Question

The nurse is developing nursing interventions for a nursing diagnosis related to mobility in a surgical client. Which statement is an example of a nursing intervention?

Answer 1

Correct Answers:

Ambulate with the client twice a day.

Rationale :

🔷 A nursing intervention is an action the nurse plans and performs to help the client achieve expected outcomes.

🔷 This statement is action-oriented, specific, and clearly describes what the nurse will do for the client.

🔷 It directly addresses the client’s mobility problem after surgery and supports recovery through safe activity.

🔷 Nursing interventions must be written as measurable care actions, not as diagnoses or expected outcomes.

🔷 Therefore, “Ambulate with the client twice a day” is the correct example of a nursing intervention.

“Client will walk in hall twice a day.”

🔷 This statement is an expected outcome, not a nursing intervention, because it describes what the client is expected to achieve.

🔷 It focuses on the client’s result rather than the nurse’s planned action.

“Client has limited mobility due to surgery.”

🔷 This statement describes the client’s problem and is part of the nursing diagnosis or assessment data.

🔷 It does not state an action the nurse will take.

“Ask nursing assistant to ambulate client in the hall twice a day.”

🔷 This statement reflects delegation, not the nursing intervention itself.

🔷 The intervention should describe the planned care action rather than the instruction given to another staff member.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Creation of a smoking prevention program undertaken in a middle school

Rationale :

💠 Health promotion focuses on preventing disease before it starts and helping people adopt healthier behaviors.

💠 A smoking prevention program in a middle school targets young people before harmful habits become established.

💠 This is a classic example of primary prevention, which is a major part of health promotion.

💠 It empowers individuals and communities to make healthier choices and reduce future health risks.

💠 Therefore, creating a smoking prevention program best demonstrates the principles of health promotion.

A discharge planning initiative between acute care and community care nurses.

💠 Discharge planning is important for continuity of care, but it is not the best example of health promotion.

💠 It focuses more on transition and coordination after illness or hospitalization.

Collaboration between several schools of nursing in an urban area.

💠 Collaboration between schools may improve education or professional development, but it does not directly demonstrate client-centered health promotion.

💠 Health promotion involves actions aimed at improving the public’s health behaviors and wellness.

Establishment of a website where clients can check emergency department wait-times.

💠 A website showing emergency department wait times may improve convenience or access to information, but it does not directly promote healthier lifestyles.

💠 It is not a preventive or wellness-focused activity.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Check that pain assessments are being performed with vital signs.
Change expected outcomes if they are not realistic.
Determine whether priorities need to be reordered.
Discontinue nursing interventions that are no longer needed.

Rationale :

“Check that pain assessments are being performed with vital signs.”

🟢 During evaluation, the nurse determines whether the care plan is being followed and whether interventions are effective.

🟢 Checking if pain assessments are occurring as planned helps the nurse judge whether implementation is consistent with the plan of care.

🟢 This supports quality care and helps determine if pain management goals are being met.

🟢 Evaluation includes reviewing both the client’s response and whether planned interventions were actually carried out.

🟢 Therefore, this is an appropriate action in the evaluation step.

“Change expected outcomes if they are not realistic.”

🟢 Evaluation includes deciding whether expected outcomes remain appropriate and achievable for the client.

🟢 If an outcome is found to be unrealistic, it should be revised so the plan remains client-centered and practical.

🟢 This reflects ongoing clinical judgment based on the client’s progress and current status.

🟢 Nursing care plans are dynamic and should be updated as needed during evaluation.

🟢 Therefore, changing unrealistic expected outcomes is part of evaluation.

“Determine whether priorities need to be reordered.”

🟢 Evaluation involves looking at the client’s progress and deciding whether the order of care priorities should change.

🟢 New problems may arise, or existing issues may improve, which can alter what needs the greatest attention.

🟢 Reordering priorities ensures the plan of care remains responsive to the client’s current condition.

🟢 This is especially important after major procedures such as a total hip replacement, where needs can change rapidly.

🟢 Therefore, this action belongs in the evaluation phase.

“Discontinue nursing interventions that are no longer needed.”

🟢 An important part of evaluation is identifying which interventions are still necessary and which are no longer beneficial.

🟢 If the client has improved or the problem has resolved, some interventions should be stopped to keep the care plan relevant.

