(Fund Ch 18) PrepU

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? a. Finances of the client b. The client's condition c. Time and resources d. Feedback from the family

a. Finances of the client The client's condition, time and resources, and feedback or input from the family are all of great value when the nurse is prioritizing the client's nursing diagnoses. The client's finances, however, should not influence the nurse's priority setting. The nursing code of ethics states that clients should receive the same treatment regardless of their ability to pay.

Quality improvement in care delivery requires which components? Select all that apply. a. Leadership commitment b. Continuous improvement c. Total client care by the nursing unit d. Focus on data collection e. Focus on the mission of the organization

a. Leadership commitment b. Continuous improvement d. Focus on data collection e. Focus on the mission of the organization When performing quality improvement the nurse should be collaborating with other departments rather than maintaining total client care by the nurses. All of the other choices are part of the quality improvement process.

A nurse is evaluating the outcome of the plan of care after teaching a client how to prepare and administer an insulin pen. Which type of outcome is the nurse addressing? a. Cognitive b. Psychomotor c. Affective d. Physiologic

b. Psychomotor Preparing and administering an insulin pen is a psychomotor outcome. Psychomotor outcomes describes the client's achievement of new skills. Cognitive outcomes describe increase in client knowledge or intellectual behaviors. Affective outcomes describe changes in client values, beliefs, and attitudes. Physiologic outcomes are concerned with how the human body works.

Which action should the nurse take when client data indicate that the stated goals have not been achieved? a. Collect more data for the database. b. Review each preceding step of the nursing process. c. Implement a standardized plan of care. d. Change the nursing orders.

b. Review each preceding step of the nursing process. If a client's goal has not been achieved the nurse should review each of the preceding steps of the nursing process in order to try to identify the contributing factors causing problems with the plan of care. By conducting the evaluation this way, the nurse may find that more data must be collected or the plan of care needs revision. An individualized plan of care rather than a standardized plan of care is often warranted.

"Measurable qualities, attributes, or characteristics that identify knowledge or health status" defines: a. standards. b. criteria. c. evaluations. d. evidence-based practice.

b. criteria. Criteria are "measurable qualities, attributes, or characteristics that identify skill, knowledge, or health status." Standards are the "levels of performance accepted by and expected of nursing staff or other health team members." Evidence-based practice incorporates delivering nursing care that evidence supports as likely to result in meeting the expected client outcomes. Evaluation involves measuring how well the client has achieved the outcomes that were set forth in the plan of care.

The nurse on a busy acute care floor identifies that several clients with heart failure are being readmitted within 2 weeks of discharge. Which step in performance improvement is the nurse demonstrating? a. Planning a strategy using indicators b. Implementing a change c. Discovering a problem d. Assessing the change

c. Discovering a problem Discovering the problem by detecting that there are several readmissions with heart failure is the first step in the process of performance improvement. The next step would be to plan a strategy using indicators, which includes calling an interdisciplinary meeting. The team would then implement a change and, lastly, assess whether the change was effective.

When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate? a. "Inadequate skills" b. "Great response" c. "Extremely well-mannered" d. "Demonstrated steps"

d. "Demonstrated steps" Written documentation of the subjective and objective data gathered and the judgment made about goal attainment is required on the client's health record. Judgments about goal attainment are written clearly and concisely. Avoid ambiguous terminology, such as "inadequate," "good," or "extremely well," which can be interpreted differently by different people. Reference:

A nurse assures a client newly admitted to the clinical unit that the client will not be harmed by any errors and can expect to be safe in the facility. This assurance represents which expectation of the health care environment? a. Transparency b. Individualization c. Control d. Safety

d. Safety Safety is represented by the expectation that the client won't be harmed by any errors and will be safe in the facility. The other choices represent other expectations of the health care environment. Transparency is the expectation that information on all aspects of a client's health and care will be provided and explained to the client and that nothing will be kept from the client. Individualization is the expectation that a client's care will be individualized or customized to meet that client's unique needs. Control is the expectation that the client will retain autonomy and the right to self-determination while receiving care.

