Implementing Nursing Care
These types of interventions are treatments nurses provide through interactions with patients or a group of patients
Direct care interventions
The _________ of nursing practice are the measurable conditions of patient, family, or community status; behavior; or perception; these are the criteria for judging the success in delivering nursing care.
Outcomes
This is the best time to begin patient education during a hospital stay.
at the time of admission
This is the technique used first when beginning a physical assessment.
inspection
In prioritizing care, a nurse should address this type of need first, according to Maslow’s Hierarchy of Needs.
physiological needs
These types of interventions allow nurses to act more quickly and appropriately and help capture patient care information that can be shared across disciplines and care settings
Standard interventions
This is the step of the nursing process where the nurse determines whether the patient's goals and expected outcomes have been achieved as a result of nursing interventions.
Evaluation
A nurse providing discharge instructions notices the patient is nodding but seems confused. The nurse should use this strategy to ensure understanding.
the teach-back method
When assessing the lungs, the nurse places hands on the patient’s back to check for equal chest expansion.
symmetrical thoracic expansion
A nurse is caring for four patients. According to the ABC framework, this patient should be seen first.
A. A patient with shortness of breath
B. A patient with a low-grade fever
C. A patient requesting pain meds
D. A patient needing discharge instructions
the patient with shortness of breath
A systematically developed set of statements about appropriate health care for specific health care problems or clinical situations
Clinical practice guidelines
When a patient's outcomes are not met, the nurse uses this part of the evaluation phase to determine whether the care plan should be modified or new interventions should be implemented.
Revising the care plan
When planning patient education, nurses must assess these three key areas related to the learner.
readiness to learn, learning needs, and preferred learning style
This sound, heard over healthy lung tissue during percussion, is described as loud and hollow.
resonance
When using the acute vs. chronic principle of prioritization, the nurse should first care for the patient with this type of condition.
an acute condition
This is a continuous process that occurs each time you interact with a patient
Assessment
After implementing a care plan for a patient with acute pain, the nurse reassesses the patient and finds their pain level has decreased from 8/10 to 3/10. This action best represents this specific component of the evaluation phase.
Measuring the effectiveness of a nursing intervention
This document, often given to patients upon discharge, reinforces verbal instructions and serves as a reference for home care.
discharge instructions
During an abdominal assessment, the correct sequence of physical exam techniques is inspection, auscultation, percussion, and this final step.
palpation
This priority-setting model helps nurses determine which patient problems require immediate attention versus those that can wait, often used in complex situations.
the urgent vs. non-urgent model (or prioritization matrix)
These are preprinted document containing medical orders and directs patient care in a specific clinical setting
Standing orders
This critical thinking skill is essential during the evaluation phase, as the nurse must compare actual patient outcomes with expected outcomes and determine the reason for any discrepancies.
clinical judgement
When educating a patient with low health literacy, the nurse should use this type of language to improve understanding.
simple, plain language without medical jargon
When performing a skin assessment, the nurse presses on a reddened area over a bony prominence and notes that it does not blanch. This finding most likely indicates this stage of pressure injury.
Stage 1
A nurse is assigned four patients. Which patient should be assessed first?
A. A patient with a blood glucose of 250 mg/dL who is due for insulin
B. A patient reporting severe abdominal pain and a distended abdomen
C. A patient with stable vital signs requesting assistance to the bathroom
D. A post-op patient who needs their surgical dressing changed
the patient reporting severe abdominal pain and a distended abdomen