Deck 14: Implementing and Evaluating Nursing Care

Question 1

The nurse is caring for a patient who has an open wound.For evaluating the progress of wound healing,what is the nurse's priority action?

A)Asking the unregulated care providers whether the wound looks better.
B)Documenting the progress of wound healing as "better" in the patient's chart.
C)Measuring the wound and observe for redness,swelling,or drainage.
D)Leaving the dressing off the wound for easier access and more frequent assessments.

Answer 1

Measuring the wound and observe for redness,swelling,or drainage.

Question 2

Which scenario best illustrates the use of data validation when an independent nursing clinical decision is made?

A)The nurse determines that a wound dressing needs to be removed when the patient reveals the time of the last dressing change,and the nurse notices that the present dressing is saturated with fresh and old blood.
B)The nurse administers pain medicine due at 1700 hours at 1600 hours because the patient complains of increased pain.
C)The nurse removes a leg cast when the patient complains of decreased mobility.
D)The nurse administers potassium when a patient complains of leg cramps.

Answer 2

The nurse determines that a wound dressing needs to be removed when the patient reveals the time of the last dressing change,and the nurse notices that the present dressing is saturated with fresh and old blood.

Question 3

Which of these options is a patient outcome indicating positive progress toward resolving the nursing diagnosis of Acute confusion?

A)Side rails are up with bed alarm activated.
B)Patient denies pain while ambulating with assistance.
C)Patient wanders halls at night.
D)Patient correctly states names of family members in the room.

Answer 3

Patient correctly states names of family members in the room.

Question 4

A nursing student asks her nursing instructor to describe the primary purpose of evaluation.Which of the following statements made by the nursing instructor is most accurate?

A)"During evaluation,you determine whether all nursing interventions were completed."
B)"During evaluation,you determine when to downsize staffing on nursing units."
C)"Nurses use evaluation to determine the effectiveness of nursing care."
D)"Evaluation eliminates unnecessary paperwork and care planning."

Question 5

The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of pressure ulcers.Which finding indicates success of the turning schedule?

A)Staff documentation of turning the patient every 2 hours.
B)Absence of skin breakdown.
C)Presence of redness only on the heels of the patient.
D)Patient's eating 100% of all meals.

Question 6

A nurse is providing education to a patient about self-administering subcutaneous injections.Which of these patient statements indicates that the patient understands the instructions?

A)"I need to use a needle 1/2 inch (1.3 cm)longer than my thumb."
B)"I will give the medicine deep into my deltoid."
C)"My belly is a good place to give my injection."
D)"I need to throw the syringe and needle into the garbage when I am done giving myself my shot."

Question 7

In which step of the nursing process does the nurse determine whether the patient's condition has improved and whether the patient has met expected outcomes?

A)Assessment.
B)Planning.
C)Implementation.
D)Evaluation.

Question 8

A new nurse states that she is confused about using evaluative measures when caring for patients and asks the charge nurse for examples and an explanation.Which of the following is the most accurate response from the charge nurse?

A)"Evaluative measures are multiple-page documents used to evaluate nurse performance."
B)"Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals."
C)"Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse."
D)"Evaluative measures are objective views of incident reports."

Question 9

A nurse administrator is at a meeting with nurses on the quality council.Several new members are sitting on the council.They ask the nurse administrator to clarify what a nursing-sensitive outcome is.Which response by the nurse administrator best defines nursing-sensitive outcomes?

A)"Nursing-sensitive outcomes determine the patient's progress as a result of prescribed treatments,such as medications."
B)"Patient falls are an example of a nursing-sensitive outcome because they are directly affected by nursing interventions."
C)"Nursing-sensitive outcomes promote universal health care."
D)"We use nursing-sensitive outcomes at this hospital to evaluate nursing tasks and to determine safe staffing ratios."

Question 10

Which of these statements made by a patient who has a nursing diagnosis of Disturbed body image is the best indicator of the patient's early acceptance of body image?

A)"I just won't go to the pool this summer."
B)"I'm worried about what those other girls will think of me."
C)"I can't wear that colour.It makes my hips stick out."
D)"I'll wear the blue dress.It matches my eyes."

Question 11

A patient recently received a diagnosis of pneumonia.The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days,with an expected outcome of having no secretions present in the lungs in 48 hours.Which of the following is an appropriate evaluative measure demonstrating progress toward this goal?

A)Nonproductive cough present in 4 days.
B)Scattered rhonchi throughout all lung fields in 2 days.
C)Respirations 30/minute in 1 day.
D)Lungs clear to auscultation after use of inhaler.

Question 12

Another term for a collaborative nursing intervention is which of the following?

A)Dependent intervention.
B)Independent intervention.
C)Interdependent intervention.
D)Physician-initiated intervention.