A hospital is evaluating its policies and procedures. What type of evaluation is the hospital conducting? a. Outcome b. Process c. Quality d. Structure

d. Structure A structure evaluation or audit focuses on the environment in which care is provided. Standards describe physical facilities and equipment, organizational characteristics, policies and procedures, fiscal resources, and personnel resources. Process/implementation evaluation determines whether program activities have been implemented as intended. Outcome/effectiveness evaluation measures program effects in the target population by assessing the progress in the outcomes or outcome objectives that the program is to achieve. Quality evaluation does not exist.

A nurse is evaluating nursing care and client outcomes by using a retrospective evaluation. Which action would the nurse perform in this approach? a. The nurse directly observes the nursing care being provided. b. The nurse reviews the client chart while the client is being cared for. c. The nurse interviews the client while the client is receiving the care. d. The nurse devises a postdischarge questionnaire to evaluate client satisfaction.

d. The nurse devises a postdischarge questionnaire to evaluate client satisfaction. Evaluations can be conducted concurrent with care (by using direct observation of nursing care, client interviews, and chart review to determine whether the specified evaluative criteria are met) or retrospectively (postdischarge questionnaires, client interviews by telephone or face to face, or chart review to collect data).

Which are components of an evaluative statement? Select all that apply. a. Description of how the client outcome was met b. Client's health history c. Name of the client's physician d. Client data that support how the outcome was met e. Client's health insurance information

a. Description of how the client outcome was met d. Client data that support how the outcome was met An evaluative statement includes a description of how the client's outcome was met and the data that support that decision. The name of the physician, information on the client's health insurance, and the client's health history would only be included if they contributed to the client's outcome.

The nurse manager on an orthopedic unit has determined that the nurses are not keeping the nursing diagnoses up-to-date on client care plans and, in turn, are not using the plan of care. What is a feasible approach to correcting this problem? a. Develop a process for periodic review of care plans that focuses on deleting and updating the nursing diagnoses. b. Request that a staff development nurse instruct the nurses on concept mapping to use instead of care planning. c. Provide an in-service on interviewing and physical assessment skills; discuss the importance of these skills with the staff. d. Delegate the updating of nursing diagnoses for all clients on the unit to one nurse for each shift.

a. Develop a process for periodic review of care plans that focuses on deleting and updating the nursing diagnoses. Upon recognizing that the nursing diagnoses are not up-to-date, an effective approach by the nurse manager is to establish a process for periodic review of the plan of care. This review process will require deletion of nursing diagnoses that have been resolved and, conversely, adding new diagnoses as needed. Implementing concept mapping will not correct the problem of poorly updated nursing diagnoses, as concept mapping requires the identification of nursing diagnoses. Developing interviewing and assessment skills is an important component of the assessment phase of the nursing process. Also, one nurse should not be responsible for updating nursing diagnoses for all client care plans on the unit.

"The client will demonstrate cast care prior to discharge" is which type of evaluative statement? a. Psychomotor b. Cognitive c. Affective d. Physical changes

a. Psychomotor This is an example of a psychomotor evaluative statement. Psychomotor outcomes are those that are related to new skill attainment. Cognitive outcomes are related to achieving greater knowledge. Affective outcomes are related to feelings and attitudes. Physical changes are related to actual body changes in the individual.

The focus of a hospital's current quality assurance program is a comparison of the health status of clients on admission and with that at the time of discharge. This form of quality assurance is characteristic of: a. outcome evaluation. b. structure evaluation. c. process evaluation. d. nursing audit.

a. outcome evaluation. Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care. Whereas the proper environment for care and the right nursing actions are important aspects of quality care, the critical element in evaluating care is demonstrable changes in client health status. Process evaluation addresses performance expectations during the various stages of the nursing process. Structure evaluation addresses the environment of care. A nursing audit focuses on the review of records.

Which nursing action would be most effective in helping a client learn self-care behaviors? a. Check with the client to ensure that personal self-care goals are being met. b. Model self-care behaviors for the client. c. Collect data on the number of self-care activities the client has performed that day. d. Ask client to discuss the client's goals for the day at the start of the shift.

b. Model self-care behaviors for the client. Modeling self-care behaviors is a nursing intervention and is the action most effective in helping the client learn the self-care behaviors. The other answer options refer to evaluation of the client's response to interventions related to learning self-care behaviors.

