A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

Teaching about medications

Performing resuscitation

Inserting a feeding tube

Documenting wound care

Ambulating a patient

Answer and Explanation

Correct Answer : A,B,C,E

A. Teaching about medications. This is correct because providing education to a patient is a direct care intervention, as it involves interaction with the patient to improve their health outcomes.

B. Performing resuscitation. This is correct because resuscitation is a hands-on, immediate intervention aimed at stabilizing a patient, making it a direct care intervention.

C. Inserting a feeding tube. This is correct because placing a feeding tube is a direct intervention that involves a hands-on nursing procedure.

D. Documenting wound care. This is incorrect because documentation is an indirect care intervention. While it is essential for communication and continuity of care, it does not directly affect the patient's condition.

E. Ambulating a patient. This is correct because physically assisting a patient with walking is a direct care intervention that helps prevent complications such as deep vein thrombosis and pneumonia.

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Correct Answer is B

Explanation

A. Planning. This is incorrect because the planning phase involves setting goals and determining interventions based on the assessment data. Allergy information should be collected before this phase.

B. Assessment. This is correct because the assessment phase involves gathering subjective and objective data about the patient. Asking about allergies is part of the initial health history to ensure safe care planning.

C. Implementation. This is incorrect because the implementation phase involves carrying out interventions based on the data collected in the assessment. Checking allergies before giving medications or treatments should occur earlier.

D. Evaluation. This is incorrect because evaluation involves determining the effectiveness of interventions. Allergy assessment should be completed long before this phase to prevent potential reactions.

A. Review the patient's medication history for any potential drug interactions. B. Educate the patient about the potential side effects of the new medication. C. Document the patient's baseline blood pressure before starting the medication. D. Assess the patient's blood pressure to determine if the medication is effective.

Correct Answer is D

Explanation

A. Reviewing medication history is important before starting a medication, not during the evaluation phase.

B. While education is important, the priority in the evaluation phase is determining whether the medication is working.

C. Baseline data is collected before treatment begins. The evaluation phase focuses on assessing the effectiveness of treatment.

D. The evaluation phase of the nursing process focuses on determining if interventions (such as medications) have achieved the desired outcomes.

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A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Correct Answer is B

Explanation

A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

Correct Answer is D

Explanation

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