Exam 14: Implementing and Evaluating Nursing Care

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 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?

Which intervention is most appropriate for the nursing diagnosis Impaired skin integrity related to shearing forces?

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 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?

Which intervention is most appropriate for the nursing diagnosis Impaired verbal communication related to loss of facial motor control and decreased sensation?

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 nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity.The patient needs many nursing interventions,including a dressing change,several intravenous antibiotics,and a walk.What actions does the nurse consider when prioritizing interventions? (Select all that apply. )

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

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 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 patient has reduced muscle strength after a left-sided stroke and is at risk for falling.Which intervention is most appropriate for the nursing diagnosis Risk for falls?

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

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?

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

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?

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?

Which of the following are examples of evaluative measures that a nurse should utilize when determining the patient's response to nursing care? (Select all that apply. )

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?