Question 13

A nurse identifies a nursing diagnosis of Risk for falls when assessing a patient upon admission.The nurse and the patient agree that the goal is for the patient to remain free from falls.However,the patient fell just before shift change.What is the nurse's priority action when evaluating the patient's plan of care?

A)Counsel the unregulated care provider on duty when the patient fell.
B)Identify factors interfering with goal achievement.
C)Remove the "fall risk" sign from the patient's door because the patient has suffered a fall.
D)Request that the more experienced charge nurse complete the documentation about the fall.

Question 14

The nurse is evaluating whether patient goals and outcomes have been met.Of the following,which is an expected outcome for a patient with a diagnosis of Impaired physical mobility?

A)The patient is able to ambulate in the hallway with crutches.
B)The patient's level of mobility will improve.
C)The nurse provides assistance while the patient is walking in the hallways.
D)The patient will deny pain while walking in the hallway.

Question 15

A nurse is getting ready to discharge to home a patient who has a nursing diagnosis of Impaired physical mobility.Before discontinuing the patient's plan of care,what does the nurse need to do?

A)Determine whether the patient has transportation to get home.
B)Evaluate whether patient goals and outcomes have been met.
C)Establish whether the patient has a follow-up appointment scheduled.
D)Ensure that the patient's prescriptions have been filled.

Question 16

A registered nurse administers pain medication to a patient suffering from fractured ribs.What type of nursing intervention is this nurse implementing?

A)Collaborative.
B)Independent.
C)Interdependent.
D)Dependent.

Question 17

The nurse is caring for a patient who has an order to change a dressing twice a day,at 0600 and 1800.At 1400,the nurse notices that the dressing is saturated.What is the nurse's next action?

A)Wait and change the dressing at 1800 as ordered.
B)Revise the plan of care and change the dressing now.
C)Reassess the dressing and the wound in 1 hour.
D)Discontinue the plan of care.

Question 18

After assembling a thorough database and carrying out nursing interventions based on priority diagnoses,the nurse proceeds to which step of the nursing process?

A)Assessment.
B)Planning.
C)Implementation.
D)Evaluation.

Question 19

A goal for a patient with a nursing diagnosis of Ineffective coping is to demonstrate effective coping skills.Which of these patient behaviours indicates that interventions performed to meet this outcome have been successful?

A)Stating that he feels better after talking with his family and friends.
B)Continuing to consume several alcoholic beverages a day.
C)Disliking the support group meetings.
D)Spending most of the day in bed.

Question 20

After assessing the patient and identifying the need for headache relief,the nurse administers acetaminophen (Tylenol)for the patient's headache.What is the nurse's next priority action for this patient?

A)Eliminate Acute pain from the nursing care plan.
B)Direct the unregulated care provider to ask if the patient's headache is relieved.
C)Reassess the patient's pain level in 30 minutes.
D)Revise the plan of care.

Question 21

Which intervention is most appropriate for the nursing diagnosis Impaired verbal communication related to loss of facial motor control and decreased sensation?

A)Obtain an interpreter for the patient as soon as possible.
B)Assist the patient in performing swallowing exercises each shift.
C)Ask the family to provide a sitter to remain with the patient at all times.
D)Provide the patient with a writing board each shift.

Question 22

Which of the following are examples of evaluative measures that a nurse should utilize when determining the patient's response to nursing care? (Select all that apply. )

A)Observations of wound healing.
B)Assessment of respiratory rate and depth.
C)Blood pressure measurement.
D)Implementation of nursing interventions.
E)Patient's subjective report of feelings about a new diagnosis of cancer.

Question 23

A patient has reduced muscle strength after a left-sided stroke and is at risk for falling.Which intervention is most appropriate for the nursing diagnosis Risk for falls?

A)Encourage patient to remain in bed most of the shift.
B)Keep all side rails down at all times.
C)Place patient in room away from the nurses' station if possible.
D)Assist patient into and out of bed every 6 hours,or as tolerated.

Question 24

Which intervention is most appropriate for the nursing diagnosis Impaired skin integrity related to shearing forces?

A)Administer pain medication every 4 hours as needed.
B)Perform the ordered dressing change twice daily.
C)Do not document the wound appearance in the chart.
D)Keep the bed's side rails up at all times.

Question 25

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity.The patient needs many nursing interventions,including a dressing change,several intravenous antibiotics,and a walk.What actions does the nurse consider when prioritizing interventions? (Select all that apply. )

A)Putting all the patient's nursing diagnoses in order of priority.
B)Considering time as an influencing factor.
C)Setting priorities solely on the basis of physiological factors.
D)Utilizing critical thinking.
E)Not changing priorities once they've been established.

Question 26

Identify elements of the evaluation process.(Select all that apply. )

A)Setting priorities for patient care.
B)Collecting subjective and objective data to determine whether criteria or standards are met.
C)Helping the patient ambulate 7.6 m (25 feet)in the hallway.
D)Documenting findings.
E)Terminating,continuing,or revising the care plan.