Question 1

A client has the goal statement "Client will be able to state two positive aspects of rehab therapy by the end of the week." What statement demonstrates that the nurse appropriately evaluated this goal?

Accepted Answer

The best choice is C because it demonstrates that the client has achieved the goal of being able to state two positive aspects of rehab therapy by the end of the week. This is the expected outcome of the goal statement and indicates that the client has made progress in their rehab therapy. Choices A, B, and D do not accurately reflect the client's progress towards the goal or the appropriateness of the evaluation.

Question 2

A client is prescribed a medication that the nurse has never administered and information about the medication is not in the drug reference manual.What should the nurse do?

Accepted Answer

The nurse should not administer a medication that they are not familiar with or that is not in the drug reference manual. Instead, the nurse should contact the pharmacy and obtain more information about the medication before administering it. This will ensure that the medication is administered safely and effectively.

Question 3

During teaching,the nurse makes sure the client understands how to activate the safety mechanism on the syringe to prevent needlestick injuries when self-administering insulin.Which guideline of implementing interventions is the nurse using?

Accepted Answer

The nurse is focusing on implementing safe care by ensuring the client knows how to use the safety mechanism on the syringe to prevent needlestick injuries.

Question 4

The nurse manager has been appointed to implement a quality assurance program at the hospital.Which components should the manager prepare to evaluate for this program?

Accepted Answer

The answer of The nurse manager has been appointed to...

Question 5

The nurse is preparing to provide care planned for a client.What actions should the nurse complete during this phase of client care?

Accepted Answer

The answer of The nurse is preparing to provide care...

Question 6

The home health nurse uses creativity and critical thinking to devise a way for a client to receive intravenous medication while sitting outside on the porch.Which skill did the nurse use for this situation?

Accepted Answer

The nurse used cognitive skills, which involve critical thinking and problem-solving to devise a solution for administering medication in a non-traditional setting.

Question 7

A teenage client has been having problems with peer support,school performance,and parental expectations,all of which contributed to an eating disorder.After gathering this assessment data,the nurse formulates the diagnosis Activity Intolerance related to weakness.What should the nurse realize after evaluating this diagnosis?

Accepted Answer

Activity intolerance is a diagnosis that indicates a decreased ability to initiate or sustain activity and can be related to physical, emotional, or psychological factors. While the client may indeed be experiencing weakness as a result of the eating disorder, there is no clear evidence from the assessment data that this weakness is directly related to her decreased ability to engage in activities. Therefore, the diagnosis of activity intolerance may not be supported by the data collected. A different diagnosis that better reflects the client's specific strengths and limitations should be considered.

Question 8

On one of the first days working alone,the new nurse with limited patient teaching experience needs to instruct tracheostomy care to a client and spouse.What action should the nurse take?

Accepted Answer

The nurse should ask the nurse mentor to assist with the teaching after reviewing the procedure. This will ensure that the nurse can provide accurate and comprehensive patient teaching, which is important in maintaining patient safety and preventing complications. The nurse mentor can also provide feedback and guidance to help the new nurse improve their teaching skills. Reading the policy and procedure manual and relying on past nursing school education may not be sufficient in ensuring safe and effective patient care. Asking for a different assignment may delay the new nurse's learning and growth in their role.

Question 9

Upon entering a room,a client and spouse are found crying.The nurse decides to sit with both of them,offering presence and listening to their fears instead of providing the planned education.What action did the nurse perform?

Accepted Answer

The answer of Upon entering a room,a client and spouse...

Question 10

The nurse is caring for a new mother and infant.Which action should the nurse take that allows the new parents to feel in control when being taught how to bathe their infant?

Accepted Answer

Allowing the parents to bathe the baby with direction and guidance from the nurse gives them a sense of control and autonomy in caring for their infant. It also provides an opportunity for them to practice the skill and receive feedback from the nurse. Option A is important, but it may not provide enough opportunity for parents to actively participate. Option B is passive learning and still requires the nurse to perform the bath initially. Option D may overwhelm the parents and make them feel less in control.

Question 11

The nurse provides routine morning care to a client,including all the medications and scheduled treatments.What action should the nurse make next?

