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

Accepted Answer

The nurse is demonstrating an awareness of the client's psychosocial background, which includes consideration of the client's socioeconomic status. Research findings and current standards of care are examples of nursing variables. Developmental stage is a client variable that addresses the developmental needs of a client.

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.

Accepted Answer

The purpose of the nursing implementation phase is to help the client achieve an optimal level 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

Accepted Answer

Coordination involves acting as a client advocate, making referrals for follow-up care, collaborating with other healthcare team members, and ensuring that the client's schedule is therapeutic. This is not a surveillance or technical type of intervention. The nurse is being supportive of the client, but advocacy is more closely associated with coordinating types of interventions.

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

Accepted Answer

Surveillance nursing interventions include detecting changes from baseline data and recognizing abnormal responses.

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.

Accepted Answer

Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals based on the client's behavioral responses. This phase involves a thorough, systematic review of the effectiveness of nursing interventions and a determination of client goal achievement.

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

Accepted Answer

Standards of care guide professional practice and serve as the framework for the evaluation practice.

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.

Accepted Answer

Evaluation using the functional health approach provides a framework for organizing and evaluating data.

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.

Accepted Answer

The major premises of quality improvement include a focus on processes and standards that lead to quality care. Numerous governmental agencies either encourage or require quality improvement. It is an ongoing process that is not necessarily an annual or biannual event.

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.

Accepted Answer

Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. Structure evaluation focuses on the environment in which care is provided, such as the number of baccalaureate-prepared nurses employed in the facility and bed occupancy rates. Process evaluation focuses on the nature and sequence of activities carried out by nursing implementing the nursing process, such as 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.

Accepted Answer

Examples of evaluation include assessing the client's response to pain medication. The focus of diagnosing is recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as a wound infection. Setting an anxiety rating with the client is an example of planning. Performing colostomy irrigation is an example of implementation.

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

Accepted Answer

While all are important diagnoses, respiratory function and pain are priority.

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.

Accepted Answer

During each encounter with clients, nurses assess function, ensuring prompt attention to emerging problems. Because a client's condition can change quickly and dramatically, astute nurses remain alert to subtle cues and inferences. As they initiate the plan of care, nurses must ensure that the planned interventions are still relevant.

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

Accepted Answer

Nurses always consider evaluation in light of how the client responded or reacted to the planned course of action. Figure 9-4 illustrates the relationship of the activities of the evaluation phase to the other phases of the nursing process. There are several purposes for carrying out evaluation:
to examine the client's behavioral responses to nursing interventions; to compare the client's behavioral responses with predetermined outcome criteria; to appraise the extent to which client goals were attained or problems resolved; to appraise involvement and collaboration of the client, family members, nurses, and healthcare team members in healthcare decisions; to provide a basis for the revision of the plan of care evaluation; to collect subjective and objective data to make judgments about nursing care delivered; and to monitor the quality of nursing care and its effect on the client's health status (Alfaro-LeFevre, 2010; Carpenito-Moyet, 2009). Specific activities during this phase include the following: reviewing client goals and outcome criteria, collecting data, measuring goal attainment, recording judgments or measurements of goal attainment, and revising or modifying the client's plan of care.

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.

Accepted Answer

Availability of equipment, layout of physical facilities, nurse-client ratios, administrative support, and maintenance of nursing staff competence are some areas of concern for structure evaluation.

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.

Accepted Answer

Process evaluation focuses on the nurse's performance and whether the nursing care provided was appropriate and competent. The phases of the nursing process are used as the framework for the evaluation of nursing care.

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.

Accepted Answer

Outcome evaluation, which focuses on the client and the client's function, is currently receiving a great deal of emphasis. Outcome evaluation determines the extent to which the client's behavioral response to nursing intervention reflects the desired client goal and outcome criteria.

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.

Accepted Answer

After collecting data, nurses form a comprehensive picture of the client's behavioral responses. The next activity is to make a judgment about goal attainment by comparing the client's actual behavioral responses to the predicted responses or predetermined outcome criteria developed in the planning phase.

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.

Accepted Answer

After collecting data, nurses form a comprehensive picture of the client's behavioral responses. The next activity is to make a judgment about goal attainment by comparing the client's actual behavioral responses to the predicted responses or predetermined outcome criteria developed in the planning phase.

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.

Accepted Answer

Competence in intellectual, interpersonal, and technical skills is required to carry out the implementation phase. Nurses can delegate parts of the plan of care to other members of the healthcare team, but the registered nurse (RN) maintains accountability for the supervision and evaluation of these people. Figure 9-1 illustrates the activities of implementation, which include the following: (a) reassess, (b) set priorities, (c) perform nursing interventions, (d) record nursing actions.

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

Accepted Answer

Surveillance or monitoring nursing interventions includes detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone; detecting odors and comparing them with past experience and knowledge of specific problems; and using touch to assess body temperature, skin condition, clamminess, or diaphoresis. Nurses use all of these surveillance or monitoring activities to determine the current status of clients and changes from previous states. Nurses often detect subtle changes in a client's condition and communicate them to the physician to minimize problems.

Quiz 9: Implementation and Evaluation

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?

The primary purpose of nursing implementation is to:

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?

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?

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

What guides professional practice?

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

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

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?

Which nursing action reflects evaluation?

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

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

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

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:

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

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

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?

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