14 Nursing Implementation NCLEX Practice Questions

14 Nursing Implementation NCLEX Practice Questions Leave the first rating Students also studied Terms in this set (11) Save Nursing Process NCLEX questions 16 terms jacquie_goggin Preview Foundations Chapter 19 Implementi...47 terms Quinlyn_Stephan2 Preview

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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."