Deck 7: Nursing Process: Implementation Evaluation

Question 1

The certified nursing assistant (CNA)is feeding a patient and notes that the patient is having difficulty swallowing.She reports this to the primary registered nurse.What should the nurse do first?

A) Assign the task to a more experienced CNA
B) Feed the patient herself
C) Assess the patient and place on NPO status
D) Call the primary care provider

Answer 1

Assess the patient and place on NPO status

Question 2

Which of the following is a client outcome criterion?

A) Central venous catheter site infection does not occur (90% of cases).
B) Client will sit out of bed in the chair for 20 minutes three times per day.
C) Postoperative phlebitis does not occur (95% of cases).
D) Falls in the facility will reduce by 2% this quarter.

Answer 2

Client will sit out of bed in the chair for 20 minutes three times per day.

Question 3

Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP)about delegating a task?

A) "Record how the patient's intake and output of fluids, please"
B) "Take the patient's temperature, pulse, respirations, and blood pressure every 2 hours today."
C) "Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)."
D) "Assist the patient with all of her meals so she will take in more calories."

Answer 3

"Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)."

Question 4

Which task can be delegated to nursing assistive personnel (NAP)?

A) Turn and reposition the patient every 2 hours.
B) Assess the patient's skin condition.
C) Change pressure ulcer dressings every shift.
D) Apply hydrocolloid dressing to the pressure ulcer.

Question 5

The nurse is preparing to insert a Foley catheter for her patient.What is the best strategy for the nurse to use to perform this insertion in a timely and efficient manner?

A) Call another nurse to assist with the procedure
B) Gather all supplies and equipment before entering the patient room
C) Instruct and explain the procedure to the patient
D) Check the patient's schedule for the day for the most convenient time

Question 6

When should the nurse collect evaluation data for this expected outcome? "Patient will maintain urine output of at least 30 mL/hour."

A) At the end of the shift
B) Every 24 hours
C) Every 4 hours
D) Every hour

Question 7

The second-year nursing student is in her clinical rotation on a medical-surgical unit.What is the most appropriate strategy that the student can use to assist her in organizing and prioritizing patient care for the day?

A) Ask the nurse what tasks need to be completed for the day
B) Make a time-sequenced "to do" list for her activities for the day
C) Ask the instructor what needs to be completed for the day
D) Ask the patient what needs to be completed for the day

Question 8

Which statement accurately describes delegation?

A) Transferring authority to another person to perform a task in a selected situation
B) Collaborating with other caregivers to make decisions and plan care
C) Scheduling treatments and activities with other departments
D) Performing a planned intervention from a critical pathway

Question 9

The nurse reviews a nursing order for a patient who is 4 days post-operative after hip surgery.It reads: Assist patient in bathing each morning.The nurse assesses the patient and notes that the patient is independent in bathing.What should the nurse do next?

A) Assist with the bath as ordered
B) Delegate the bath to the nursing assistant
C) Discontinue the nursing order on the plan of care
D) Collaborate with the nurse who originally wrote the order

Question 10

A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative.How should the nurse proceed?

A) Ask a colleague for help, because the nurse cannot safely perform the procedure alone.
B) Gather the equipment and prepare it before informing the client about the procedure.
C) Obtain an order to restrain the client before inserting the urinary catheter.
D) Inform the primary provider that the nurse cannot perform the procedure because the client is confused.

Question 11

Which type of client-centered evaluation is performed at specific,scheduled times?

A) Intermittent
B) Ongoing
C) Terminal
D) Process

Question 12

Which of the following is the most valid criterion for determining the status of a patient's anxiety at discharge? The patient:

A) Has a relaxed facial expression
B) Reports that he feels more relaxed today
C) Shows no physiological signs of anxiety (e.g., pallor)
D) Asks no further questions about home care

Question 13

The nurse works with the respiratory therapist to administer a patient's breathing treatments.He reports the patient's breathing status and tolerance of the treatment to the primary care provider.The nurse then discusses with the patient the options for further treatment.This is an example of:

A) Delegation
B) Collaboration
C) Coordination of care
D) Supervision of care

Question 14

Before inserting a nasogastric tube,the nurse reassures the client.Reassuring the client requires which type of nursing skill?

A) Psychomotor
B) Interpersonal
C) Cognitive
D) Critical thinking

Question 15

A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia.This medication is unfamiliar to the nurse,and she cannot find it in the hospital formulary or other references.How should she proceed?

A) Administer the medication as ordered.
B) Hold the medication and notify the prescriber.
C) Consult with a pharmacist before administering it.
D) Ask the patient's RN for information about the medication.

Question 16

The nurse reviews the patient chart and sees a physician prescription for a new medication.The nurse is able to clearly read the medication name but the dose is not legible.What is the best action by the nurse?

A) Contact the physician for clarification.
B) Ask another nurse to read the order.
C) Ask the unit secretary to read the order.
D) Contact the pharmacist to read the order.

Question 17

The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus.Which intervention by the nurse best promotes client cooperation with the treatment plan?

A) Teaching the client that he must lose weight to control his blood sugar
B) Informing the client that he must exercise at least three times per week
C) Explaining to the client that he must come to the diabetic clinic weekly
D) Determining the client's main concerns about his diabetes

Question 18

Which of the following is the best example of the implementation phase of the nursing process?

A) Patient verbalizes pain is reduced from an 8 to a 3 after receiving pain medication.
B) Nurse observes that patient has a small, quarter-sized skin tear over coccyx area.
C) Nurse writes in the care plan: Patient requires 2 person assist with ambulation to bathroom.
D) Nurse inserts Foley catheter after reporting to physician patient's inability to void.

Question 19

Which criterion might be used in structure evaluation?

A) "Staff refrains from sharing computer passwords."
B) "Healthcare provider washes hands with each client contact."
C) "A defibrillator is present on each client care area."
D) "Nurse verifies client identification before initiating care."

Question 20

Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)?

A) Nurse who delegated the task
B) LPN working with the NAP
C) Unit nurse manager
D) Charge nurse for the shift

Question 21

Which of the following is the most appropriate task(s)to be delegated to the licensed practical nurse (LPN)? Select all that apply.

A) Administer oral pain medications
B) Insert an indwelling (e.g., Foley) catheter
C) Perform an admission assessment on a new patient
D) Establish a new teaching plan for a diabetic patient

Question 22

Which of the following nursing activities is most reflective of the evaluation phase of the nursing process?

A) Administering pain medication prior to changing a complex wound dressing
B) Obtaining patient's blood pressure 30 minutes after administering blood pressure medication
C) Reporting that there have been three patient falls in the past month on the nursing unit
D) Teaching the patient how to perform daily Accu-Cheks for blood sugar readings

Question 23

The nurse has just completed wound care on her patient who has a large abdominal wound.What should the nurse do soon after this is completed? Select all that apply.

A) Assess the patient's response to the procedure
B) Teach the patient about the procedure
C) Document the procedure in the nursing progress notes
D) Ask the patient to assist in the wound care at the next scheduled dressing change

Question 24

The nurse and nursing assistive personnel (NAP)are caring for a group of patients on the medical-surgical floor.For which of the following patients can the nurse delegate to the NAP the task of bathing? Select all that apply.

A) 75-year-old patient newly admitted with dehydration
B) 65-year-old patient hospitalized for a stroke, whose blood pressure reading is 189/90 mm Hg
C) 92-year-old patient with stable vital signs who was admitted with a urinary tract infection
D) 56-year-old patient with chronic renal failure who has vital signs within his normal range