Chap 18. Evaluating

Which action should the nurse take during the evaluation phase of the nursing process? Document reassessment of pain after medication administration. Provide the client with a follow-up appointment after discharge. Have the client give input into plan of care upon admission. Discontinue the indwelling urinary catheter per the provider's order.

Document reassessment of pain after medication administration. Rationale: The evaluation phase includes documenting a reassessment of pain following an intervention such as the administration of pain medication. Providing a client with an appointment and discontinuing an indwelling urinary catheter are interventions. Having a client give input into a plan of care is part of the planning process.

Standard of performance describe

Physical facilities and equipment; Organizational characteristics, Policies, and procedures; Fiscal resources; Personel resources.

Which action should the nurse perform in the evaluation phase? Carry out treatment procedures. Set priorities for care. Record interventions. Revise the plan of care.

Revise the plan of care. Rationale: The nurse should revise the plan of care during the evaluation phase. It provides the feedback mechanism that starts the entire chain of events again. Setting priorities is part of the planning phase. Carrying out treatment procedures and recording interventions are activities in the implementation phase of the nursing process.

Quality Assurance

an externally driven process, demonstrating nursing excellence by. meeting professional standards of care.

The nurse works as a client advocate for an older adult client admitted with hyponatremia. Which action can the nurse take to help the client advocate for oneself? Encourage the client to ask questions. Help the client with skin care. Coordinate client activities. Incorporate therapeutic use of self.

Encourage the client to ask questions. Rationale: By encouraging the client to ask questions about one's care, the nurse teaches the client about self-advocacy. Providing skin care is a maintenance intervention undertaken to allow the client to preserve function and reduce the incidence of complications but does not help to promote self-advocacy. Acting in the advocacy role, the nurse would coordinate client activities. Incorporating therapeutic use of self in the care enables the nurse to be supportive of the client.

The nurse is caring for a postoperative client who reports ineffective pain management with pain rated a 7 on a 0-10 rating scale. Based on the information provided by the client, which step should the nurse take first to modify the care plan? Create a new nursing diagnosis to reflect new goals. Evaluate the use of current pain relief measures. Request a stronger analgesic from the provider. Provide additional relief with non-pharmacologic measures.

Evaluate the use of current pain relief measures. Rationale: Prior to proceeding with any changes in the plan of care, the nurse must first perform evaluation of the client's current pain relief measures. Once this has been performed, it might be appropriate to request a stronger analgesic or reinforce education for nonpharmacologic pain relief measures. Creating a new nursing diagnosis and goals would come after evaluating the current pain relief measures.

An older adult client who is recovering from a stroke is scheduled to be transferred to the rehabilitation unit in the morning. The client is tearful and reports feeling lonely and abandoned in the hospital unit. The family visits daily, and flowers and cards are in the room. Documentation in the chart indicates that the client's pastor has been by twice in the past week to visit. Which nursing diagnosis and outcome criteria need to be addressed immediately for this client? Ineffective Coping; verbalizes support systems. Impaired Walking; unilateral neglect. Altered Mobility; able to tie shoes. Dysfunctional Family Processes; family contact daily.

Ineffective Coping; verbalizes support systems. Rationale: When considering appropriate evaluation criteria, be certain they relate directly to the diagnosis and the diagnosis relates to the assessment data. There are no data to support unilateral neglect. Tying shoes evaluates a client's abilities, not mobility. The nurse assesses that the family visits daily, so the family process is functional. Ineffective coping is appropriately evaluated by identification of coping mechanisms, such as support systems.

After incorrectly administering digoxin to a client, a nurse admits the error to the nurse manager and peers to prevent them from making the same mistake. This is an example of which approach to quality assurance? Quality by inspection Quality as opportunity Quality by supervision Quality as repetition

Quality as opportunity Rationale: In this example, the nurse is attempting to ensure quality by taking the opportunity to share the nurse's experience to help other nurses. Quality as opportunity focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Quality by inspection focuses on finding deficient workers and removing them. Quality by supervision and quality as repetition are not specific approaches to quality assurance.

The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted? Quality assurance Magnet status Peer review Quality improvement

Quality assurance. Rationale: Accreditation by the Joint Commission evaluates quality assurance. Quality assurance is an externally driven process, demonstrating nursing excellence by meeting professional standards of care. Quality improvement is an internally driven, continuous process focusing on the processes of client care. Peer review is a process whereby individual nurses improve their professional performance through the evaluation of one staff member by another staff member on the same level of the hierarchy. Magnet status is awarded by the American Nurses Credentialing Center, recognizing health care organizations for their excellence in nursing.

The nurse manager observes one of the unit nurses failing to wash hands on entering a client room. Hospital protocol is to wash hands before and after entering a client room. This scenario is an example of which approach to quality assurance? Quality by inspection Quality as opportunity Quality by perception Quality as initiative

Quality by inspection Rationale: Quality by inspection is an approach to quality assurance in which nurses watch for deficient workers and remove them in an effort to prevent harm to clients. Quality as opportunity, on the other hand, focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Quality by perception and quality as initiative are not specific approaches to quality assurance.

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention? Educational Psychomotor Maintenance Surveillance

Surveillance Rationale: Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Educational interventions require instruction, demonstration, and return demonstration of knowledge or a skill set. Psychomotor interventions involve the nurse physically working with the client. Maintenance interventions involve the nurse assisting the client with performing routine activities of daily living.

Which nurse is using criteria to determine expected standards of performance? The nurse manager provides the staff nurse feedback regarding job performance for the previous year. The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education. The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation.

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. Rationale: Standards are the levels of performance accepted and expected by the nursing staff and other health team members, such as institutional policies and procedures. The nurse preceptor providing feedback to the new graduate nurse after 6 weeks of orientation is an example of peer review. The nurse manager providing the staff nurse feedback regarding job performance for the previous year is typical of an annual employee review. The nurse seeking input from the UAP on a family's response to education is inappropriate, as the nurse may not delegate evaluation to the UAP.

Which of the following best summarizes the evaluation step of the nursing process? The nurse completes a health assessment to establish a database. The client and family have met health care goals and no longer need care. The nurse and client identify nursing diagnoses and appropriate interventions. The nurse and client measure achievement of planned outcomes of care.

The nurse and client measure achievement of planned outcomes of care. Rationale: In evaluation, which is the fifth step of the nursing process, the nurse and client together measure how well the client has achieved the outcomes specified in the plan of care. Establishing a health assessment is the first stage of the nursing process. Identifying nursing diagnosis is the second stage and implementation of care is the fourth stage. When the client no longer needs care, the relationship is terminated.