Test bank Ch. 9 (implantation and
evaluation) A+ Guide
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 - correct
answer ✅✅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.
2. The nurse manager is creating the patient assignment
for today. She has five registered nurses (RNs), two
licensed practical nurses (LPNs), and five nurse
technicians (NAs) scheduled. When making the
,Test bank Ch. 9 (implantation and
evaluation) A+ Guide
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. - correct answer ✅✅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.
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?
, Test bank Ch. 9 (implantation and
evaluation) A+ Guide
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.
c. Check the provider orders for all forms of prescription
medications.
d. Document that the 6 rights of medication
administration were followed. - correct answer ✅✅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.
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.
evaluation) A+ Guide
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 - correct
answer ✅✅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.
2. The nurse manager is creating the patient assignment
for today. She has five registered nurses (RNs), two
licensed practical nurses (LPNs), and five nurse
technicians (NAs) scheduled. When making the
,Test bank Ch. 9 (implantation and
evaluation) A+ Guide
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. - correct answer ✅✅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.
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?
, Test bank Ch. 9 (implantation and
evaluation) A+ Guide
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.
c. Check the provider orders for all forms of prescription
medications.
d. Document that the 6 rights of medication
administration were followed. - correct answer ✅✅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.
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.
