chapter 9: Implementation and Evaluation

A plan of care for a client with a low potassium level includes providing information about the effect of medications and about dietary intake of foods high in potassium. How would a nurse measure achievement of an outcome for this plan?

Laboratory data

What activity is carried out during the implementing step of the nursing process?

Planned nursing actions (interventions) are carried out.

Why are quality-assurance programs important in nursing?

They enable nursing to be accountable for the quality of care.

When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client?

"We ask your name to ensure that we are treating the right client."

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?

Assess the client's response to the ambulation.

Which parties are essential for the nurse to include in the implementation of a client's plan of care?

Client, family, and physician

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action?

Collaborate with other disciplines to revise the discharge plans.

While implementing the plan of care for a client, the nurse uses interpersonal skills. What would the nurse most likely use?

Communication

A nurse caring for an older adult client who has dementia observes another nurse putting restraints on the client without a physician's order. The client is agitated and not cooperating. What would be the best initial action of the first nurse in this situation?

Confront the nurse and explain how this could be dangerous for the client.

The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do?

Delay the instruction until the visitors leave.

A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first?

Determine the client's willingness to follow the regimen.

The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect?

Evaluation

A nurse who has been employed by the facility is scheduled for an evaluation by a group of nurses with similar education and experience. The nurse most likely is undergoing what?

Individual peer review

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include?

Risk factors for and prevention of diabetes mellitus

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

The client's expected outcome is "The client will maintain skin integrity by discharge." Which measure is best in evaluating the outcome?

The condition of the skin over bony prominences

Which of the following best summarizes the evaluation step of the nursing process?

The nurse and client measure achievement of planned outcomes of care.

A nurse is changing a sterile pressure injury dressing based on an established protocol. What does this mean?

Written plans are developed that specify nursing activities for this skill.

"The levels of performance accepted by and expected of nursing staff or other health team members" defines:

standards.

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate?

"I provide indirect care to my clients by coordinating their treatment with other disciplines."

Which action is appropriate when evaluating a client's responses to a plan of care?

Continue the plan of care if more time is needed to achieve the goals/outcomes.

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action?

Discontinue the education and attempt at another time.

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention?

Discuss possible alternatives to a blood transfusion with the physician.

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?

Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization.

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action?

Go to the client and assess the client's pain.

The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first?

Assess for bladder distention.

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse mostappropriately remedy this conflict?

Communicate with the physicians to coordinate their orders.

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's mostappropriate action?

Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention?

Encourage the client to provide as much self-care as possible.

The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted?

Quality assurance

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?

Reassess the appropriateness of the method of instruction.

An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply.

-Assisting the client with personal hygiene needs and ambulation -Transporting the infant to the mother's room according to hospital policy

Before implementing any planned intervention, which action should the nurse take first?

Reassess the client to determine whether the action is needed.

A nurse is caring for a postoperative client after a scheduled ileostomy. Which action by the nurse reflects an effective cognitive outcome?

The client identifies three strategies for minimizing leakage of an ileostomy bag

A client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem?

The client is able to explain when and why the client needs to check the blood glucose level.

A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?

To be sure the intervention is safe

As part of a quality improvement initiative nurses are asked to complete a structure evaluation. Which information should the nurse include in this work? Select all that apply.

-Because there is no door on the unit's diet kitchen, client families feel free to walk in and serve themselves coffee. -Newly purchased beds are difficult to move through client room doors.

A client's plan of care identifies the following goal: The client will demonstrate correct technique to administer insulin to control his blood glucose levels by discharge. What would the nurse use to determine that the client's goal has been met? Select all that apply.

-Client self-administers insulin into outer thigh. -Client states the need to apply pressure to the injection site. -Client demonstrates drawing up correct amount of prescribed insulin in syringe.

The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond?

Discuss with the client the reasons for declining surgery.

Which factor should the nurse most consider when determining which interventions would best meet the needs of a client?

The client's response to health and illness

A nurse finds that a client is not achieving the set outcomes for care and reviews the plan. Which are appropriate actions for the nurse to take while reviewing the plan of care? Select all that apply.

-Modify the nursing diagnosis. -Make the outcome statement more realistic. -Adjust the time limits on the outcome statement. -Increase the complexity of the outcome statement.

A nurse is caring for a client diagnosed with cancer and implements psychosocial interventions. What would be most appropriate for the nurse to do?

Encourage the client to talk about fears and concerns.

The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What parameters would the nurse document to support evaluation of pain management?

Effectiveness of intervention including current pain scale, time frame, and client self-report.

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which?

Finances of the client

Which nurse is using criteria to determine expected standards of performance?

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client?

A client with a high fever receiving intravenous fluids, antibiotics, and oxygen

A client being treated with chemotherapy for breast cancer tells the nurse that she no longer wants to receive the medication because of the overwhelming nausea and vomiting. What is the best response by the nurse?

"I will consult with the health care provider to see how the nausea and vomiting can be prevented."

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply.

-The client verbalizes understanding of the instructions. -The client is able to answer the nurse's questions. -The client discusses the specifics of what was taught during the session.

A client is receiving care on a rehabilitative medicine unit during recovery from a stroke. The client voices frustration that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the client's frustration?

Facilitate communication between the different professionals and attempt to coordinate care.

A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care?

Another registered nurse with critical care certification

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's mostappropriate action?

Ask the client to verbalize the medication regimen and diet modifications required.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?

Assess the client to determine the cause of the pain.

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take?

Assess the client's blood pressure to determine if the medication is indicated.

The nurse is caring for the client with pneumonia. An expected client outcome is, "The client will maintain adequate oxygenation by discharge." Which outcome criterion indicates the goal is met?

Client no longer requires supplemental oxygen.

Which statement related to the evaluation of outcome attainment for a client is correct?

Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders.

While assessing a postoperative client, the nurse notes the client's vital signs are within normal limits, the white blood cell count is 12,000/µL (12 × 109/L), and the client's abdominal wound has a 0.5-in (1.25-cm) gap at the lower end with yellow-green discharge. The nurse would prioritize which intervention?

Contact the health care provider.

A nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which action should the nurse perform before revising a plan of care?

Discuss any lack of progress with the client.

A hospitalized client has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. The client reports feeling mortified to attempt a bowel movement on a commode at the bedside, where staff and other clients can hear. The nurse should respond by modifying which resource?

Environment

The client is about to have blood drawn before seeing the health care provider. The spouse, while smiling and holding the client's hand, states, "Here comes the blood sucker. It is going to hurt bad." This statement is an example of which types of intervention? Select all that apply.

Psychosocial Supportive Physical

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action?

Revise the care plan to allow the client to ambulate to the bathroom independently.

A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage?

Risk of self-harm

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?

Surveillance

One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated?

throughout the client's hospital admission

According to the Canadian Nurses Association, who determines the scope of nursing practice?

nurses