🟢 This prevents unnecessary care and allows attention to shift to current priorities.

🟢 Evaluation supports ongoing modification of the nursing plan based on outcomes.

🟢 Therefore, discontinuing unneeded interventions is an appropriate evaluation action.

“Add additional nursing diagnoses to address new problems.”

🟢 Adding new nursing diagnoses belongs more directly to the diagnosis and planning phases after reassessment identifies new issues.

🟢 Although evaluation may lead to reassessment, writing new diagnoses is not itself the evaluation action being emphasized here.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Ensures that the agency is correctly reimbursed for the visit

Rationale :

🟣 In home health care, accurate and properly formatted documentation is essential for legal, clinical, and financial reasons.

🟣 One major reason is that reimbursement from insurers or Medicare depends on clear documentation of the services provided and the client’s needs.

🟣 If the record is incomplete or inaccurate, the agency may not be paid appropriately for the visit.

🟣 Documentation must reflect the care given, the client’s status, and the medical necessity for services.

🟣 Therefore, accurate documentation helps ensure the agency is correctly reimbursed.

Guarantees that the nurse will not be legally liable for unexpected outcomes.

🟣 Good documentation can help support legal defense, but it does not guarantee that the nurse will never be legally liable.

🟣 Liability depends on the facts of the case, not documentation alone.

Allows the client to gauge progress over time.

🟣 Documentation can help track progress, but this is not the primary reason emphasized in this context.

🟣 The question focuses more on why correct formatting and accuracy are especially necessary in home care systems.

Facilitates safe delegation of care to unlicensed caregivers.

🟣 Documentation can support communication, but this is not the best answer here.

🟣 The stronger rationale is the link between required documentation and agency reimbursement.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

"Is the client’s family willing to participate in care?"

Rationale :

🟡 The need for future home visits depends partly on how much support the client has available at home.

🟡 If family members are willing and able to participate in care, the client may need fewer professional visits.

🟡 For a chronic sacral ulcer, ongoing wound care can require significant assistance, and caregiver participation strongly affects planning.

🟡 Home care frequency should be based on the client’s needs, safety, and the support system available.

🟡 Therefore, asking whether the family is willing to participate in care is an important question for determining visit needs.

“When was the client first diagnosed with this wound?”

🟡 The onset of the wound provides history, but it does not directly determine current frequency of future visits.

🟡 Current care needs and available support are more important for planning.

“Is the client willing to create a plan of care?”

🟡 Client participation is valuable, but willingness to create a plan does not by itself determine how often visits are needed.

🟡 The nurse must assess practical care needs and support resources.

“How does the client describe the client’s coping style?”

🟡 Coping style may affect adjustment, but it is not the best predictor of how often wound-care visits are required.

🟡 Direct caregiving ability and assistance at home are more relevant.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Functional status

Rationale :

🔶 The Outcome and Assessment Information Set (OASIS) is used in home health care to assess important aspects of the client’s condition and care needs.

🔶 One major domain included in OASIS is the client’s functional status, such as ability to bathe, dress, ambulate, and manage activities of daily living.

🔶 This information helps determine the level of assistance the client requires and supports care planning and reimbursement.

🔶 Functional assessment is essential in deciding what home services are medically necessary.

🔶 Therefore, the nurse should assess the client’s functional status when using OASIS.

“Compliance with care.”

🔶 Adherence may be discussed in overall care, but compliance is not the main domain emphasized here.

🔶 OASIS focuses more directly on measurable clinical and functional status.

“Psychiatric status.”

🔶 Mental and emotional health may be touched on in assessment, but this is not the best answer among the options.

🔶 Functional status is the clearer core domain associated with OASIS.

“Spiritual state.”

🔶 Spiritual assessment can be important in holistic nursing, but it is not a primary OASIS domain used for determining home health needs.

🔶 OASIS focuses more on clinical and functional measures.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Placing the unaffected leg forward when sitting down

Rationale :

✅ When sitting down while using crutches, the client should move the unaffected leg forward and use it to bear weight safely.

✅ The crutches are usually held on one side while the client reaches back for the chair and lowers themselves carefully.

✅ Using the stronger leg for support helps maintain balance and reduces the risk of falling.

✅ Safe crutch technique protects both the injured extremity and the client’s overall stability.