Which are psychomotor outcomes? Select all that apply. a. Accurately drawing up insulin b. The client will safely ambulate using a walker. c. The client will identify signs and symptoms of infection. d. The client will rate pain as a 2 on a 0 to 10 pain rating scale. e. The client will report increased confidence in testing blood glucose level.

a. Accurately drawing up insulin b. The client will safely ambulate using a walker. Examples of psychomotor outcomes include accurately drawing up insulin and ambulating safely using a walker. Identifying signs and symptoms of infection is an example of a cognitive outcome. Rating pain as a 2 on a 0 to 10 scale is a physiologic outcome. An example of an affective outcome is reporting increased confidence in testing blood glucose level.

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? a. Quality by inspection b. Quality as opportunity c. Quality by supervision d. Quality as repetition

b. Quality as opportunity 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.

What outcome does the nurse hope to achieve by evaluating the plan of care of a client who is being discharged? a. To direct future nurse-client interactions b. To formulate a database of nursing diagnoses c. To allow the nurse to terminate the nurse-client relationship d. To transfer medical prescriptions to the plan of care

a. To direct future nurse-client interactions The purpose of evaluation is to allow the client's achievement of expected outcomes and, when necessary, to modify the plan of care to direct future nurse-client interactions. The plan of care encompasses more than the relationship between the nurse and the client. It is important to evaluate the achievements by the client. The nurse develops nursing diagnoses during the diagnosis phase of the nursing process, not the evaluation phase. Medical prescriptions are physician interventions, not nursing interventions, and thus would not be included in the nursing plan of care. The purpose or outcome of evaluating the plan of care is not to terminate the nurse-client relationship.

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of: a. an affective outcome. b. a psychomotor outcome. c. a physiologic outcome. d. a cognitive outcome.

d. a cognitive outcome. Cognitive outcomes demonstrate increases in client knowledge, such as strategies for minimizing leakage of an ileostomy bag. An affective outcome involves changes in the client's values, beliefs, and attitude. Physiologic outcomes are physical changes in the client. Psychomotor outcomes describe the client's achievement of new skills.

A group of nurses on the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. This program is termed: a. Peer review b. Quality and Safety Educatin for Nurses (QSEN) c. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) d. American Association of Critical-Care Nurses (AACN)

a. Peer review Peer review is a process by which one nurse evaluates the performance of another to improve professional performance. QSEN has as its goal the preparation of nurses with the knowledge, skills, and attitudes necessary to improve the quality and safety of health care systems. AACN strives to provide safe work environments. HCAHPS measures client satisfaction with health care.

The nurse is assessing the client's behavioral response to a nursing intervention. This type of evaluation is known as: a. structural evaluation. b. behavior modification. c. outcome evaluation. d. process evaluation.

c. outcome evaluation. Outcome evaluation, which focuses on the client and the client's function, is currently receiving a great deal of emphasis. Outcome evaluation determines the extent to which the client's behavioral response to nursing intervention reflects the desired client goal and outcome criteria. The focus of a process evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. A structure evaluation or audit focuses on the environment in which care is provided. Behavior modification is not a type of evaluation but a type of intervention that focuses on helping clients make lifestyle changes to achieve health goals.

Which action by the nurse is an example of peer review? a. The nurse seeks feedback from the nurse manager regarding job performance for the previous year. b. The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education. c. The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. d. The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation.

d. The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation. Peer review involves the evaluation of one staff member by another staff member on the same level in the hierarchy of the organization for the purpose of professional performance improvement. The nurse preceptor providing feedback to the new graduate nurse after 6 weeks of orientation is an example of peer review. The nurse manager and the UAP are not on the same level in the organization as the nurse. Consulting policies and procedures is not peer review.

A client reports to the nurse quitting smoking 6 months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome? a. Affective b. Cognitive c. Psychomotor d. Physiologic

a. Affective Affective outcomes pertain to changes in client values, beliefs, and attitudes and are more complex to evaluate. Changes in behaviors, such as the cessation of smoking or nutritional changes that lead to weight loss, are examples of affective outcomes. Cognitive outcomes involve an increase in client knowledge and are evaluated by asking the client to repeat information. Psychomotor outcomes describe the client's achievement of a new skill and are evaluated by having the client perform the skill. Physiologic outcomes result in physical changes and are evaluated through physical assessment.

