Deck 6: Implementation and Evaluation

Question 1

The nurse compares actual nursing outcomes to the expected nursing outcomes in order to:

A) prepare the patient to be discharged from the facility.
B) determine if the patient's health problems have been treated.
C) calculate charges for nursing services during the patient's hospital stay.
D) determine if progress is made or to determine if revisions are needed.

Answer 1

determine if progress is made or to determine if revisions are needed.

Question 2

The nurse is assessing a patient who just returned from a bowel resection 1 hour ago. The nurse notes a dressing over the suture line that is wet with sero sanguineous drainage. The nurse should initially:

A) perform a sterile dressing change.
B) document and report the wet dressing to the charge nurse.
C) reinforce the wet dressing and document.
D) place a towel on the bed and turn the patient to the operated side.

Answer 2

reinforce the wet dressing and document.

Question 3

During morning care in a skilled nursing facility, the student nurse notices that the patient who is at risk for impaired skin integrity has developed a small open area on his sacrum. To best address this situation, the student would first:

A) position the patient to lie on his side, document it, and inform the head nurse.
B) position the patient on his side and encourage him to massage around the area.
C) report to the primary care provider so that the nursing care plan can be revised.
D) tell the nursing assistant to change the patient's position every 2 hours.

Answer 3

position the patient to lie on his side, document it, and inform the head nurse.

Question 4

The general rule is that the initial care plan for a patient is:

A) developed by an RN in an acute care setting.
B) used as the basis of care throughout a hospital stay without alteration.
C) completed on the day of admission.
D) developed by the primary care provider and incorporated into the nursing care.

Question 5

The nurse administering a medication to a patient is performing an intervention that is:

A) an independent nursing action.
B) an interdependent nursing action.
C) a semi-dependent nursing action.
D) a dependent nursing action.

Question 6

At the 7:00 AM handoff report, the nurse receives the report that patient A had a sleepless night related to pain and just fell asleep after an increased pain medication administration 1/2 hour ago. Patient B, who is scheduled for surgery at 8:30 AM, is also sleeping. How would an organized nurse plan the early morning activities?

A) Wake patient A for breakfast.
B) Perform time flexible tasks that can be done while both patients sleep.
C) Prepare patient B now; allow patient A to sleep.
D) Assign a nursing assistant to wake and help feed patient A.

Question 7

Preparing a patient for a diagnostic test, and telling the patient what to expect during and after the test, is considered:

A) an independent nursing action.
B) the doctor's responsibility.
C) a dependent nursing action that requires the doctor's authorization.
D) an interdependent nursing action.

Question 8

The nurse giving a patient a back massage is performing an intervention considered to be:

A) a dependent nursing action.
B) an independent nursing action.
C) an interdependent nursing action.
D) a semi-dependent nursing action.

Question 9

The nurse explains that a multidisciplinary step-by-step approach to patient care is:

A) documented in the nursing care plan in the patient's medical record.
B) not used often since managed care became part of health care.
C) referred to as a clinical pathway and is used instead of a nursing care plan.
D) more expensive than the traditional separation of health care services.

Question 10

The nurse caring for a group of patients would show cultural sensitivity to assign an older male nursing assistant to the care of:

A) a 45-year-old white male patient with uncontrolled diabetes.
B) a 50-year-old Hispanic man with a broken leg.
C) a 55-year-old Japanese man with irritable bowel syndrome.
D) a 60-year-old Muslim woman with pneumonia.

Question 11

The nurse is aware that the nursing audit is a valuable process used to:

A) determine whether a particular patient received the care indicated in the nursing care plan.
B) evaluate whether nursing care for a group of patients meets the standards of care in that facility.
C) determine the cost of nursing care in the hospital in order to set rates for daily care.
D) identify careless or negligent nursing care to protect the facility from lawsuits.