✅ Therefore, placing the unaffected leg forward when sitting down indicates effective use of crutches.

“Placing the crutches on lower step and moving the affected leg first when descending stairs.”

✅ When descending stairs, the correct sequence is usually crutches first, then the affected leg, then the unaffected leg, but the wording here does not clearly reflect safe standard technique.

✅ This is not the best answer compared with the clearly correct sitting technique.

“Placing the crutches on the unaffected side to rise from a sitting position.”

✅ When rising from a chair, the client typically holds both crutches on the affected side or in one hand while pushing up with the other hand from the chair.

✅ Placing them on the unaffected side is not the standard technique.

“Advancing affected leg first, then crutches, then unaffected leg when ascending stairs.”

✅ When ascending stairs, the unaffected leg goes first, followed by the affected leg and crutches.

✅ This option uses the wrong sequence.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Call the client to obtain permission to visit.

Rationale :

⭐ After receiving a referral for home care, the nurse should first contact the client to obtain consent and arrange the visit.

⭐ Home care requires respect for the client’s privacy, autonomy, and right to accept or refuse services in the home.

⭐ Permission must be obtained before the nurse or agency proceeds with the visit.

⭐ This step also allows the nurse to begin establishing rapport and verify practical details for care.

⭐ Therefore, the first action is to call the client to obtain permission to visit.

“Have community services make contact with the client.”

⭐ The home health nurse or agency should first obtain the client’s permission directly rather than immediately involving outside services.

⭐ Client consent is a priority before expanding the care process.

“Obtain a health care provider's prescription for the visit.”

⭐ A provider order is often necessary, but the question asks what the nurse should do first after obtaining the referral.

⭐ In the home setting, confirming the client’s willingness to receive the visit is the immediate first step.

“Arrange for a home health aide to initially visit the client.”

⭐ A home health aide should not be assigned before the nurse establishes the visit and assesses the client’s needs.

⭐ The initial nursing contact and permission come first.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Resolve to convey respect for the client's beliefs and choices.

Rationale :

🔵 Home health nursing requires the nurse to care for clients in their own environment, where the client’s lifestyle and choices must be respected.

🔵 Even if the nurse does not agree with smoking, therapeutic care requires professionalism, respect, and nonjudgmental communication.

🔵 The nurse can still provide teaching about risks and safety without disrespecting the client’s autonomy.

🔵 Adapting to the client’s home setting is a key difference between hospital care and home health care.

🔵 Therefore, the nurse should resolve to convey respect for the client’s beliefs and choices.

Request another assignment if there is dissonance with the client's lifestyle.

🔵 Personal disagreement with a client’s habits is not a reason to refuse care in ordinary circumstances.

🔵 Nurses are expected to provide respectful care even when client choices differ from their own values.

Ask the client to come to the agency to receive treatment, if possible.

🔵 Home health care is designed to deliver services in the client’s home, not shift the setting for the nurse’s comfort.

🔵 This does not reflect the purpose or philosophy of home care.

Try to adapt the client's home to the norms of a hospital environment.

🔵 The client’s home should not be transformed to match hospital culture unnecessarily.

🔵 The nurse adapts care to the home environment while maintaining safety and professionalism.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Make the information directly relevant to the client's condition.

Rationale :

🟤 Older adults learn best when teaching is clearly meaningful and connected to their own daily life and health needs.

🟤 Explaining how the antiplatelet medication helps prevent complications of coronary artery disease makes the teaching personally important to the client.

🟤 Relevance improves motivation, attention, and retention of the information.

🟤 Teaching should also be paced appropriately and reinforced, but personal relevance remains one of the strongest ways to enhance adult learning.

🟤 Therefore, the nurse should make the information directly relevant to the client’s condition.

Use color-coded materials that are succinct and engaging.

🟤 Attractive materials can help, but they are not the most important factor in promoting learning for this client.

🟤 Relevance to the client’s own health condition is more powerful than visual style alone.

Exclude family members from the session to prevent distraction.

🟤 Family members can often support learning and medication management, especially for older adults.

🟤 They should not be excluded automatically unless the client prefers privacy.

Provide links to websites that contain evidence-based information.

🟤 Evidence-based websites can be useful, but many older clients may prefer direct explanation and discussion.