Which authoritative statements guide current professional nursing practice? a. American Nurses Association Standards of Nursing Practice b. National Institutes of Health publications c. Nursing Interventions Classification d. Risk Appraisal Index

a. American Nurses Association Standards of Nursing Practice Standards of care are authoritative statements made by nursing organizations. These standards guide professional practice and serve as the framework for the evaluation of nursing practice. The American Nurses Association Standards of Clinical Nursing Practice (2010) are the current standards of care that define the who, what, where, when, why, and how of nursing practice. The Nursing Interventions Classification is a standardized system for classifying nursing inteventions. The National Institutes of Health is not specific to nursing practice. Risk appraisal index is not an authoritative statement and is not specific to nursing practice.

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

a. Document reassessment of pain after medication administration. 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.

The nurse is reassessing a client with leukemia who has received several packed red blood cell transfusions over the past week. Which question should the nurse ask the client to evaluate the treatment? a. Have you had any fevers?b. Have you experienced any tenderness in your joints? c. Have you noticed any bruising? d. Have you experienced any headaches?

a. Have you had any fevers? The administration of red blood cells is intended to correct an anemic condition in a client with leukemia. Leukemia destroys the bone marrow's ability to produce healthy white blood cells, red blood cells, and platelets. Headaches occur in patients with anemia as a result of decreased oxygenation, which causes arterial swelling. Joint or bone pain occurs as a result of the expansion of bone marrow from the accumulation of white blood cells. Bruising is a symptom of thrombocytopenia which occurs as a result of a decreased platelet production.

Before discharge the client will demonstrate aseptic dressing changes. This is an example of which type of evaluative statement? a. Psychomotor b. Cognitive c. Affective d. Physical changes

a. Psychomotor Psychomotor outcomes are those that are related to new skill attainment, such as learning aseptic dressing changes. Cognitive outcomes are related to achieving greater knowledge. Affective outcomes are related to feelings and attitudes. Physical changes are related to actual body changes in the individual.

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? a. Quality by inspection b. Quality as opportunity c. Quality by perception d. Quality as initiative

a. Quality by inspection 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.

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? a. The client is able to explain when and why the client needs to check the blood glucose level. b. The client can demonstrate the correct technique for using a new glucometer. c. The client has maintained blood glucose levels within acceptable range in the days prior to discharge. d. The client expresses a desire to change the way that the client eats and exercises.

a. The client is able to explain when and why the client needs to check the blood glucose level. The ability to describe the rationale and technique for blood glucose monitoring indicates that the client has achieved a cognitive outcome. Demonstration of the technique constitutes a psychomotor outcome, whereas the expression of a desire for change is an affective outcome. The maintenance of healthy blood blood glucose levels is a physiologic outcome.

Which statements are true of factors that influence client responses and outcome achievement and of how the nurse should use them? Select all that apply. a. The nurse should draw on positive factors to deal with other variables in the future. b. The nurse should reinforce negative behaviors to achieve desired outcomes. c. A client's strong motivation to learn appropriate health behaviors is an example of a positive factor. d. A nurse uses only positive factors to manipulate client outcomes. e. The nurse should identify which factors are helpful to attaining outcomes and manipulate them to achieve goals.

a. The nurse should draw on positive factors to deal with other variables in the future. c. A client's strong motivation to learn appropriate health behaviors is an example of a positive factor. e. The nurse should identify which factors are helpful to attaining outcomes and manipulate them to achieve goals. The nurse should reinforce positive, not negative, behaviors to achieve the outcomes for the client. The nurse can manipulate both positive and negative factors to improve client outcomes. The other choices are all true regarding positive factors.

A nurse is reviewing the plan of care for a client. Which should the nurse identify as problems related to the planning phase of the nursing process? Select all that apply. a. The plan of care only contains standard knowledge that most nurses would implement if there was no plan of care. b. Long-term goals are vague. c. Outcomes are incorrectly developed. d. Nursing orders are superficial. e. Database input does not reflect changes in a client's condition.

a. The plan of care only contains standard knowledge that most nurses would implement if there was no plan of care. b. Long-term goals are vague. c. Outcomes are incorrectly developed. d. Nursing orders are superficial. Database input is done during the assessment phase of the plan of care. The other choices are all completed during the planning phase of the nursing process.

