Question 1

A physician prescribes an indwelling urinary catheter for a client who is mildly confused and combative. In which manner does the nurse proceed?

Accepted Answer

A) Ask a colleague for help because the nurse cannot safely perform the procedure alone. 
B) Gather and prepare the equipment before informing the client about the procedure. 
C) Obtain a prescription to restrain the client before inserting the urinary catheter. 
D) Inform the physician the nurse cannot perform the procedure because the client is confused.

Question 2

The nurse is providing care for a patient after joint replacement surgery. The standardized care plan states, "Patient will ambulate 50 feet in the hall with a walker before discharge." Which patient variable affecting this goal is the nurse unable to control?

Accepted Answer

A) Confusion and lethargy related to pain medication 
B) Compromised respiratory function due to severe chronic obstructive pulmonary disease (COP
D)  
C) Reluctance to ambulate due to pain at level 7 
D) Presence of a spouse who pushes the patient to rest

Question 3

The nurse is providing care for a patient in an acute care facility. The nurse plans to evaluate the effectiveness of the plan of care. Which action does the nurse need to take to achieve a valid evaluation?

Accepted Answer

A) Read the documentation by the previous nurse. 
B) Collect reassessment data on the patient. 
C) Look at the physician's progression notes. 
D) Ask the patient's view about each nursing goal.

Question 4

Which client outcome criterion does the nurse use when evaluating client behaviors that affect the client's health status?

Accepted Answer

A) Central venous catheter site infection does not occur in 90% of cases. 
B) Client will sit in the bedside chair for 20 minutes three times per day. 
C) Postoperative phlebitis does not occur in 95% of surgical patients. 
D) Falls in the facility will be reduced by 2% at the end of the year.

Exam 7: Implementation Evaluation

A physician prescribes an indwelling urinary catheter for a client who is mildly confused and combative. In which manner does the nurse proceed?

The nurse is providing care for a patient after joint replacement surgery. The standardized care plan states, "Patient will ambulate 50 feet in the hall with a walker before discharge." Which patient variable affecting this goal is the nurse unable to control?

The nurse is providing care for a patient in an acute care facility. The nurse plans to evaluate the effectiveness of the plan of care. Which action does the nurse need to take to achieve a valid evaluation?

Which client outcome criterion does the nurse use when evaluating client behaviors that affect the client's health status?