Ch20- EAQ

Which expected outcome would be appropriate for a patient who is vomiting? 1 Patient stops vomiting in 2 hours. 2 The antiemetic (drug to stop vomiting) will be administered every 6 hours. 3 The antiemetic will not produce side effects in the patient. 4 Patient will not vomit again.

1

Which factor helps ensure quality data collection of nursing practices and enables evaluation across health care organizations? 1 Standard nursing language 2 Transcription services 3 Computerized nursing records 4 Voice dictation of nursing notes

1

Which action would the nurse perform when modifying a care plan after a patient has been evaluated? Select all that apply. One, some, or all responses may be correct. 1 Evaluate the interventions. 2 Redefine nursing diagnoses. 3 Reassess patient factors. 4 Conclude the evaluation process. 5 Continue unrealistic outcome time frames.

1,2,3

Which action would the nurse take when a nursing goal is not met in the care of a patient? Select all that apply. One, some, or all responses may be correct. 1 Reassess the patient. 2 Repeat the entire nursing process. 3 Revise the care plan. 4 Notify the health care provider immediately. 5 Discontinue the care plan for the patient.

1,2,3

Which evaluative criterion would the nurse use to measure nursing care for a patient who is short of breath? Select all that apply. One, some, or all responses may be correct. 1 Observe the patient's level of comfort. 2 Measure the respiratory rate. 3 Ask the patient if breathing is easier. 4 Administer a bronchodilator. 5 Instruct the patient to perform deep breathing.

1,2,3

Which purpose describes the importance of a nurse documenting patient outcomes? Select all that apply. One, some, or all responses may be correct. 1 To inform other health care team members 2 To share information about the patient's progress 3 To make ongoing clinical decisions 4 To acknowledge revision of the care plan 5 To replicate the care in another patient

1,2,3,4

Which action demonstrates nursing competency when evaluating a patient? Select all that apply. One, some, or all responses may be correct. 1 Reflect on the situation. 2 Understand a patient situation. 3 Recognize errors or omissions. 4 Examine the results of care according to clinical data collected. 5 Compare achieved effects with goals and expected outcomes.

1,2,3,4,5

Which criterion is an evaluative measure to determine healing of a chronic, nonhealing skin ulcer in an elderly patient who has diabetes and is receiving antibiotics? Select all that apply. One, some, or all responses may be correct. 1 Color of the ulcer 2 Diameter of the ulcer 3 Diabetes that caused the ulcer 4 Odor in the ulcer 5 Antibiotics for the ulcer

1,2,4

Which intervention would the nurse perform when communicating the patient's progress with the patient and the family members? Select all that apply. One, some, or all responses may be correct. 1 Share the patient's results with the patient. 2 Inform the patient's family about the patient's progress, with the patient's permission. 3 Avoid discussing clinical results with the patient. 4 Follow agency guidelines about sharing medical information. 5 Provide appropriate nursing care without any documentation.

1,2,4

Which information correctly describes the evaluation process? Select all that apply. One, some, or all responses may be correct. 1 Is a complex process 2 Usually reveals obvious changes in patients 3 Involves making clinical decisions 4 Requires the use of assessment skills 5 Is performed once for each intervention

1,3,4

A patient with a fractured ankle has an expected outcome of walking with crutches. The patient is able to walk with crutches after instruction from the nurse. Which action would the nurse take next for this patient? 1 Help the patient walk. 2 Discontinue the current interventions. 3 Instruct the patient to walk without support. 4 Demonstrate the use of crutches instead of instructing.

2

When delivering patient care, which intervention does the nurse perform as part of the evaluation process? 1 Performs treatment to enhance patient outcomes 2 Recognizes unmet outcomes 3 Chooses interventions that are evidence-based 4 Utilizes up-to-date approaches for delivering patient-centered care

2

Which action would the nurse take for a patient who has an outcome of walking the entire hallway by 10/17 and the patient walks halfway down the hallway on 10/16? 1 Discontinue the care plan. 2 Continue with the care plan. 3 Notify the health care team immediately. 4 Modify the care plan with the health care team's input.

