Chapter 6. Nursing Process: Planning Interventions

Chapter 6. Nursing Process: Planning Interventions

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

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

 

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 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

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