CH 19: Implementing Nursing Care
What is one benefit and one limitation of standard nursing interventions?
Answer: Benefit = consistency; Limitation = may not fit individual needs
Rationale: Standard interventions guide practice but may lack personalization.
What is the difference between assessment measures and evaluative measures?
Answer: Assessment = baseline; Evaluation = measuring progress over time
Rationale: Both are data-based, but evaluation measures effectiveness of interventions.
What are the six links in the infection chain?
Infectious agent, Reservoir, Portal of exit, Mode of transmission, Portal of entry, & Susceptible host
What are seizure precautions, and why are they important?
Answer: Padding side rails, clear airway, suction/O₂ ready
Rationale: Prevents injury and maintains breathing during seizures.
A patient insists on eating fried chicken right after surgery even though they’re on clear liquids. As the nurse, do you:
A.) Laugh and grab some hot sauce
B.) Gently explain the diet restrictions and why they matter
C.) Pretend you didn’t hear them
Answer: B.) Gently explain the diet restrictions and why they matter
Rationale: Patient education is key! Post-op diets prevent complications like aspiration or delayed healing. Ignoring or joking misses an opportunity to promote safety and recovery.
Why are standing orders helpful for nurses?
Answer: Allow timely interventions without waiting for orders
Rationale: Standing orders streamline routine or urgent care.
Why is documenting outcomes in the electronic health record important?
Answer: Ensures continuity, communication, and legal documentation
Rationale: EHR is the official record of patient care and outcomes.
List two normal body defenses against infection.
Answer: Skin, mucous membranes, gastric acid, immune response
What is status epilepticus, and why is it a medical emergency?
Answer: Seizure >5 minutes or repeated without recovery; life-threatening
Rationale: Can cause brain damage → emergency intervention required.
You’re learning a new skill. Which “rookie mistake” do you avoid?
A.) Jumping in without reviewing protocols
B.) Asking a more experienced nurse for help
C.) Practicing on a mannequin first
Answer: A.) Jumping in without reviewing protocols
Rationale: Preparation prevents errors. It’s safe (and encouraged!) to ask for guidance or practice first. The mistake is skipping protocol review.
A nurse is assisting a patient with ADLs. Give one strategy to promote independence.
Answer: Encourage independence, use adaptive equipment
Rationale: Promotes safety while maintaining dignity.
A patient’s expected outcome was to maintain oxygen saturation above 95%, but it remains at 90%. What should the nurse do next?
Answer: Revise care plan and interventions
Rationale: If expected outcomes are unmet, interventions must be reassessed.
How does medical asepsis differ from surgical asepsis?
Answer: Medical = reduces pathogens; Surgical = sterile field
Rationale: Medical = “clean,” surgical = “sterile.”
Define workplace violence in healthcare.
Answer: Threatening/violent behaviors at work (physical or verbal)
Rationale: Affects staff and patient safety in healthcare.
Your patient goal was: “Pt will ambulate 50 ft by end of shift.” They walked 100 ft. What should you do?
A.) High-five them and update the care plan
B.) Ignore it because they already met the goal
C.) Keep the same goal forever
Answer: A.) High-five them and update the care plan
Rationale: Goals should be dynamic. If the patient exceeds them, celebrate progress and revise to encourage continued improvement.
What should a nurse do before performing a procedural skill for the first time?
Answer: Review protocols, seek supervision, practice if possible
Rationale: Ensures patient safety and skill accuracy.
How does critical thinking influence the evaluation process?
Answer: Critical thinking ensures objective analysis and evidence-based conclusions
Rationale: Avoids bias and improves care effectiveness.
What PPE is required for airborne precautions?
Answer: N95 respirator or PAPR
Rationale: Airborne pathogens require tight-fitting respiratory protection.
Give two examples of safety interventions during a seizure.
Answer: Turn patient on side, protect head
Rationale: Prevent aspiration and injury.
You’re in a PPE fashion show. What’s the correct “catwalk” order when putting on gear?
Answer: Hand hygiene → gown → mask/respirator → goggles/face shield → gloves
Rationale: This order prevents contamination. Hand hygiene first, then gown, then mask, eye protection, and gloves last to avoid contaminating clean surfaces.
How does reflection improve the implementation of nursing care?
Answer: It allows nurses to learn from practice and improve care
Rationale: Reflection supports growth and safer interventions.
Why is reflection during evaluation essential in nursing practice?
Answer: Identifies omissions, errors, and promotes accountability
Rationale: Reflection ensures continuous improvement in practice.
A nurse sees redness, heat, and swelling at a wound site. Are these signs of localized or systemic infection?
Answer: Localized infection
Rationale: Redness, swelling, heat, pain = confined to one area.
When should restraints be used in patient care?
Answer: As a last resort, when patient is a danger to self or others
Rationale: Restraints have risks; should only be used after alternatives fail.
True or False: Reflection during evaluation is basically your brain’s way of saying, “Hey, let’s not mess this up the same way twice.”
Answer: True!
Rationale: Reflection identifies mistakes, successes, and areas for improvement—helping you provide better care next time.