14 Nursing Implementation NCLEX Practice Questions

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• A school nurse notices that a female adolescent

student is losing weight and decides to perform a focused assessment of her nutritional status to determine if she has an eating disorder. How should the nurse proceed?

• Perform the focused assessment. This is an

independent nurse-initiated intervention.

• Request an order from Jill's physician since this is a

physician-initiated intervention.

• Request an order from Jill's physician since this is a

collaborative intervention.

• Request an order from the nutritionist since this is a

collaborative intervention.

• Perform the focused assessment. This is an independent nurse-initiated

intervention.

• A nurse is using the implementation step of the nursing

process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step?Select all that apply.

• The nurse carefully removes the bandages from a burn

victim's arm.

• The nurse assesses a patient to check nutritional status.
• The nurse formulates a nursing diagnosis for a patient

with epilepsy.

• The nurse turns a patient in bed every 2 hours to

prevent pressure ulcers.

• The nurse checks a patient's insurance coverage at the

initial interview.

• The nurse checks for community resources for a patient

with dementia.

• The nurse carefully removes the bandages from a burn victim's arm.
• The nurse turns a patient in bed every 2 hours to prevent pressure ulcers.
• The nurse checks for community resources for a patient with dementia.
• Nurses use the Nursing Interventions Classification

Taxonomy structure as a resource when planning nursing care for patients. What information would be found in this structure?

• Case studies illustrating a complete set of activities that

a nurse performs to carry out nursing interventions

• Nursing interventions, each with a label, a definition,

and a set of activities that a nurse performs to carry it out, with a short list of background readings

• A complete list of nursing diagnoses, outcomes, and

related nursing activities for each nursing intervention

• A complete list of reimbursable charges for each

nursing intervention

• Nursing interventions, each with a label, a definition, and a set of activities that a

nurse performs to carry it out, with a short list of background readings

• A new RN is being oriented to a nursing unit that is

currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment.What is the best response of the RN?

• Allow the UAPs to do the admission assessment and

report the findings to the RN.

• Do his or her own admission assessments but don't

interfere with the practice if other professional RNs seem comfortable with the practice.

• Tell the charge nurse that he or she chooses not to

delegate the admission assessment until further clarification is received from administration.

• Contact his or her labor representative and complain

about this practice.

• Tell the charge nurse that he or she chooses not to delegate the admission

assessment until further clarification is received from administration.

• A nurse performs nurse-initiated nursing actions when

caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply.

• A nurse administers 500 mg of ciprofloxacin to a

patient with pneumonia.

• A nurse consults with a psychiatrist for a patient who

abuses pain killers.

• A nurse checks the skin of bedridden patients for skin

breakdown.

• A nurse orders a kosher meal for an orthodox Jewish

patient.

• A nurse records the I&O of a patient as prescribed by

his physician.

• A nurse prepares a patient for minor surgery according

to facility protocol.

• A nurse checks the skin of bedridden patients for skin breakdown.
• A nurse orders a kosher meal for an orthodox Jewish patient.
• A nurse prepares a patient for minor surgery according to facility protocol.
• A nurse is about to perform pin site care for a patient

who has a halo traction device installed. What is the first nursing action that should be taken prior to performing this care?

• Administer pain medication.
• Reassess the patient.
• Prepare the equipment.
• Explain the procedure to the patient.
• Reassess the patient.

• A student nurse is on a clinical rotation at a busy

hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident with the procedure.What would be the student's best response?

• Tell the RN that he or she lacks the technical

competencies to change the dressing independently.

• Assemble the equipment for the procedure and follow

the steps in the procedure manual.

• Ask another student nurse to work collaboratively with

him or her to change the dressing.

• Report the RN to his or her instructor for delegating a

task that should not be assigned to student nurses.

• Tell the RN that he or she lacks the technical competencies to change the

dressing independently.

• A nurse develops a detailed plan of care for a 16-year-

old female who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response?

• "You know your personal situation better than I do, so I

will respect your wishes."

• "If you don't accept these services, your baby's health

will suffer."

• "Let's take a look at the plan again and see if we can

adjust it to fit your needs."

• "I'm going to assign your case to a social worker who

can explain the services better."

• "Let's take a look at the plan again and see if we can adjust it to fit your needs."