Deck 15: Implementing and Evaluating

Question 1

During the process of implementing cares and treatments for a client, the nurse realises there are several entities included in this phase.

A) Evaluating the outcome of the interventions.
B) Reassessing the client.
C) Documenting the history and physical.
D) Supervising delegated care.
E) Implementing the nursing interventions.

Answer 1

Reassessing the client.
Supervising delegated care.
Implementing the nursing interventions.

Question 2

The nurse understands that respect for the dignity of the client is extremely important in providing nursing care. Which of the following is an example of this aspect?

A) Providing all cares to all clients whenever possible.
B) Telling the other staff that the client is demanding, so they are able to meet the client's needs.
C) Presenting information to the client's family about the client's condition.
D) Encourage clients to participate in their own hygienic cares.

Answer 2

Encourage clients to participate in their own hygienic cares.

Question 3

A client is learning how to administer insulin. The nurse makes sure that the client understands how to activate the safety mechanism on the syringe to prevent needlestick injuries. This is an example of which of the guidelines for implementing interventions?

A) Implement safe care.
B) Adapt activities to the individual client.
C) Base nursing interventions on scientific knowledge, research and standards of care.
D) Encourage clients to participate actively in implementing nursing interventions.

Answer 3

Implement safe care.

Question 4

A client is struggling to learn how to care for a new colostomy. The nurse is following the written care plan and has selected to provide written information along with a demonstration on how to accurately measure the stoma for attaching the appliance. Upon entering the room, the client is crying along with the client's spouse. The nurse decides to sit with both of them, offering presence and listening to their fears instead of the planned education. This is an example of which of the following?

A) Supervising delegated care.
B) Determining the nurse's need for assistance.
C) Implementing nursing intervention.
D) Reassessing the client.

Question 5

A nurse is working on a medical unit and assigns an unregulated nursing assistant to take vital signs for several clients. The nursing assistant completes this task and documents them accordingly. One of the clients had a blood pressure reading of 180/110, and it wasn't until the end of the shift that the nurse realised this value. The doctor was notified and orders were received for treatment, but not until much later in the shift. Which of the two responsibilities of delegation did the nurse fail to carry out?

Question 6

The written goal statement in a client's care plan is: Client will have clear lung sounds bilaterally within three days. One of the interventions to meet this goal is that the nurse will teach the client to cough and deep breathe and have the client do this several times every two hours. At the end of the third day, the client's lungs are indeed clear. In order to relate the intervention to the outcome, the nurse should:

A) write this evaluation statement: Goal met, lung sounds clear by third day.
B) tell the client that the lungs are clear.
C) ask how many times per day the client practiced the coughing and deep breathing exercises.
D) document the assessment findings to show the effectiveness of the intervention.

Question 7

In the nursing process, the implementation phase consists of:

A) carrying out interventions developed during planning care.
B) evaluating care previously undertaken.
C) assessing the client's response to treatment.
D) auditing concurrent data.

Question 8

The student nurse must accurately perform a sterile dressing change before completing a unit of the course. This student is being evaluated on which of the following?

A) Technical skill.
B) Academic skill.
C) Cognitive skill.
D) Interpersonal skill.

Question 9

A nurse has provided routine morning cares to a client, including all the medications and scheduled treatments. The most appropriate action after this is completed is for the nurse to:

A) get supplies organised for the next client's medications and treatments.
B) report this to the Nurse Unit Manager.
C) document all cares in the progress notes.
D) move on to the next assignment to increase the nurse's efficiency.

Question 10

A new graduate nurse was working with a nurse mentor during the first three months of employment. On one of the first days working alone, the graduate nurse is assigned to care for a client with a new tracheostomy and must provide teaching to the client as well as the client's spouse. This nurse is not familiar with the teaching aspect. The best action for the nurse is to:

A) read the policy and procedure manual before the teaching session.
B) ask for a different assignment until the nurse feels comfortable with this one.
C) do the best the nurse can by remembering what was taught in nursing school.
D) ask the nurse mentor to assist with the teaching after reviewing the procedure.

Question 11

A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhoea and vomiting was implemented for a home health client who began with these symptoms five 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 diarrhoea or vomiting for the past five days. The nurse should:

A) document that the problem has been resolved and discontinue the care for the problem.
B) assume that whatever the cause was, the symptoms may return, but document that the goal was met.
C) keep the problem on the care plan, in case the symptoms return.
D) document that the potential problem is being prevented since the symptoms have stopped.

