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.

Accepted Answer

The nurse performs evaluative measures,such as completing a wound assessment,to evaluate wound healing.Nurses do not delegate assessment to unregulated care providers.Documenting "better" is subjective and does not objectively describe the wound.Leaving the dressing off for the nurse's benefit of easier access is not a part of the evaluation process.

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.

Accepted Answer

Changing the wound dressing is the only independent nursing action given.The nurse validates what the patient says by observing the dressing.In addition,this option is the only assessment option that involves data validation.Administering pain medicine or potassium and removing a leg cast are examples of nursing interventions.

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.

Accepted Answer

The outcome for the identified nursing diagnosis Acute confusion would address a decrease in or absence of confusion.One sign of orientation is when a patient responds to questions appropriately.Thus,one possible sign that a patient's confusion is improving is that a patient can correctly state the names of family members in the room.Keeping the side rails up and using a bed alarm are interventions to promote patient safety and prevent falls.The patient's denying pain indicates positive progress toward resolving a diagnosis of Acute pain or Chronic pain.The patient's wandering the halls is a sign of confusion.

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."

Accepted Answer

The purpose of evaluation is to determine the effectiveness of nursing care.The other options are not true statements.Evaluation entails more than simply determining whether nursing interventions were completed.The evaluation process is not used to determine when to downsize staffing or how to eliminate paperwork and 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.

Accepted Answer

To determine whether a turning schedule is successful,the nurse needs to assess for the presence of skin breakdown.Redness on any part of the body,including only the patient's heels,indicates that the turning schedule was not successful.Documentation of interventions does not evaluate whether patient outcomes were met.The patient's eating 100% of meals does not indicate the effectiveness of a turning schedule.

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."

Accepted Answer

The skin is made up of several layers.The outer layer is called the epidermis.The second layer of skin is the dermis.The connective tissue under the dermis is called the subcutaneous tissue.This is where subcutaneous injections are given.The abdomen is a good site for subcutaneous injections because this is an area that has a lot of subcutaneous tissue.Using a needle 1/2 inch (1.3 cm)longer than a person's thumb is not an evidence-informed method for measuring needle length necessary for subcutaneous injection.The deltoid is a muscle,not a subcutaneous site.Disposing of needles and syringes into a garbage can creates a biomedical hazard and therefore is not appropriate.

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.

Accepted Answer

In the five-step nursing process,the evaluation phase is the final step involving conducting evaluative measures to determine whether nursing interventions have been effective and whether the patient has met expected outcomes.Assessment,the first step of the process,includes data collection,validation,sorting,and documentation.Planning,the third step of the process,involves setting priorities,identifying patient goals and outcomes,and prescribing nursing interventions.During implementation,nurses initiate nursing care,which is necessary to help patients achieve their goals.

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."

Accepted Answer

Evaluative measures are used to determine whether patients have met their goals and outcomes.Evaluative measures are not multiple-page documents,and they are used to assess the patient's status,not the nurse's performance.Evaluative measures are not used for completing an incident report.

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."

Accepted Answer

A nursing-sensitive outcome is a measurable patient or family statement,behaviour,or perception that is largely influenced by and sensitive to nursing interventions.Patient falls are one nursing-sensitive outcome because they are a direct measure of nursing care.Because the prescriber prescribes treatments,the progress of the patient's condition as a result of prescribed treatments is not an evaluation of a nursing-sensitive outcome.Promotion of universal health care and determining staffing ratios are not components of nursing-sensitive outcomes.

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."

Accepted Answer

The nurse evaluating interventions for the diagnosis Disturbed body image is assessing for positive comments made by the patient that indicate acceptance of the patient's looks and body image.The only positive comment made is that the patient is wearing the blue dress to match her eyes.The other comments do not reflect positive changes in body image.

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.

