Deck 14: Implementing and Evaluating

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?

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

Answer 1

Goal met,client able to state two positive aspects of therapy by week's end.

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?

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

Answer 2

Call the pharmacy and do further investigating before administering the medication.

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?

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

Answer 3

Implement safe care.

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?

A)Methods
B)Structure
C)Finances
D)Process
E)Outcome

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?

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

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?

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

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?

A)The data collected would support the diagnosis.
B)The diagnosis is directly related to the data presented.
C)The nursing diagnosis is not relevant to the data.
D)The data are not sufficient enough to support this diagnosis.

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?

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

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?

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

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?

A)Telling the parents everything the nurse is doing and why
B)Letting the parents watch a video after the bath
C)Letting the parents bathe the baby with direction and guidance from the nurse
D)Giving lots of advice and suggestions about different methods

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?

A)Move on to the next assignment to increase the nurse's efficiency.
B)Report this to the charge nurse.
C)Document all care in the progress notes.
D)Get supplies organized for the next client's medications and treatments.

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?

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

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?

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

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?

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

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?

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

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?

A)Management
B)Structure
C)Process
D)Outcome

Question 17

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

A)Allowing the client to complete hygienic care when possible
B)Providing all care to the client whenever possible
C)Telling the other staff that the client is demanding,so they are able to meet the client's needs
D)Presenting information to the client's family about the client's condition

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?

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

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?

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

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?

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

Question 21

The nurse is preparing to evaluate care provided to a client.What behaviors should the nurse demonstrate that show an understanding of the relationship of evaluation to the other phases of the nursing process?
Standard Text: Select all that apply.

A)Effectively assessing the client's needs
B)Selecting the appropriate nursing diagnosis related to the client's needs
C)Collecting client-focused data with a specific need in mind
D)Evaluating by using assessment data to determine effective achievement of goals and outcomes
E)Basing evaluation on assessment data collected during the admission phase

Question 22

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?

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

Question 23

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

A)Client problems updated
B)Data linked to NOC indicators
C)Data compared to desired outcomes
D)Interventions changed on the care plan
E)Physician notified of changes in the care plan

Question 24

The nurse notes that assessment data indicate a change in a client's condition.What should the nurse ask before changing this client's plan of care?
Standard Text: Select all that apply.

A)How difficult will it be to change the care plan?
B)Are the new data complete?
C)Are the new data accurate?
D)Do the new data require a change in the care plan?
E)Will the primary medical provider agree with the need to alter the care plan?

Question 25

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?

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

Question 26

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?
Standard Text: Select all that apply.

A)Purposeful activity
B)Nursing accountability
C)Continuous
D)Judgments
E)Opinion

Question 27

A client recovering from total knee replacement surgery falls out of bed on the night shift and dies.Which quality improvement actions should the nurse manager expect to complete for this client occurrence?
Standard Text: Select all that apply.

A)A root cause analysis
B)Paperwork about a sentinel event
C)Analysis of the nurse assigned to the client
D)Number of times the client was observed on the night shift
E)Number of hours since the client last received pain medication

Question 28

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?
Standard Text: Select all that apply.

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 intervention

Question 29

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?

A)Concurrent
B)Peer review
C)Nursing audit
D)Retrospective