Question 12

During the process of implementing cares and treatments for a client, the nurse realises there are several processes included in the phase.

A) Evaluating the outcome of the interventions.
B) Reassessing the client.
C) Documenting the history and physical signs.
D) Implementing the nursing interventions.
E) Supervising delegated care.

Question 13

A nurse works in an acute psychiatric setting and sees clients as they are admitted for inpatient psychiatric care. Many of the clients exhibit paranoid behaviour. The most important skill this nurse can utilise for these clients is which of the following?

A) Cognitive skill.
B) Therapeutic skill.
C) Technical skill.
D) Interpersonal skill.

Question 14

The goal statement for a client's care plan reads as follows: Client will be able to state two positive aspects of rehab therapy by the end of the week. Which of the following is an appropriately written evaluation statement?

A) Goal not met, client able to state one positive aspect by the end of the week.
B) Goal met, client able to state two positive aspects of therapy by week's end.
C) Goal met, client able to state one positive aspect by the end of the week.
D) Goal incomplete, client not able to positively state anything about rehab.

Question 15

The nurse is teaching a client about his medication that must be taken with food in the morning. The client states that he didn't 'like the idea' of swallowing tablets early. The nurse should:

A) tell him to take it when it suited him.
B) tell him how the medication works and why it has to be with food.
C) tell him it doesn't matter if he takes it at all.
D) give lots of advice and suggestions about different tablets.

Question 16

A client had an outcome goal stated as follows: Client will have a decrease in pain level (down to a three) within 45 minutes of receiving oral analgesic. Which statement by the client will the nurse use to evaluate this goal?

A) "I still have some pain."
B) "I'm getting really sleepy from that medication. I think I'll take a nap."
C) "My pain is a four."
D) "Will the pain ever go away?"

Question 17

A nurse is working in a busy research hospital. One of the clients assigned to the nurse's care is to receive a medication that the nurse is not familiar with and is not listed in the drug reference manual. The best action of the nurse is to:

A) call the physician and ask what the medication is and what it is for.
B) ask the client about this medication.
C) follow the physician's orders as written and give the medication.
D) call the pharmacy and do further investigating before administering the medication.

Question 18

A nursing student does not understand the difference between evaluation and assessment - both are ongoing and both are areas of data collection. In order to differentiate between the two, the student should remember that:

A) the difference is in how the data are used.
B) evaluation is completed at the end of the process.
C) assessment is done at the beginning of the process.
D) they are the same and there is no need to differentiate.

Question 19

The implementing phase of the nursing process includes:

A) enacting and evaluating nursing interventions.
B) analysing and evaluating client data.
C) validating and clustering client data.
D) assessing and planning client problems.

Question 20

The home health nurse must devise a way to administer IV antibiotics to a client who insists on being outside during the infusion. Using creativity and critical thinking, the nurse is able to meet the client's requests. This is an example of which of the following?

A) Technical skill.
B) Creativity.
C) Cognitive skill.
D) Interpersonal skill.

Question 21

When a nurse determines whether a goal has been met, he/she documents an evaluation statement that consists of two parts. What are they?

Question 22

A nursing unit's records of client care have been reviewed for accuracy in documentation. This type of review is which of the following?

A) Individual audit.
B) Concurrent audit.
C) Nursing audit.
D) Peer review.

Question 23

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?

A) The interventions are dependent of nursing.
B) The interventions are not clear enough.
C) The goal is unrealistic.
D) The goal statement is written inaccurately.

Question 24

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

A) Discard the nursing plan and start over from the assessment phase.
B) Modify the whole nursing plan.
C) Review the data and make sure that the diagnosis is relevant.
D) Investigate whether the best nursing interventions were selected.

Question 25

An example of a system that records errors or near misses in client care is ________.

Question 26

An ongoing systematic process of evaluating and promoting excellence in health care delivery in Australia is called:

A) a quality audit.
B) quality assurance.
C) a quality cause analysis.
D) a root cause analysis.

Question 27

A nursing unit has had a large number of negative client responses about various aspects of their care in the previous quarter. The quality assurance officer is evaluating this unit, paying particular attention to which of the components of care?

A) Process.
B) Outcome.
C) Structure.
D) Competency.

Question 28

When undertaking a concurrent audit, the nurse will:

A) review the medical record after the client is discharged.
B) undertake direct observation of client care.
C) undertake a root cause analysis.
D) use the HEAPS framework.