🟤 This option is less effective than making the teaching immediately relevant and personal.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
The nurse is developing nursing interventions for a nursing diagnosis related to mobility in a surgical client. Which statement is an example of a nursing intervention?

2 :
A nurse is aware that an increasing emphasis is being placed on health, health promotion, wellness, and self-care. Which of the following activities would best demonstrate the principles of health promotion?

3 :
The nurse is evaluating the plan of care for a client who had a total hip replacement. Which action(s) will the nurse perform during this step of the nursing process? Select all that apply.

4 :
A home health nurse has completed a visit to a client and has immediately begun to document the visit. Accurate documentation that is correctly formatted is necessary for what reason?

5 :
A home health nurse has completed a scheduled home visit to a client with a chronic sacral ulcer. The nurse is now evaluating and documenting the need for future visits and the frequency of those visits. What question should the nurse use when attempting to determine this need?

7 :
The home care nurse is assessing a client's use of crutches in the home. Which of the following actions by the client indicates that the client is using the crutches effectively?

8 :
The home health nurse receives a referral from the hospital for a client who needs a home visit for wound care. After obtaining the referral, what action should the nurse first take?

9 :
A hospital nurse is transitioning to a home health nurse position. The nurse has that the client smokes while at home. What will the nurse need to do to work therapeutically with the client in the home setting?

10 :
The nurse is planning to teach a 75-year-old client with coronary artery disease about administering the prescribed antiplatelet medication. How can the nurse best enhance the client's ability to learn?

QLexNursing

1 : The nurse is developing nursing interventions for a nursing diagnosis related to mobility in a surgical client. Which statement is an example of a nursing intervention?

2 : A nurse is aware that an increasing emphasis is being placed on health, health promotion, wellness, and self-care. Which of the following activities would best demonstrate the principles of health promotion?

3 : The nurse is evaluating the plan of care for a client who had a total hip replacement. Which action(s) will the nurse perform during this step of the nursing process? Select all that apply.

4 : A home health nurse has completed a visit to a client and has immediately begun to document the visit. Accurate documentation that is correctly formatted is necessary for what reason?

5 : A home health nurse has completed a scheduled home visit to a client with a chronic sacral ulcer. The nurse is now evaluating and documenting the need for future visits and the frequency of those visits. What question should the nurse use when attempting to determine this need?

7 : The home care nurse is assessing a client's use of crutches in the home. Which of the following actions by the client indicates that the client is using the crutches effectively?

8 : The home health nurse receives a referral from the hospital for a client who needs a home visit for wound care. After obtaining the referral, what action should the nurse first take?

9 : A hospital nurse is transitioning to a home health nurse position. The nurse has that the client smokes while at home. What will the nurse need to do to work therapeutically with the client in the home setting?

10 : The nurse is planning to teach a 75-year-old client with coronary artery disease about administering the prescribed antiplatelet medication. How can the nurse best enhance the client's ability to learn?

1 :
The nurse is developing nursing interventions for a nursing diagnosis related to mobility in a surgical client. Which statement is an example of a nursing intervention?

2 :
A nurse is aware that an increasing emphasis is being placed on health, health promotion, wellness, and self-care. Which of the following activities would best demonstrate the principles of health promotion?

3 :
The nurse is evaluating the plan of care for a client who had a total hip replacement. Which action(s) will the nurse perform during this step of the nursing process? Select all that apply.

4 :
A home health nurse has completed a visit to a client and has immediately begun to document the visit. Accurate documentation that is correctly formatted is necessary for what reason?

5 :
A home health nurse has completed a scheduled home visit to a client with a chronic sacral ulcer. The nurse is now evaluating and documenting the need for future visits and the frequency of those visits. What question should the nurse use when attempting to determine this need?

7 :
The home care nurse is assessing a client's use of crutches in the home. Which of the following actions by the client indicates that the client is using the crutches effectively?

8 :
The home health nurse receives a referral from the hospital for a client who needs a home visit for wound care. After obtaining the referral, what action should the nurse first take?

9 :
A hospital nurse is transitioning to a home health nurse position. The nurse has that the client smokes while at home. What will the nurse need to do to work therapeutically with the client in the home setting?

10 :
The nurse is planning to teach a 75-year-old client with coronary artery disease about administering the prescribed antiplatelet medication. How can the nurse best enhance the client's ability to learn?