Question 12

Prior to the nurse implementing a nursing procedure for a patient, the nurse should initially:

A) question the rationale for the procedure.
B) perform a physical assessment of the patient.
C) check the agency manual for the procedure.
D) mentally review the procedure.

Question 13

The nurse documents interventions periodically during the shift in nurses' notes primarily to:

A) validate the number of nonlicensed personnel who interact with the patient.
B) indicate that the nursing care plan has been implemented.
C) briefly summarize activities during the shift.
D) confirm that the nursing diagnoses in the care plan are appropriate.

Question 14

Nurses design interventions that are appropriate for a patient that are:

A) based on the primary care provider's orders and the medical diagnosis.
B) expected to help the patient meets the goals most quickly.
C) used to evaluate whether the nursing care plan should be revised.
D) based on cost effectiveness and staff availability.

Question 15

In assigning tasks to the nursing assistant, the nurse could appropriately select:

A) range of motion exercises to lower limbs.
B) sterile dressing change on a leg wound.
C) postoperative education to a post-hysterectomy patient.
D) witnessing of the signature on an operative permit.

Question 16

The nurse is aware that one of the time flexible tasks to be accomplished would be:

A) administering daily insulin 30 minutes before breakfast.
B) taking the patient's vital signs once a day.
C) weighing the patient before breakfast.
D) monitoring a critical patient's vital signs every 15 minutes.

Question 17

A review of a patient's nursing care plan before beginning care allows the nurse to:

A) make revisions in the plan as indicated by the shift report.
B) use critical thinking skills to organize care for the patient.
C) begin nursing interventions without needing an initial assessment.
D) skip the shift report and begin with the initial assessment.

Question 18

Before performing a catheterization, the inexperienced nurse should:

A) close the door or curtains to provide the patient with privacy.
B) provide necessary education and explanation of the procedure to the patient.
C) observe rules of Standard Precautions to protect herself from exposure to blood or body fluids.
D) review the agency's procedure manual for the accepted way of performing the procedure.

Question 19

The nurse evaluates that the patient has met the outcome of feeding himself independently. The nurse should:

A) inactivate the nursing diagnosis from the care plan.
B) notify the primary care provider that the patient can now feed himself.
C) document the ability to self-feed and mark the nursing diagnosis as resolved.
D) inform the RN to document the self-feeding and to cancel the nursing diagnosis.

Question 20

An example of an appropriately worded nursing goal or outcome for the nursing diagnosis of "Risk for falls related to weakness" would be:

A) nurse will assist the patient to the bathroom every 2 hours.
B) patient will be free of injury from falls.
C) patient will call for assistance when ambulating for the next week.
D) nurse will keep room well lit 24 hours a day.

Question 21

The nurse coming on duty has received a report that an IV of 1000 mL of 5% glucose in 0.9% normal saline is running at a rate of 50 mL an hour to be followed by another 1000 mL to be run at the same rate. The reporting nurse states that the second IV should be hung at 9:00 AM. The prudent nurse should: (Select all that apply.)

A) hang the next 1000 mL when the first is finished.
B) check to label on the present IV.
C) confirm the flow rate.
D) check the order for the IVs.
E) speed up the flow so that the IV will be completed by 9:00 AM.

Question 22

Standards of care are set by: (Select all that apply.)

A) the state's nurse practice act.
B) professional medical association standards.
C) the facility's policies and procedures.
D) the primary care provider in charge of the patient's treatment.
E) the director of nurses and the agency administrator.

Question 23

The agency-wide process that takes into consideration nursing audits and compliance to standards of every department is the ______________________.

Question 24

The purpose of the evaluation step of the nursing process is to: (Select all that apply.)

A) determine if outcomes have been reached and the goals are met.
B) compare actual outcomes with expected outcomes.
C) identify inefficient care given by assigned staff.
D) confirm that nursing interventions are effective.
E) ensure that the facility has not put itself at risk for litigation.

Question 25

When an agency is using a clinical pathway/care map protocol of health care provision, there is no need for a ________________.