Accepted Answer

Documentation is a crucial part of nursing care and should be done promptly and accurately. It provides evidence of the care provided, potential changes in the client's condition, and communication with other healthcare professionals. The nurse should document all care in the progress notes to ensure that it is complete and accurate.

Question 12

The nurse provides care to clients admitted to a mental health facility who exhibit paranoid behavior.Which skill should the nurse use when caring for these clients?

Accepted Answer

Interpersonal skills are essential for nurses caring for clients with paranoid behavior, as they involve establishing trust, building rapport, and communicating effectively to reduce anxiety and promote a sense of safety.

Question 13

A home care client must correctly self-administer insulin injections before being discharged from the agency.On what skill is this client being evaluated?

Accepted Answer

The client is being evaluated on their technical skill, as administering insulin injections requires the ability to perform a specific physical task correctly.

Question 14

A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss,secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago.A goal was that the client's symptoms would be eliminated within 48 hours.The client is being seen after a week,and has had no diarrhea or vomiting for the past 5 days.What should the nurse do?

Accepted Answer

The goal of eliminating the client's symptoms has been met as they have had no diarrhea or vomiting for the past 5 days. Therefore, the nurse should document that the problem has been resolved and discontinue the care for the problem. Keeping the problem on the care plan or assuming that the symptoms may return without any evidence to support it would not be warranted. Documenting prevention of a potential problem is also not appropriate as the problem had already occurred and has now been resolved.

Question 15

A client has the goal statement "Client will have clear lung sounds bilaterally within 3 days." One intervention to meet this goal is for the nurse to teach the client to cough and deep breathe and have the client do this several times every 2 hours.At the end of the third day,the client's lungs are indeed clear.What should the nurse do to relate the intervention to the outcome?

Accepted Answer

The answer of A client has the goal statement "Client...

Question 16

A care area has been short staffed for the past month with a heavy client load and high acuity.The nurses have been working extra as well as double shifts and often do not have time to make sure that properly working equipment is cleaned,returned,and stored in the appropriate areas.At what level should this care area be evaluated?

Accepted Answer

The situation described involves issues related to the availability and management of resources, which falls under the "Structure" level of evaluation. This includes staffing, equipment, and facilities necessary for providing care.

Question 17

The nurse is providing care to an assigned client.Which action indicates that the nurse supports the client's respect for dignity?

Accepted Answer

Allowing the client to complete hygienic care when possible supports the client's independence and respect for their own capabilities, which is a key aspect of dignity. Providing all care to the client whenever possible may discourage the client's independence and undermine their dignity. Telling other staff that the client is demanding can damage the client's reputation and decrease respect for their dignity. Presenting information to the client's family about the client's condition may be important, but it is not directly related to the client's respect for dignity.

Question 18

The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse.What should the nurse emphasize as the major difference between these two steps in the nursing process?

Accepted Answer

Assessment involves collecting data to understand the patient's condition, while evaluation involves analyzing the data to determine if the patient's goals have been met. The difference lies in the purpose and use of the data collected.

Question 19

A client has neurologic deficits that are causing tremors,unsteadiness,and weakness.An appropriate diagnosis of Risk for Falls related to unsteady gait,secondary to neurologic dysfunction has been formulated.A goal for this client is not to sustain any injuries for the next month;however,the client has fallen several times.In this situation,what should the nurse do?

Accepted Answer

The nurse should investigate whether the best nursing interventions were selected as falls have still occurred despite the established nursing plan. This may involve reassessing the client's needs and identifying any gaps in the nursing interventions provided. Modification of the nursing plan may be necessary to increase effectiveness in preventing falls. Reviewing the data and diagnosis, as well as discarding the nursing plan and starting over, may not necessarily address the issue of falls and may not be the most appropriate course of action.

Question 20

A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process.The goal statement is as follows: Client will be free of pain within 48 hours.As an intervention,the nurse will administer narcotic analgesics and titrate to an appropriate level.What is the flaw in this plan?

Accepted Answer

The goal statement is unrealistic for a client with terminal cancer, as it may not be possible to completely alleviate their pain within 48 hours. The nurse should work with the client and healthcare team to establish a more realistic and achievable goal for pain management, such as reducing the severity of the pain and improving the client's quality of life.

Quiz 14: Implementing and Evaluating