Why are quality-assurance programs important in nursing? a. They enable nursing to be accountable for the quality of care. b. They facilitate increased enrollment in educational programs. c. They specify how resources are used or not used. d. They allow increased retention of qualified nurses.

a. They enable nursing to be accountable for the quality of care. Quality-assurance (QA) programs enable nursing to be accountable to society for the quality of nursing care. They are a response to the public mandate for professional accountability. QA programs do not facilitate increased enrollment in education programs, specify how resources are to be used, or increase retention of nurses.

Identifying the kind and amount of nursing services required is a possible solution for: a. inadequate staffing. b. clients who fail to communicate their needs. c. nurses who are bored. d. nurses frustrated with substandard care.

a. inadequate staffing. A possible solution for inadequate staffing is to identify the kind and amount of nursing services required. Using a team conference to develop a consistent plan of care is a possible solution for the client who fails to communicate needs. Educating the client to become an assertive health care consumer is a possible solution for the client who quietly accepts whatever care is delivered or not delivered. A possible solution for the nurse who is a candidate for burnout is to learn to give quality care during the designated work period. An initiative to focus on quality improvement is a possible solution to nurses frustrated with substandard care. Reviewing task assignments and work schedules is a possible solution to bored nurses.

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? a. Another nurse manager b. Another registered nurse with critical care certification c. One of the staff critical care physicians d. Another staff nurse from the medical-surgical unit

b. Another registered nurse with critical care certification Peer review is the evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. Therefore, another registered nurse who is certified in critical care would be appropriate to evaluate a critical care nurse certified in critical care. A nurse manager and a critical care physician are at a higher level in the hierarchy than a staff nurse certified in critical care. A staff nurse without certification in critical care would also not be appropriate to evaluate a nurse with this certification.

A nurse overhears a coworker telling a somewhat offensive joke to a client. Which nursing action is indicated? a. Report what was overheard to the charge nurse. b. Discuss the occurrence with the coworker. c. Apologize to the client for the coworker's behavior. d. Investigate whether the coworker and client have a previous relationship.

b. Discuss the occurrence with the coworker. The first step is to confront the coworker. If the behavior continues or the nurse does not seem to understand the gravity of the mistake, it would be appropriate to discuss the situation with the charge nurse. It makes no difference if the client and coworker have a previous relationship or not, given the unprofessional nature of the incident. The client-nurse boundary should be protected. Apologizing to the client may draw attention to the issue.

Which client outcomes are psychomotor outcomes? Select all that apply. a. The client identifies five low-sodium foods. b. The client describes how to empty a Jackson-Pratt drain. c. The client measures capillary blood glucose level. d. The client self-catheterizes using clean technique. e. The client reports imagery is effective in controlling anxiety.

b. The client measures capillary blood glucose level. d. The client self-catheterizes using clean technique. Psychomotor outcomes describe the client's achievement of new skills, such as measuring capillary blood glucose level and self-catheterization. Cognitive outcomes demonstrate increases in client knowledge, such as identifying low-sodium foods and describing how to empty a wound drain. An affective outcome involves changes in the client's values, beliefs, and attitude, such as using imagery to control anxiety.

The nurse participates in a quality assurance program and reviewing evaluation data from the previous year. Which should the nurse recognize as an example of outcome evaluation? a. A 4% increase in the number of baccalaureate-prepared nurses employed in the facility b. Bed occupancy rates of 97% in the critical care areas and 92% in the non-critical care areas c. A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery d. A rate of 98% of clients admitted to the hospital who had a nursing history completed within 24 hours after admission

c. A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. Structure evaluation focuses on the environment in which care is provided, such as the number of baccalaureate-prepared nurses employed in the facility and bed occupancy rates. Process evaluation focuses on the nature and sequence of activities carried out by nursing implementing the nursing process, such as a rate of 98% of clients admitted to the hospital who had a nursing history completed within 24 hours after admission.

