CHAPTER 9: Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford

Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford Chapter 9: Implementation and Evaluation Multiple Choice Questions 1. Which of the following nursing actions is classified 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 Answer: A Explanation: Direct-care interventions involve face-to-face patient contact, such as administering injections, performing wound care, or providing bedside education. These actions directly impact patient outcomes through hands-on care. Why Other Options Are Wrong: B, C, and D are incorrect because they are indirect-care interventions, which benefit patients without direct interaction (e.g., reporting, collaboration, or equipment preparation). 2. What key principle must the nurse manager remember when delegating tasks to licensed practical nurses (LPNs) and nurse technicians (NAs)? A. RNs are responsible for all care delegated to unlicensed nursing personnel B. Delegation is considered a direct intervention for patient care C. LPNs operate independently and may delegate patient care D. Nursing practice is clearly delineated and standard across the country Answer: A Explanation: Delegation transfers task responsibility while the RN retains accountability. RNs must ensure tasks align with the delegatee’s scope of practice and competency, per state nurse practice acts. Why Other Options Are Wrong: B is incorrect because delegation is indirect care. C is incorrect as LPNs typically work under supervision and cannot delegate. D is incorrect due to variations in state-specific nursing regulations. 3. What is the nurse’s priority action when a patient reports new shortness of breath during medication preparation? A. Provide oxygen without an order B. Complete three medication checks C. Check provider orders for prescribed interventions D. Document adherence to the six rights of medication administration Answer: C Explanation: The nurse must first address the emergent symptom (shortness of breath) by verifying orders for oxygen or other prescribed treatments, ensuring timely and legal intervention. Why Other Options Are Wrong: A is incorrect because oxygen administration requires an order. B and D are incorrect as safety checks, while important, are secondary to addressing the patient’s acute distress. 4. What is the most appropriate nursing action after completing a patient’s initial assessment and care plan? 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 Answer: A Explanation: Continuous reassessment allows for dynamic adjustments to the care plan based on the patient’s evolving condition, ensuring responsive and individualized care. Why Other Options Are Wrong: B is incorrect because care plans must adapt to patient needs. C is incorrect as reassessment should occur more frequently. D is incorrect because evaluation focuses on outcomes, not ongoing monitoring. 5. How should the nurse classify a female patient’s request for a same-gender caregiver during a bed bath? A. Gender diversity involving generational norms B. Life span diversity C. Disability diversity D. Morphology diversity Answer: A Explanation: Gender diversity reflects preferences influenced by cultural, generational, or personal comfort levels, which nurses must respect to provide patient-centered care. Why Other Options Are Wrong: B is incorrect as it pertains to age-related needs. C is incorrect because it addresses physical/mental limitations. D is incorrect as it relates to body size adaptations. 6. Which provider order should the nurse question for a Jehovah’s Witness patient? A. Obtain vital signs every shift B. Regular diet as tolerated C. Activity as tolerated D. Infuse 1 unit packed red blood cells Answer: D Explanation: Jehovah’s Witnesses typically decline blood transfusions due to religious beliefs, necessitating alternative interventions aligned with patient values. Why Other Options Are Wrong: A, B, and C are incorrect as they do not conflict with the patient’s faith-based restrictions. 7. Which goal should the nurse modify for a blind patient with a wound? A. The patient will report foul-smelling wound drainage B. The patient will report pain promptly C. The patient will avoid injuries D. The patient will report purulent wound drainage Answer: D Explanation: Blind patients cannot visually assess drainage characteristics (e.g., purulence), requiring alternative evaluation methods like odor or tactile cues. Why Other Options Are Wrong: A, B, and C are incorrect because they rely on non-visual patient capabilities (smell, verbal reporting, safety awareness). 