2

Which action would the nurse take for a patient who reports frequent periods of nausea that interfere with eating after chemotherapy treatments? 1 Reassess the patient. 2 Prepare a suitable diet plan for the patient. 3 Discontinue interventions for nausea. 4 Advise the patient to stop taking pain-relieving medications.

2

Which patient response would indicate that the expected outcome of describing signs and symptoms of a wound infection has been met? 1 "I may have a fever after surgery, which is common." 2 "There will be more tenderness around the incision if I have an infection." 3 "Redness around the incision site is expected, and I need not report it." 4 "If there is more swelling around the stitches, it indicates that the wound is healing."

2

Which outcome would be appropriate for the depressed patient who lost weight but has a goal to return to baseline weight in 3 months? Select all that apply. One, some, or all responses may be correct. 1 Patient discusses the source of depression by next clinic visit. 2 Patient achieves an intake of 2400 calories daily in 2 weeks. 3 Patient reports improvement in appetite in 1 week. 4 Patient identifies food protein sources. 5 Patient does not display signs of depression in 2 weeks.

2,3

Arrange the steps to be taken by the nurse in the appropriate order to evaluate the effectiveness of the care plan in meeting the expected outcome for the patient. 1. If there is no or partial agreement between the desired outcome and the patient's response, determine the reason. 2. Review the outcome criteria in the care plan to identify the exact desired patient behavior or response. 3. Evaluate the patient's actual behavior or response. 4. Compare the established outcome criteria with the actual behavior or response. 5. Judge the degree of agreement between the outcome criteria and the actual behavior or response.

2,3,4,5,1

Which action would the nurse perform when revising interventions for a patient? Select all that apply. One, some, or all responses may be correct. 1 Continue with all existing interventions. 2 Modify the frequency of interventions. 3 Maintain high-quality standards of care. 4 Avoid changes in the frequency of interventions. 5 Change the level of nursing care.

2,3,5

The nurse would evaluate which goal based upon the following reassessment: upon removal of the intravenous (IV) line from the right arm, the site was clean and dry with no signs of redness or tenderness? 1 Patient expresses acceptance of health status by day of discharge. 2 Patient's surgical wound will be free of drainage. 3 Patient's IV site will remain free of infection. 4 Patient understands when to call the health care provider to report complications.

3

Which action would be appropriate when the clinic nurse teaches interventions to a patient who is diagnosed with a urinary tract infection and during the follow-up visit, the patient's laboratory report shows an absence of infection? 1 Modify the care plan. 2 Redefine the nursing diagnosis. 3 Discontinue the care plan. 4 Continue the intervention.

3

Which action would the nurse perform to redefine the diagnosis after evaluation of a patient goal? 1 Rewrite the expected outcomes. 2 Discontinue the interventions. 3 Revise the patient's problem list. 4 Reassess the patient.

3

Which action would the nurse take for a patient who agrees with the nurse that expected outcomes were met? 1 Modify the care plan. 2 Revise the plan of care. 3 Discontinue the care plan. 4 Continue with the plan of care.

3

Which element is the final step of the nursing process? 1 Counseling 2 Discharge 3 Evaluation 4 Implementation

3

Which interpretation would the nurse make regarding a patient with pneumonia whose cough decreased and respiratory rate decreased from 33 to 25 breaths/min after nebulization treatments? 1 Discontinue the care plan. 2 The patient can be discharged to home immediately. 3 The patient needs continued nebulization therapy. 4 Modify the care plan to include a transfer to the intensive care unit (ICU).

3

Which option would be a suitable nursing-sensitive expected outcome for a patient with acute pain? 1 Patient will achieve pain relief by discharge. 2 Surgical wound will have no drainage in 2 days. 3 Reports pain severity reduced from 8 to 6 in 2 days. 4 Describes purpose of pain medicine by discharge.