"The levels of performance accepted by and expected of nursing staff or other health team members" defines: a. criteria. b. evaluation. c. standards. d. evidence-based practice.

c. standards. Standards are the "levels of performance accepted by and expected of nursing staff or other health team members." Criteria are "measurable qualities, attributes, or characteristics that identify skill, knowledge, or health status." Evidence-based practice incorporates delivering nursing care that evidence supports as likely to result in meeting the expected client outcomes. Evaluation involves measuring how well the client has achieved the outcomes that were set forth in the plan of care.

For a client with a self-care deficit, the long-term goal is that the client will be able to dress oneself by the end of the 6-week therapy. For best results, when should the nurse evaluate the client's progress toward this goal? a. When the client is discharged b. At the end of the 6-week therapy c. Only when the client shows some progress d. As soon as possible

d. As soon as possible Evaluating the progress of a long-term goal prior to the end date encourages and motivates the client to continue working toward the goal. Waiting until the client is discharged or at the end of the 6 weeks does not provide the client the opportunity to feel a sense of accomplishment and motivation to continue working toward the goal. Only evaluating when the client shows progress may lead to the client becoming discouraged.

A nurse has been providing discharge teaching to a client with type 1 diabetes. Which outcome indicates that the teaching has been effective? a. Before discharge, the client will attempt to administer a subcutaneous injection. b. By a certain date, the client will talk to a dietitian regarding information for a diabetic diet. c. Before discharge, the client will understand proper foot care and eye care. d. By a certain date, the client will verbalize signs and symptoms of hypoglycemia.

d. By a certain date, the client will verbalize signs and symptoms of hypoglycemia. Teaching has been effective when the client verbalizes signs and symptoms of hypoglycemia, indicating that the client knows the information. Attempting to administer an injection is not an outcome that is effective. If the client was actually able to demonstrate an injection by oneself, then this outcome would be effective. Talking to a dietitian and understanding care do not demonstrate to the nurse that the teaching has been effective, but rather represent passive learning without a measurable outcome.

Which action is appropriate when evaluating a client's responses to a plan of care? a. Reinforce the plan of care when each expected outcome is achieved. b. Terminate the plan if there are difficulties achieving the goals/outcomes. c. Terminate the plan of care upon client discharge. d. Continue the plan of care if more time is needed to achieve the goals/outcomes.

d. Continue the plan of care if more time is needed to achieve the goals/outcomes. The client's goals/outcomes sometimes are not met or partially met only because more time is needed for the plan of care to be effective. It is not necessary to reinforce the plan of care when each expected outcome is achieved because as goals are met, the plan can simply continue to the next goal. Termination of the plan is not warranted due to difficulties in achieving goals/outcomes; modifications to the plan of care may only be required. The plan of care may continue past discharge if necessary.

A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement? a. Psychomotor b. Cognitive c. Affective d. Physical changes

d. Physical changes Physical changes are related to actual body changes in the infant. Psychomotor outcomes are those that are related to new skill attainment. Cognitive outcomes are related to achieving greater knowledge. Affective outcomes are related to feelings and attitudes.

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

d. Revise the plan of care. 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.

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? a. Educational b. Psychomotor c. Maintenance d. Surveillance

d. Surveillance 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 nursing action reflects evaluation? a. The nurse identifies that the client does not tolerate activity. b. The nurse sets a tolerable pain rating with the client. c. The nurse auscultates the client's lungs and abdomen. d. The nurse assesses urine output following administration of a diuretic.

d. The nurse assesses urine output following administration of a diuretic. Assessing the client's response to a diuretic medication is an example of evaluation. Recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as activity intolerance, is the focus of diagnosing. Auscultating the client's lungs and abdomen is an example of assessment. Setting a tolerable pain rating with the client is an example of planning.

The primary purpose for evaluating data about a client's care according to a functional health approach is to: a. meet accreditation standards. b. determine implementation of medical orders. c. evaluate the need for health care consultations. d. revise or modify the client care plan.

d. revise or modify the client care plan. Evaluation using the functional health approach provides a framework for organizing and evaluating data allowing the nurse to modify the client care plan. Evaluation has no influence upon meeting accreditation standards, implementation of medical orders, or the need for health care consultations.

