Exam (elaborations)
Chapter 09 Implementation and Evaluation
- Course
- Fundamentals of Nursing
- Institution
- Oxford College Of Emory University
Chapter 09 Implementation and Evaluation
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DAWITChapter 09: Implementation and Evaluation
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 3RD Edition
MULTIPLE CHOICE
1. The nurse identifies which action as a direct-care intervention?
a. Administration of an injection
b. Making the change-of-shift report
c. Collaborating with members of the health care team
d. Ensuring availability of needed equipment
ANS: A
Direct care refers to interventions that are carried out by having personal contact with patients.
For example, direct-care interventions include cleaning an incision, administering an
injection, ambulating with a patient, and completing patient teaching at the bedside. Indirect
care includes nursing interventions that are performed to benefit patients but do not involve
face-to-face contact with patients. Examples of indirect care include making the
change-of-shift report, communicating and collaborating with members of the
interdisciplinary health care team, and ensuring availability of needed equipment.
DIF: Applying OBJ: 9.2 TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Caregiving
2. The nurse manager is creating the patient assignment for today. She has five registered nurses
(RNs), two licensed practical NurR
nU seSs I
(LNPGs),Band O
NT five nurse technicians (NAs) scheduled.
When making the assignment, the nurse manager needs to remember which fact of
delegation?
a. RNs are responsible for all care delegated to unlicensed nursing personnel.
b. Delegation is considered direct intervention for patient care.
c. LPNs operate independently and may delegate patient care.
d. Nursing practice is clearly delineated and is standard across the country.
ANS: A
Delegation is the transfer of responsibility for performing a task to another person while the
nurse who delegated the task remains accountable. Delegation is an indirect intervention
based on assessment findings and established care priorities. Nurses must be familiar with the
nurse practice act in their practice jurisdiction to ensure legal delegation. The nursing process
cannot be delegated. In most jurisdictions, LPNs function in a dependent role and may not
delegate.
DIF: Applying OBJ: 9.2 TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and Infection
Control NOT: Concepts: Care Coordination
3. The nurse is preparing to administer medications to a patient. When the patient reports new
shortness of breath, which action by the nurse is most appropriate?
a. Provide the patient with oxygen since it does not require a provider order.
b. Complete at least three checks to ensure that the proper medication is given.
, DAWIT
c. Check the provider orders for all forms of prescription medications.
d. Document that the 6 rights of medication administration were followed.
ANS: C
All forms of prescription medication (i.e., oral, topical, and parenteral) require an order before
administration, as does providing oxygen to a patient. The nurse would check for an as needed
order for oxygen. Nurses must complete three checks, follow the six rights of medication
administration, and document appropriately when administering medications, but those
actions are not the priority due to the change in the patient‘s condition. The nurse must first
address the patient‘s shortness of breath.
DIF: Applying OBJ: 9.2 TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Care Coordination
4. After completing a patient‘s initial assessment and developing a plan of care, what action by
the nurse is most appropriate?
a. Continuously reassess the patient.
b. Restrict changes to the care interventions.
c. Reassess the patient at the start of each shift.
d. Evaluate patient goal attainment at intervals.
ANS: A
After the nurse completes a patient‘s initial assessment and develops a plan of care, continual
reassessment of the patient detects noticeable changes in the patient‘s condition, requiring
adjustments to interventions outlined in the plan of care. The need for continual patient
reassessment underscores the dynamic nature of the nursing process and is crucial to
providing essential care. NURSINGTB.COM
DIF: Evaluating OBJ: 9.8 TOP: Evaluation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Care Coordination
5. The male nurse is caring for a female patient who needs a complete bed bath. The patient
requests that a female nurse bathe her. The male nurse recognizes this request as an example
of what type of diversity?
a. Gender diversity involving generational norms.
b. Life span diversity
c. Disability diversity
d. Morphology diversity
ANS: A
The nurse must perform the procedures competently and safely, taking into consideration any
special needs of the patient. Gender diversity occurs with the identification of gender roles
that may affect care delivery. Some patients may prefer care from nurses of the same gender.
This preference may stem from generational norms, personal comfort, or cultural
considerations. With life span diversity, interventions must always be age or developmental
level appropriate. Disability diversity requires that interventions be individualized for each
patient and adapted for any limitations. The nurse must ensure safe practice in relation to
patient body size (morphology diversity) and should seek additional support or equipment
when necessary.
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