Chapter 6. Nursing Process: Planning Interventions

Chapter 6. Nursing Process: Planning Interventions

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. Which of the following nursing interventions is an indirect-care intervention?

a)	Emotional support
b)	Teaching
c)	Consulting
d)	Physical care

 

 

ANS:  C

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, advocating, and managing the environment. Direct-care interventions include emotional support, patient teaching, and physical care.

 

Difficulty: Easy

Nursing Process: Implementation

Client Need: Safe and Effective Nursing Care

Cognitive Level: Comprehension

 

PTS:   1

 

2. 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?

a)	Collaborative
b)	Interdependent
c)	Dependent
d)	Independent

 

 

ANS:  D

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.”

 

Difficulty: Moderate

Nursing Process: Implementation

Client Need: PHY

Cognitive Level: Application

 

PTS:   1

 

3. The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not at present have any respiratory problems. The nurse’s teaching plan includes coughing and deep-breathing exercises. Which type of nursing intervention is the nurse performing?

a)	Health promotion
b)	Treatment
c)	Prevention
d)	Assessment

 

 

ANS:  C

The nurse is teaching the client coughing and deep-breathing exercises, which help prevent postoperative pneumonia. Therefore, the nurse is employing 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.

 

Difficulty: Moderate

Nursing Process: Interventions

Client Need: PHSI

Cognitive Level: Application

 

PTS:   1

 

4. A 55-year-old patient returned to the medical-surgical unit after undergoing a right hemicolectomy (abdominal surgery) for colon cancer. Which of the following is an appropriate, correctly written nursing order for this patient?

a)	7/12/15 Encourage use of the incentive spirometer every hour while the client is awake—D. Goodman, RN
b)	By 7/12/15, uses incentive spirometer 10 times every hour while awake to 1,000 mL
c)	Incentive spirometer hourly while awake
d)	Offer incentive spirometer to the client—J. Smith, RN

 

 

ANS:  A

The option beginning with a date and ending with the RN’s signature contains necessary information. It contains the date the order was written along with specific instruction for the nurse that is written in terms of nursing behavior. “Uses incentive spirometer 10 times . . .” is an example of an expected outcome. “Incentive spirometer hourly . . .” is an example of a medical order. In this case, the date and nurse’s signature are missing. “Offer incentive spirometer . . .” does not provide the nurse with enough detailed instruction. Therefore, it is a poorly written nursing order.

 

Difficulty: Moderate

Nursing Process: Planning

Client Need: PHSI

Cognitive Level: Application

 

PTS:   1