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered: a. process. b. outcome. c. goal. d. subjective. e. structure.

e. structure. Availability of equipment, layout of physical facilities, nurse-client ratios, administrative support, and maintenance of nursing staff competence are some areas of concern for structure evaluation. Process, outcome, goal, and subjective evaluation address those respective categories.

The nurse should evaluate client outcomes at which time? a. As early as possible b. The day of discharge c. Within 24 hours after identifying them d. Several days after discharge

a. As early as possible Nurses should evaluate client outcome achievement as early as possible. Celebrating outcome attainment with the client usually helps encourage the client and leads to further outcome achievement. When failure to meet designated outcomes is detected early, the care plan can be modified to remedy the failure. Waiting until the day of discharge may be too late. Evaluting outcomes after the client has been discharged would be difficult. Evaluating outcomes within 24 hours may be too soon or unnecessarily late, depending on the nature of the outcomes.

The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome? a. At the completion of each meal b. On 3/2 c. On 3/3 d. At the client's direction

a. At the completion of each meal The nurse should collect data at the completion of each meal to ensure the accuracy of the data and to monitor the client's progress toward meeting the goal so that the nurse can make changes to the plan when the client fails to make sufficient progress or celebrate with the client when the client demonstrates success. Although the final evaluation of goal attainment must occur on or shortly after 3/2, data collection must begin far earlier than that. It would not be appropriate for the client to direct when data collection should occur.

A nurse is evaluating a client to determine outcome achievement. The nurse determines that the client's outcome was partially met. When documenting the evaluative statement, the nurse records which other information? a. Data that support the decision of the outcome being partially met b. The client's verbal agreement of the outcome not being met c. The reason the outcome was only partially met d. The revision to the initial outcome identified

a. Data that support the decision of the outcome being partially met The two-part evaluative statement includes a decision about how well the outcome was met, along with client data or behaviors that support this decision. Client statements, reasons for not meeting the outcome, and revisions to the outcome statement are not included.

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

a. Quality assurance 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.

Which parts of the nurse's decision about care occur after evaluating the client's responses to the plan of care? Select all that apply. a. Terminate the plan of care b. Modify the plan of care c. Continue the plan of care d. Begin the plan of care e. Communicate the plan of care

a. Terminate the plan of care b. Modify the plan of care c. Continue the plan of care Based on the client's responses to the plan of care, the nurse decides to terminate the plan if expected outcomes are achieved, modify the plan if there are difficulties in achieving the outcomes, or continue the plan if more time is needed to achieve the outcomes. Beginning the plan of care occurs in the implementation phase, and communicating the plan of care occurs in the outcome identification and planning phase.

Which are cognitive client outcomes? Select all that apply. a. The client lists the side effects of digoxin. b. The client describes how to perform progressive muscle relaxation. c. The client identifies signs and symptoms of hypoglycemia. d. The client correctly ambulates with a walker. e. The client reports cycling 30 minutes three times each week.

a. The client lists the side effects of digoxin. b. The client describes how to perform progressive muscle relaxation. c. The client identifies signs and symptoms of hypoglycemia. Cognitive outcomes demonstrate increases in client knowledge, such as listing side effects of medications, identifying signs and symptoms of hypoglycemia, and describing progressive muscle relaxation. Psychomotor outcomes describe the client's achievement of new skills, such as correct ambulation with a walker. An affective outcome involves changes in the client's values, beliefs, and attitude, such as the client's report of cycling.

Which client outcome is an example of a physiologic outcome? a. The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula. b. The client reports walking for 30 minutes each day. c. The client demonstrates active range-of-motion exercises with left upper extremity. d. The client explains how to administer a vaginal cream.

a. The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula. Physiologic outcomes are physical changes in the client, such as pulse oximetry. An affective outcome involves changes in the client's values, beliefs, and attitude, such as engaging in exercise. Cognitive outcomes demonstrate increases in client knowledge, such as administration of a vaginal cream. Psychomotor outcomes describe the client's achievement of new skills, such as performing active range-of-motion exercises.