3

Which patient finding would be the most suitable nursing-sensitive outcome for a patient who is immobile, does not ambulate, and has a nursing diagnosis of backache? 1 Will remain free of skin breakdown in the hospital 2 Will be satisfied with the care delivered by the nurse 3 Will have reduced back pain 4 Will be able to explain the physiological effects of massage

3

Which problem would the nurse add to the care plan after evaluating a diabetic patient who had a problem with glucose control but is now restless and asking many questions about an upcoming procedure on the big toe? 1 Anxiety 2 Glucose control 3 Diabetes 4 Risk of toe infection

3

Which question would the nurse ask to evaluate a patient's expectations of care? 1 "Are you hurting anywhere?" 2 "How would you rate your pain level?" 3 "Have you received adequate pain relief care?" 4 "What makes your pain decrease?"

3

Which step of the nursing process describes the nurse observing that the patient's redness on the heels has decreased over the past 2 days after using measures to relieve pressure points? 1 Planning 2 Diagnosis 3 Evaluation 4 Assessment

3

After evaluation of the patient, which action would the nurse take when the intervention is unsuitable? Select all that apply. One, some, or all responses may be correct. 1 Reprioritize the nursing diagnosis. 2 Discontinue the care plan. 3 Discontinue the unsuitable intervention. 4 Add new interventions. 5 Change the frequency of the intervention.

3,4

Arrange the steps in proper sequence for measures the nurse would take when a patient does not meet the goal stated in the care plan. 1. Select a new intervention. 2. Establish new goals and expected outcomes. 3. Reassess the patient. 4. Determine the accuracy of the nursing diagnosis.

3,4,2,1

A patient had high blood sugar when the nurse tested it previously, but the patient says the blood sugar was normal when tested at home right before coming to the clinic. Which action would the nurse take next? 1 Ask the patient if he or she would like a consult to another endocrinologist. 2 Advise the patient to change the type of insulin. 3 Advise the patient to decrease the dose of insulin. 4 Ask the patient to show the technique for checking blood sugar levels.

4

Which action would the nurse take for a patient who continues to have congested lungs after coughing and deep-breathing exercises? 1 Double the dose of antibiotics. 2 Hand over the patient to another nurse. 3 Repeat the patient's chest x-ray. 4 Increase frequency of coughing and deep-breathing exercises.

4

Which determination does an evaluative measure make? 1 If nursing education meets the standards of care 2 If nurses follow the nursing process 3 If nurses record the number of patient falls 4 If nursing care was effective for meeting expected outcomes

4

Which feature is typical of "missed care"? 1 Incorrect nursing diagnoses 2 Misworded outcomes 3 Wrong care goals 4 Not completed interventions

4

Which initial action would the nurse take for a postoperative patient who realizes that strain on the incision site could cause tearing of the stitches, but some of the patient's stitches are pulled out? 1 Advise the patient to maintain complete bed rest for at least a month. 2 Immediately arrange for admission of the patient to the hospital. 3 Report to the health care provider that the patient is not following the instructions given. 4 Ask if the patient understands which activities can cause strain at the incision site.

4

Which modification would the nurse make to the care plan for a patient with diabetes who can no longer prepare or administer insulin because of tremors and has a caregiver who lives in the home? 1 Continue with the current care plan. 2 Continue with the patient preparing the insulin but have the caregiver administer it. 3 Teach the caregiver to prepare the insulin but have the patient administer it. 4 Teach the caregiver to prepare and inject the insulin.

4

Which option explains the primary purpose for the nurse performing evaluative measures? 1 To verify specific nursing interventions were completed 2 To validate the nurse's physical assessment 3 To make sure the nurse made the correct nursing diagnoses 4 To determine whether a patient met expected outcomes

4

Which statement is true about the standards of care? 1 It is implemented to standardize nursing language for outcomes. 2 It is used to analyze the findings obtained from evaluation. 3 It is judgments regarding whether changes have occurred in the patient's condition. 4 It is the minimum acceptable level of care to ensure that a patient receives high-quality care.

4

Arrange the steps of the nursing process in their appropriate order. 1. Planning 2. Implementation 3. Diagnosis 4. Assessment 5. Evaluation

4,1,3,2,5