Exam 14: Implementing and Evaluating

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?

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?

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?

A nursing unit's records of client care have been reviewed for accuracy in documentation.Which type of review is being completed on these records?

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

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?

The nurse is implementing care and treatments for assigned clients.What actions should the nurse prepare to complete during this phase of the nursing process? (Select all that apply)

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?

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?

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?

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?

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?

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?

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?

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

The nurse reviews clients' records and the care they received while in the hospital for an insurance company.Part of the job description requires the nurse to make sure that the client and insurance company were billed for services and treatment/therapies rendered and that there were no errors in billing.Which type of audit is the nurse completing?

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?

The nurse is evaluating care provided to a client.Which nursing actions indicate that the phases of evaluation were completed by the nurse appropriately? (Select all that apply)

A nursing unit has had a large number of negative client responses about various aspects of their care in the previous quarter.When evaluating this care area,on which care component should the quality assurance officer focus?

After implementing interventions and reassessing the client's response,the nurse completes the process by evaluating.What attributes of evaluation should the nurse include when completing this step of the nursing process? (Select all that apply)