A nurse evaluates clients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse? a. The nurse evaluates the client's goal/outcome achievement. b. The nurse evaluates the plan of care. c. The nurse evaluates the competence of nurse practitioners. d. The nurse evaluates the types of health care services available to the client.

a. The nurse evaluates the client's goal/outcome achievement. The priority is to evaluate the client's goal/outcome achievement. This determines if the nursing diagnosis has been resolved. If the client's goal/outcome had not been met the nurse should then begin evaluating all aspects of the plan of care. It is not the responsibility of the nurse to evaluate the competence of nurse practitioners. The nurse can evaluate services available to the client but this is not the purpose of the evaluation phase of the nursing process.

Which is a psychomotor client goal? a. By 18AUG2015, the client will value health sufficiently to quit smoking. b. By 18AUG2015, the client will demonstrate improved motion in the left arm. c. By 18AUG15, the client will list three foods that are low in salt. d. By 18AUG2015, the client will learn three exercises designed to strengthen leg muscles.

b. By 18AUG2015, the client will demonstrate improved motion in the left arm. Psychomotor client goals refer to the client's achievement of new skills, such as demonstrating improved motion in the left arm. Valuing health by quitting smoking is an example of an affective goal. Listing three foods low in salt is a cognitive goal. Learning exercises to strengthen leg muscles is an affective goal.

"The client will verbalize appropriate cast care on discharge" represents which type of outcome? a. Psychomotor b. Cognitive c. Affective d. Physical change

b. Cognitive This is an example of a cognitive outcome. Cognitive outcomes are related to achieving greater knowledge. Psychomotor outcomes are those that are related to new skill attainment. Affective outcomes are related to feelings and attitudes. Physical changes are related to actual body changes in the individual.

A client comes into the clinic for a routine postoperative visit. While the nurse is assessing the level of pain, the client states that there is occasional discomfort but that pain levels have improved daily since returning home from the hospital. What should the nurse's response be regarding the client's plan of care? a. Terminate the plan of care. b. Continue the plan of care. c. Promptly modify the plan of care. d. Suggest increasing the pain medication.

b. Continue the plan of care. The nurse should continue the plan of care, as the client is progressing toward the ultimate outcome—the healing of the surgical site. There is no need to modify the plan, as the client is responding. The client is still having some pain, so it would not be appropriate to discontinue the plan of care. With the improvement in the client's pain, there is no need to increase pain medication; the nurse should just remind the client to take it when pain is uncomfortable.

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? a. Report the nurse applying the restraints to the supervisor. b. File an incident report and have the second nurse sign it. c. Confront the nurse and explain how this could be dangerous for the client. d. Contact the physician for an order for the restraints.

c. Confront the nurse and explain how this could be dangerous for the client. Confronting the nurse and explaining the danger for the client is a form of peer evaluation. Peer evaluation involves evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. This is an important mechanism nurses can use to improve their professional performance; it can be done formally or informally. Reporting the nurse does not enhance a good working relationship and does not follow the chain of command. An incident report is not warranted at this point in time. The physician should not be contacted for an order unless it is decided that the restraint is going to be left on the client.

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

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

The health care team has convened to discuss the care of an end-of-life client who is not able to achieve an acceptable level of comfort. The physician asks for the nurse's perspective of the situation. Which standard for establishing and sustaining healthy work environments does this action represent? a. Skilled communication b. Effective decision making c. True collaboration d. Appropriate staffing

c. True collaboration This scenario represents true collaboration, as nurses and other health care team members are demonstrating mutual respect, shared responsibility, and shared decision making. Although skilled communication and effective decision making are likely to be involved in true collaboration, these are not the focus of this scenario. There is no evidence of whether staffing is appropriate in this scenario.

A new mother is having difficulty breastfeeding a newborn infant. A goal was established stating that 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 having discontinued breastfeeding. The nurse evaluates the original goal as: a. met. b. partially met. c. completely unmet. d. inappropriately chosen for this client.

c. completely unmet. After collecting data and evaluating the client's behavioral responses, the nurse makes a judgment about goal attainment by comparing the client's actual behavioral responses with the predicted responses or predetermined outcome criteria developed in the planning phase. In this case the mother abandoned breastfeeding, which represents a complete failure to meet the collaborative goal established. If the mother reported breastfeeding the baby every 4 to 5 hours, the nurse could consider the goal partially met. There is no evidence that the goal was inapropriately chosen for the client.