8. Which action exemplifies an independent nursing intervention? A. Administering oral medications B. Administering oxygen C. Providing emotional support D. Administering intravenous medication Answer: C Explanation: Independent interventions, like emotional support or repositioning, fall within the nurse’s scope without requiring provider orders. Why Other Options Are Wrong: A, B, and D are incorrect as they are dependent interventions requiring provider orders. 9. What is the priority teaching topic for a postoperative patient immediately after surgery? A. Signs of infection B. Use of patient-controlled analgesia C. Activity limitations at discharge D. Physical therapy Answer: B Explanation: Immediate postoperative teaching should address pain management (e.g., PCA pump use) to ensure comfort and participation in recovery activities. Why Other Options Are Wrong: A, C, and D are incorrect as they are more relevant to discharge planning, not immediate postoperative needs. 10. Which patient is most ready to learn? A. A patient requesting pain medication for severe discomfort B. A patient reporting nausea and vomiting C. A patient newly diagnosed with pancreatic cancer D. A diabetic patient scheduled for discharge in 2 days Answer: D Explanation: Readiness to learn requires psychological and physical stability. A stable diabetic patient facing discharge is motivated and capable of retaining education. Why Other Options Are Wrong: A, B, and C are incorrect because pain, nausea, or recent trauma impair the ability to focus on learning. 11. What is the best rationale for involving family members in a patient’s teaching plan? A. Empowers the patient and support system B. Reduces family questions C. Ensures treatment compliance D. Interests family members Answer: A Explanation: Family involvement enhances patient support and shared understanding, fostering collaborative care and adherence to health plans. Why Other Options Are Wrong: B is incorrect as education aims to encourage questions. C is incorrect because compliance depends on the patient’s choices. D is incorrect as family interest is secondary to patient empowerment. 12. Which examples describe indirect care interventions? A. Change-of-shift report, team collaboration, equipment preparation B. Wound cleaning, medication administration, ambulation C. Physician referrals, counseling, patient education D. Delegation, vital signs, hygiene assistance Answer: A Explanation: Indirect care includes tasks like reporting, collaboration, and resource management, which support patient care without direct contact. Why Other Options Are Wrong: B is incorrect as it lists direct-care actions. C is incorrect because referrals and counseling are distinct concepts. D mixes indirect (delegation) and direct tasks (vital signs). 13. Which referral is inappropriate for a nurse to initiate independently? A. Music therapist B. Community agencies C. Adaptive care services D. Dermatologist Answer: D Explanation: Referrals to medical specialists (e.g., dermatologists) require provider authorization, unlike referrals for therapeutic or community services. Why Other Options Are Wrong: A, B, and C are incorrect as nurses can independently refer to these support services. 14. What must nurses prioritize to implement research-based interventions effectively? A. Rely solely on nursing research B. Focus on practices rather than outcomes C. Read current literature and maintain updated knowledge D. Limit interdisciplinary collaboration Answer: C Explanation: Evidence-based practice requires nurses to stay informed through recent literature, integrating research findings into patient care. Why Other Options Are Wrong: A is incorrect because evidence-based practice includes multidisciplinary research. B is incorrect as outcomes are central to evaluation. D is incorrect as collaboration enhances care quality. 15. What role does the nurse fulfill when advocating for a patient’s needs? A. Advocate B. Primary care provider C. Collaborator D. Delegator Answer: A Explanation: Advocacy involves supporting patients’ rights, coordinating care, and ensuring their voices are heard in health decisions. Why Other Options Are Wrong: B is incorrect as PCPs are physicians or advanced practitioners. C is incorrect because collaboration involves teamwork, not advocacy. D is incorrect as delegation assigns tasks, not supports patient rights. 16. Which task cannot be delegated to unlicensed assistive personnel (UAP)? A. Obtaining vital signs B. Assessing lung sounds C. Bathing a patient D. Ambulating a patient Answer: B Explanation: Assessment (e.g., lung sounds) is a critical nursing responsibility that cannot be delegated, as it requires clinical judgment. Why Other Options Are Wrong: A, C, and D are incorrect because UAP can perform these tasks under RN supervision. 