Question 1

In the implementation step of the nursing process, a nurse is to utilize certain activities to be effective in the care of a client. Which activity is the priority?

Accepted Answer

A)   Reassess client's needs.
B)   Document nursing care.
C)   Prioritize evaluation of care.
D)   Differentiate between subjective and objective data. A

Question 2

What guides professional practice?

Accepted Answer

A)   ANA Standards of Nursing Practice
B)   National Institutes of Health publications
C)   Nursing Intervention Classification
D)   Risk Appraisal Index A

Question 3

The nurse is assessing the client's behavioral response to a nursing intervention. This type of evaluation is known as:

Accepted Answer

A)   structural evaluation.
B)   behavior modification.
C)   outcome evaluation.
D)   process evaluation.
E)   goal evaluation. C

Question 4

A new mother is having difficulty breastfeeding her newborn infant. A goal was established stating the baby would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports that she discontinued breastfeeding. The nurse evaluates the original goal as:

Accepted Answer

A)   met.
B)   partially met.
C)   completely unmet.
D)   inappropriately chosen for this client.

Question 5

When the nurse prepares to discharge a client, and subsequently evaluates the effectiveness of the nursing care, the nurse should determine whether the:

Accepted Answer

A)   physician orders have been completed.
B)   client's goals have been achieved.
C)   critical pathways are completed.
D)   documentation is thorough.

Question 6

After the nursing plan of care has been developed, the nurse knows that:

Accepted Answer

A)   each client encounter is an opportunity to reassess and revise the plan if necessary.
B)   the plan will be followed by other healthcare providers and filed with the client's chart upon discharge.
C)   the responsibility for the assessment of the client has ended.
D)   care plans are rigid and do not change.

Question 7

The primary purpose for evaluating data about a client's care according to a functional health approach is to:

Accepted Answer

A)   meet accreditation standards.
B)   determine implementation of medical orders.
C)   evaluate the need for healthcare consultations.
D)   revise or modify the nursing care plan.

Question 8

Which nursing action can be categorized as a surveillance or monitoring intervention?

Accepted Answer

A)   Auscultating of bilateral lung sounds
B)   Providing hygiene
C)   Administering paracetamol tablet
D)   Use of therapeutic communication skills

Question 9

Which is a major premise of a quality improvement program? Select all that apply.

Accepted Answer

A)   It determines whether nursing standards are being upheld.
B)   Some governmental agencies mandate quality improvement programs.
C)   It focuses on processes rather than individuals.
D)   It should ideally be performed one to two times per year.
E)   Its focus is on ensuring excellence in care.

Question 10

Which statement describes the purpose of evaluation? Select all that apply.

Accepted Answer

A)   To examine the client's behavioral responses to nursing interventions
B)   To appraise the extent to which client goals were attained or problems resolved
C)   To appraise involvement and collaboration of the client, family members, nurses, and healthcare team members in healthcare decisions
D)   To ensure the plan of care was followed as it was originally prepared
E)   To collect subjective and objective data to make judgments about nursing care delivered

Question 11

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention?

Accepted Answer

A)   Supportive
B)   Surveillance
C)   Collaborative
D)   Maintenance

Question 12

The nurse participates in a quality assurance program and reviewing evaluation data from the previous year. Which does the nurse recognize as an example of outcome evaluation?

Accepted Answer

A)   A 4% increase in the number of baccalaureate prepared nurses are employed in the facility.
B)   A 97% bed occupancy rate in the critical care areas; 92% bed occupancy rate in the noncritical care areas.
C)   A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery.
D)   98% of all hospital admissions had a nursing history completed within 24 hours of admission.

Question 13

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable?

Accepted Answer

A)   Psychosocial background
B)   Developmental stage
C)   Research findings
D)   Current standards of care

Question 14

The nurse is discussing dietary options with a client who is upset because the client is unable to have the food the client wants to eat. The nurse states "You may not be able to have steak but can have grilled salmon or grilled chicken. Which do you prefer?" What is the purpose for giving clients options to their care?

Accepted Answer

A)   Allowing the client to have options supports decision-making abilities.
B)   Giving the client options makes him feel that he or she controls his or her care.
C)   The food choices are available in the menu.
D)   The client must eat hospital food that is good for him or her.

Question 15

The nurse is assessing the client's self-care capabilities for after discharge from the hospital. Which barrier greatly contributes to the nursing goals being unmet? Select all that apply.

Accepted Answer

A)   The availability of assistive devices
B)   Poor communication skills
C)   Inadequate emotional coping skills
D)   Debilitating illness
E)   Family's lack of interest in the plan of care

Question 16

Which purpose of the evaluation phase of the nursing process is a priority during client care?

Accepted Answer

A)   Examining the client's behavioral response to the care received.
B)   Providing basis for the revision of plan of care.
C)   Monitoring the quality and effects of the nursing care.
D)   Appraising collaboration of the client and family.

Question 17

What are the two priority nursing diagnoses? Select all that apply.

Accepted Answer

A)   Risk for infection
B)   Anxiety
C)   Acute pain
D)   Ineffective airway clearance
E)   Feeding self-care deficit

Question 18

The primary purpose of nursing implementation is to:

Accepted Answer

A)   improve the client's postoperative status.
B)   identify a need for collaborative consults.
C)   help the client achieve optimal levels of health.
D)   implement the critical pathway for the client.

Question 19

A client has terminal cancer and the practitioner has ordered a diagnostic imaging test. The client tells the nurse, "I don't want the test performed." So the nurse agrees to dialogue with the practitioner on the client's behalf. The nurse's actions are what type of intervention?

Accepted Answer

A)   Surveillance
B)   Supportive
C)   Coordinating
D)   Technical

Question 20

Which nursing action reflects evaluation?

Accepted Answer

A)   The nurse identifies that the client has wound drainage.
B)   The nurse sets an anxiety level of 3 or less with the client.
C)   The nurse performs a colostomy irrigation.
D)   The nurse assesses the client's response to pain medication.

Exam 9: Implementation and Evaluation