Accepted Answer

Goals are broad statements that describe changes in a patient's condition or behaviour.Expected outcomes are shorter term measurable criteria used to evaluate goal achievement.When an outcome is met,the patient is making progress toward goal achievement.In this case,the patient's goal is to not experience shortness of breath with activity in 3 days.One way to achieve this goal is to eliminate respiratory secretions in the airway.The nurse can evaluate this expected outcome by assessing the patient's lung sounds.If the lung sounds are clear,at least periodically throughout the day,the nurse can determine that the patient is making progress toward achieving the expected outcome.The time frame of 4 days in the first option is not appropriate because this time frame exceeds the time frame stated in the goal.Scattered rhonchi indicate fluid in the lungs,and a respiratory rate of 30 per minute is higher than normal.Either of these indicates that the patient is still probably experiencing respiratory distress.

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.

Accepted Answer

A collaborative,or interdependent,intervention requires the combined knowledge,skill,and expertise of multiple health care professionals.A dependent intervention requires an order from a health care provider.An independent intervention is an action that the nurse initiates.

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.

Accepted Answer

After a change in the patient's condition or an untoward event,the nurse attempts to identify factors interfering with goal achievement.In this case,the nurse identifies the factors that interfered with goal achievement to determine the cause of the fall.The fall may not have been due to an error by the unregulated care provider;therefore,counselling should be reserved until after the cause has been determined.The patient remains at risk for falls,so the "fall risk" sign should remain on the door.The nurse witnessing the fall or the nurse assigned to the patient needs to complete the documentation.The charge nurse can be consulted to review the documentation.

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.

Accepted Answer

An outcome is an expected,favourable,and measurable result of nursing care.The patient's being able to ambulate in the hallway with crutches is an expected outcome of nursing care.Improvement in the patient's level of mobility is a broader goal.The nurse's assisting a patient to ambulate is an intervention.The patient's denial of pain is an expected outcome for Acute pain,not for Impaired physical mobility.

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.

Accepted Answer

The nurse needs to evaluate whether goals and outcomes have been met before revising,continuing,or discontinuing a plan of care.The patient needs transportation,but that does not address the patient's mobility status.Whether the patient has a follow-up appointment and ensuring that prescriptions are filled are not immediately relevant to the problem of mobility.

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.

Accepted Answer

The nurse does not have prescriptive authority to order pain medications,unless the nurse is an advanced practice nurse.The intervention is therefore dependent.A collaborative,or interdependent,intervention involves therapies that require combined knowledge,skill,and expertise from multiple health care providers.An independent intervention does not require an order or collaboration with other health care providers.

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.

Accepted Answer

Based on evaluative data,the nurse revises,discontinues,or continues a patient's plan of care.Because the dressing is saturated,the nurse needs to revise the plan of care and change the dressing now.Waiting until 1800 or for another hour is not appropriate because assessment data-that the dressing is saturated-indicate that the dressing needs to be changed now.Data are insufficient to support discontinuing the plan of care.Instead,data at this time indicate the need for revision of 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.

Accepted Answer

In the five-step nursing process,evaluation is the last step,following assessment,diagnosis,planning,and intervening.Assessment involves gathering information about the patient.Next,nursing diagnoses are determined.During the planning phase,patient outcomes are determined.Implementation involves carrying out appropriate nursing interventions.

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.

Accepted Answer

Evaluative data that show signs of effective coping will help the nurse determine whether the patient has met the outcome.Among the options listed,talking to family and friends is the only positive one.The other behaviours indicate unsuccessful progress toward meeting the patient's goal.

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.

Accepted Answer

The nurse's next priority action for this patient is to evaluate whether the nursing intervention of administering acetaminophen was effective.The nurse does not have enough evaluative data at this point to determine whether the nursing diagnosis of Acute pain needs to be deleted.Assessment is the nurse's responsibility and is not to be delegated to an unregulated care provider.The nurse does not have enough evaluative data to determine whether the patient's plan of care needs to be revised.

Quiz 14: Implementing and Evaluating Nursing Care

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?

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

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

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?

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

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 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 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?

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?

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

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

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?

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 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?

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?