17. Which examples represent independent nursing interventions? A. Repositioning, hygiene care, active listening B. Medication administration, oxygen therapy, IV insertion C. Physician consultations, diagnostic testing, surgery D. Family counseling, financial planning, legal advice Answer: A Explanation: Independent interventions (e.g., repositioning, listening) are within the nurse’s scope and require no provider orders. Why Other Options Are Wrong: B is incorrect as these are dependent interventions. C and D are incorrect because they involve other professionals’ roles. 18. What type of intervention is administering prescribed morphine sulfate IV? A. Independent nursing intervention B. Dependent nursing intervention C. Referral D. Indirect care procedure Answer: B Explanation: Administering prescribed medications is a dependent intervention, requiring a provider’s order and nursing clinical judgment. Why Other Options Are Wrong: A is incorrect as independent interventions need no orders. C is incorrect because referrals involve other providers. D is incorrect as medication administration is direct care. 19. What is essential for accurate nursing documentation? A. Timely, precise, and professional entries B. Avoiding electronic health records (EHRs) C. Excluding legal or billing uses D. Limiting interdisciplinary access Answer: A Explanation: Documentation must be timely, accurate, and professional to ensure legal compliance, continuity of care, and reimbursement. Why Other Options Are Wrong: B is incorrect as EHRs are standard and secure. C is incorrect because records are legal documents used for billing. D is incorrect as interdisciplinary access improves care coordination. 20. What is the focus of the evaluation phase in the nursing process? A. Recording implemented care B. Medical and nursing goals C. Long-term goals only D. Patient responses and outcomes Answer: D Explanation: Evaluation assesses patient responses to interventions and goal attainment, guiding care plan adjustments for improved outcomes. Why Other Options Are Wrong: A is incorrect because evaluation focuses on outcomes, not documentation. B is incorrect as it prioritizes provider goals over patient-centered results. C is incorrect as both short- and long-term goals are evaluated. 21. What should the nurse do if a patient’s short-term goals are unmet? A. Revise the care plan B. Assume patient noncompliance C. Avoid care plan changes D. Reassess only after major interactions Answer: A Explanation: Unmet goals require care plan revisions to address barriers (e.g., unrealistic goals, ineffective interventions) and improve outcomes. Why Other Options Are Wrong: B is incorrect as it assumes blame without assessment. C is incorrect because care plans must adapt. D is incorrect as reassessment should be continuous. 22. How is the nursing process best described? A. Linear and rigid B. Dynamic and cyclic C. Rarely reevaluated D. Unmodifiable Answer: B Explanation: The nursing process is dynamic and cyclic, adapting to patient needs through ongoing assessment, planning, intervention, and evaluation. Why Other Options Are Wrong: A is incorrect because the process is flexible, not linear. C and D are incorrect as continual reevaluation and modifications are essential. Multiple Response Questions 1. Which interventions are prevention-oriented? (Select all that apply.) A. Immunization programs B. Cleansing an incision C. Cardiac risk factor modification D. Placing infants prone when sleeping E. Teaching patients to request handwashing Answer: A, B, C, E Explanation: Prevention-oriented interventions include immunizations, infection control (incision care), risk reduction (cardiac education), and hygiene practices (handwashing). Why Other Options Are Wrong: D is incorrect because infants should sleep supine to prevent SIDS, not prone. 2. Which procedures are invasive? (Select all that apply.) A. Administering oral medications B. Starting an IV line C. Repositioning the patient D. Inserting a urinary catheter Answer: B, D Explanation: Invasive procedures breach body tissues (e.g., IV insertion, catheterization), unlike oral medications or repositioning. Why Other Options Are Wrong: A and C are incorrect as they are noninvasive. 3. What are the five rights of delegation? (Select all that apply.) A. Right patient B. Right time C. Right person D. Right supervision E. Right task Answer: C, D, E Explanation: Delegation requires the right task, person, direction, supervision, and circumstances to ensure safe and effective care. Why Other Options Are Wrong: A and B are incorrect as they pertain to medication administration, not delegation.