how well equipment functions), and outcome evaluations focus on changes in client status (e.g., whether reported satisfaction levels vary with type of person who answers the call light). An
audit would be a chart or document review.
Which of the following is true regarding the relationship of implementing to the other phases of the nursing process?
1. The findings from the assessing phase are reconfirmed in the implementing phase.
2. After implementing, the nurse moves to the diagnosing phase.
3. The nurse's need for involvement of other health care team members in implementing occurs during the planning phase.
4. Once all
interventions have been completed, evaluating can begin.
Answer 1
Rationale: During implementing, the nurse also assesses and compares with the initial assessment. Evaluating follows implementing (option 2), mobilization of other health care teams is a part of implementing (option 3), and evaluating occurs during or immediately after each intervention, not waiting for all interventions to be completed (option 4).
The care plan calls for administration of a medication plus client education on diet and exercise for high blood pressure. The nurse finds the blood pressure extremely elevated. The client is very distressed with this finding. Which nursing skill of implementing would be needed most?
1. Cognitive
2. Intellectual
3. Interpersonal
4. Psychomotor
Answer 3
Rationale: This client needs psychosocial support rather than skills related to knowledge
(options 1 and 2) or hands on activity (option 4).
Which of the following demonstrates appropriate use of guidelines in implementing nursing interventions? Select all that apply.
1. No interventions should be carried out without the nurse having clear rationales.
2. Always follow the primary care provider's orders exactly, without variation.
3. Encourage all clients to be as dependent as desired and allow the nurse to perform care for
them.
4. When possible, give the client options in how interventions will be implemented.
5. Each intervention should be accompanied by client teaching.
Answer 1, 4, and 5
Rationale: Nurses should always have clear rationales for their actions, clients should be given options whenever possible, and client teaching is a constant, integral part of implementing. Primary care provider orders must be critically evaluated and modified to meet
individual client needs (option 2). Clients may have nurses provide needed care but should take care of themselves whenever possible since dependency has its own complications (option 3).
Which of the following represents application of the components of evaluating?
1. Goal achievement must be written as either completely met or unmet.
2. Data related to expected outcomes must be collected.
3. If the outcome was achieved, conclude that the
plan was effective.
4. After determining that the outcome was not met, start over with a new nursing care plan.
Answer 2
Rationale: Evaluating requires that client behaving be compared to expected outcomes. Goals may be partially met in addition to completely met or unmet (option 1). An outcome may be achieved but not be a direct result of the plan or interventions (option 3). A care plan should be continued, modified, or terminated based on
achievement of outcomes (option 4).
An element of quality improvement, rather than quality assurance, is which of the following?
1. Focus is on individual outcomes
2. Evaluates organizational structures
3. Aims to confirm that quality exists
4. Plans corrective actions for problems
Answer 4
Rationale: Quality improvement plans corrective actions for problems. QI focuses on process rather than
outcomes (option 1), client care rather than confirmation of quality (option 3).