Deck 9: Implementation and Evaluation

Question 1

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable?

A) Psychosocial background
B) Developmental stage
C) Research findings
D) Current standards of care

Answer 1

Psychosocial background

Question 2

The primary purpose of nursing implementation is to:

A) improve the client's postoperative status.
B) identify a need for collaborative consults.
C) help the client achieve optimal levels of health.
D) implement the critical pathway for the client.

Answer 2

help the client achieve optimal levels of health.

Question 3

A client has terminal cancer and the practitioner has ordered a diagnostic imaging test. The client tells the nurse, "I don't want the test performed." So the nurse agrees to dialogue with the practitioner on the client's behalf. The nurse's actions are what type of intervention?

A) Surveillance
B) Supportive
C) Coordinating
D) Technical

Answer 3

Coordinating

Question 4

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention?

A) Supportive
B) Surveillance
C) Collaborative
D) Maintenance

Question 5

When the nurse prepares to discharge a client, and subsequently evaluates the effectiveness of the nursing care, the nurse should determine whether the:

A) physician orders have been completed.
B) client's goals have been achieved.
C) critical pathways are completed.
D) documentation is thorough.

Question 6

What guides professional practice?

A) ANA Standards of Nursing Practice
B) National Institutes of Health publications
C) Nursing Intervention Classification
D) Risk Appraisal Index

Question 7

The primary purpose for evaluating data about a client's care according to a functional health approach is to:

A) meet accreditation standards.
B) determine implementation of medical orders.
C) evaluate the need for healthcare consultations.
D) revise or modify the nursing care plan.

Question 8

Which is a major premise of a quality improvement program? Select all that apply.

A) It determines whether nursing standards are being upheld.
B) Some governmental agencies mandate quality improvement programs.
C) It focuses on processes rather than individuals.
D) It should ideally be performed one to two times per year.
E) Its focus is on ensuring excellence in care.

Question 9

The nurse participates in a quality assurance program and reviewing evaluation data from the previous year. Which does the nurse recognize as an example of outcome evaluation?

A) A 4% increase in the number of baccalaureate prepared nurses are employed in the facility.
B) A 97% bed occupancy rate in the critical care areas; 92% bed occupancy rate in the noncritical care areas.
C) A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery.
D) 98% of all hospital admissions had a nursing history completed within 24 hours of admission.

Question 10

Which nursing action reflects evaluation?

A) The nurse identifies that the client has wound drainage.
B) The nurse sets an anxiety level of 3 or less with the client.
C) The nurse performs a colostomy irrigation.
D) The nurse assesses the client's response to pain medication.

Question 11

What are the two priority nursing diagnoses? Select all that apply.

A) Risk for infection
B) Anxiety
C) Acute pain
D) Ineffective airway clearance
E) Feeding self-care deficit

Question 12

After the nursing plan of care has been developed, the nurse knows that:

A) each client encounter is an opportunity to reassess and revise the plan if necessary.
B) the plan will be followed by other healthcare providers and filed with the client's chart upon discharge.
C) the responsibility for the assessment of the client has ended.
D) care plans are rigid and do not change.

Question 13

Which statement describes the purpose of evaluation? Select all that apply.

A) To examine the client's behavioral responses to nursing interventions
B) To appraise the extent to which client goals were attained or problems resolved
C) To appraise involvement and collaboration of the client, family members, nurses, and healthcare team members in healthcare decisions
D) To ensure the plan of care was followed as it was originally prepared
E) To collect subjective and objective data to make judgments about nursing care delivered

Question 14

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:

A) process.
B) outcome.
C) goal.
D) structure.

Question 15

The nursing supervisor is presenting the staff nurse with the nurse's yearly performance evaluation. This type of evaluation would be called:

A) technical evaluation.
B) structural evaluation.
C) process evaluation.
D) goal evaluation.

Question 16

The nurse is assessing the client's behavioral response to a nursing intervention. This type of evaluation is known as:

A) structural evaluation.
B) behavior modification.
C) outcome evaluation.
D) process evaluation.
E) goal evaluation.

Question 17

A client with a recently fractured left femur has been reluctant to comply with physical therapy for fear of the pain associated with movement. A goal for this client is to attend therapy treatments three times each day. The nurse is evaluating the goal for this client. The client states, "I don't like therapy; it hurts, but I have been going twice a day." The client chart has an entry from the last shift nurse stating the client went to therapy two times with encouragement. The nurse evaluates the goal as:

A) goal met.
B) goal partially met.
C) goal completely unmet.
D) goal revision needed.

Question 18

A new mother is having difficulty breastfeeding her newborn infant. A goal was established stating the baby would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports that she discontinued breastfeeding. The nurse evaluates the original goal as:

A) met.
B) partially met.
C) completely unmet.
D) inappropriately chosen for this client.

Question 19

In the implementation step of the nursing process, a nurse is to utilize certain activities to be effective in the care of a client. Which activity is the priority?

A) Reassess client's needs.
B) Document nursing care.
C) Prioritize evaluation of care.
D) Differentiate between subjective and objective data.

Question 20

Which nursing action can be categorized as a surveillance or monitoring intervention?

A) Auscultating of bilateral lung sounds
B) Providing hygiene
C) Administering paracetamol tablet
D) Use of therapeutic communication skills

Question 21

The nurse is discussing dietary options with a client who is upset because the client is unable to have the food the client wants to eat. The nurse states "You may not be able to have steak but can have grilled salmon or grilled chicken. Which do you prefer?" What is the purpose for giving clients options to their care?

A) Allowing the client to have options supports decision-making abilities.
B) Giving the client options makes him feel that he or she controls his or her care.
C) The food choices are available in the menu.
D) The client must eat hospital food that is good for him or her.

Question 22

The nurse is to delegate certain tasks to unlicensed assistive personnel (UAP). Which task can be appropriately assigned to a UAP?

A) Securing the client's jewelry before surgery.
B) Reassessing the client's sacrum for redness when doing bed bath.
C) Providing client assistance to the bedside commode.
D) Requesting the UAP to get the unit of blood from the blood bank.

Question 23

The nurse is assessing the client's self-care capabilities for after discharge from the hospital. Which barrier greatly contributes to the nursing goals being unmet? Select all that apply.

A) The availability of assistive devices
B) Poor communication skills
C) Inadequate emotional coping skills
D) Debilitating illness
E) Family's lack of interest in the plan of care

Question 24

The client complains of right knee pain of 6/10 on the pain scale and requests for medication. The nurse assesses and flushes the IV site before giving the IV pain medication. Which type of intervention skill is the nurse using?

A) Interpersonal skill
B) Intellectual skill
C) Technical skill
D) Mechanical skill

Question 25

Which purpose of the evaluation phase of the nursing process is a priority during client care?

A) Examining the client's behavioral response to the care received.
B) Providing basis for the revision of plan of care.
C) Monitoring the quality and effects of the nursing care.
D) Appraising collaboration of the client and family.