Fundamentals: Chapter 20: Evaluation

3. A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate? a. "An evaluation helps you determine whether all nursing interventions were completed." b. "During evaluation, you determine when to downsize staffing on nursing units." c. "Nurses use evaluation to determine the effectiveness of nursing care." d. "Evaluation eliminates unnecessary paperwork and care planning."

ANS: C Evaluation is a methodical approach for determining if nursing implementation was effective in influencing a patient's progress or condition in a favorable way. During evaluation, you do not simply determine whether nursing interventions were completed. The evaluation process is not used to determine when to downsize staffing or how to eliminate paperwork and care planning.

14. A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal? a. "I'm worried about what those other girls will think of me." b. "I can't wear that color. It makes my hips stick out." c. "I'll wear the blue dress. It matches my eyes." d. "I will go to the pool next summer."

ANS: C The nurse is evaluating the improvement in body image. The only positive comment made is that the patient is wearing the blue dress to match her eyes. Worrying about others, making my hips stick out, and going to the pool next summer do not reflect positive changes in body image.

7. The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule? a. Staff documentation of turning the patient every 2 hours b. Presence of redness only on the heels of the patient c. Patient's eating 100% of all meals d. Absence of skin breakdown

ANS: D To determine whether a turning schedule is successful, the nurse needs to assess for the presence of skin breakdown. Redness on any part of the body, including only the patient's heels, indicates that the turning schedule was not successful. Documentation of interventions does not evaluate whether patient outcomes were met. Eating 100% of meals does not evaluate the effectiveness of a turning schedule.

12. A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome? a. States feels better after talking with family and friends b. Consumes high-carbohydrate foods when stressed c. Dislikes the support group meetings d. Spends most of the day in bed

ANS: A Evaluative data that show signs of effective coping will help the nurse determine whether the patient has met the outcome. Talking to family and friends is the only positive option. During evaluation, you perform evaluative measures that allow you to compare clinical data, patient behavior measures, and patient self-report measures collected before implementation with the evaluation findings gathered after administering nursing care. Next, you evaluate whether the results of care match the expected outcomes and goals set for a patient. Consuming high-carbohydrate foods (patient is a diabetic), disliking support group, and spending the day in bed indicate unsuccessful progress toward meeting the patient's goal.

18. A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met? a. Heart rate 78 beats/min on 12/3 b. Heart rate 78 beats/min on 12/4 c. Heart rate 80 beats/min on 12/3 d. Heart rate 80 beats/min on 12/4

ANS: A Heart rate 78 beats/min on 12/3 indicates the goal has been met. Comparing expected and actual findings allows you to interpret and judge a patient's condition and whether predicted changes have occurred. Expected outcome states less than 80, not 80. The date is by 12/3, not 12/4.

8. A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next? a. Reassess the patient and situation. b. Revise the turning schedule to increase the frequency. c. Delegate turning to the nursing assistive personnel. d. Apply medication to the area of skin that is broken down.

ANS: A If a nursing diagnosis is unresolved or if you determine that a new problem has perhaps developed, reassessment is necessary. A complete reassessment of patient factors relating to an existing nursing diagnosis and etiology is necessary when modifying a plan. The nurse must assess before revising, delegating and applying medication. The breakdown may be a result of inadequate nutritional intake and medication cannot be applied unless there is an order.

16. A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse's priority when evaluating the patient? a. Identify factors interfering with goal achievement. b. Counsel the nursing assistive personnel on duty when the patient fell. c. Remove the fall risk sign from the patient's door because the patient has suffered a fall. d. Request that the more experienced charge nurse complete the documentation about the fall.

ANS: A When goals and outcomes are not met, you identify the factors that interfere with their achievement. The nurse identifies factors that interfered with goal achievement to determine the cause of the fall. The fall may not have been due to an error by the nursing assistive personnel; therefore, counseling should be reserved until after the cause has been determined. The patient remains a fall risk, so the fall risk sign should remain on the door. The nurse witnessing the fall or the nurse assigned to the patient needs to complete the documentation. The charge nurse can be consulted to review the documentation.

20. A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient's responses to nursing care? (Select all that apply.) a. Observations of wound healing b. Daily blood pressure measurements c. Findings of respiratory rate and depth d. Completion of nursing interventions e. Patient's subjective report of feelings about a new diagnosis of cancer

ANS: A, B, C, E You examine the results of care by using evaluative measures, which are assessment skills and techniques (e.g., observations, physiological measurements, use of measurement scales, and patient interview). Examples of evaluative measures include assessment of wound healing and respiratory status, blood pressure measurement, and assessment of patient feelings. You conduct evaluative measures to determine if your patients met expected outcomes, not if nursing interventions were completed.

11. The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse's next action? a. Wait and change the dressing at 1800 as ordered. b. Revise the plan of care and change the dressing now. c. Reassess the dressing and the wound in 2 hours. d. Discontinue the plan of care for wound care.

ANS: B Because the dressing is saturated and leaking, the nurse needs to revise the plan of care and change the dressing now. Reflection-in-action involves a nurse's ability to recognize how a patient is responding and then adjusting interventions as a result. A nurse will either change the frequency of an intervention, change how the intervention is delivered, or select a new intervention. Waiting until 1800 or for another 2 hours is not appropriate because assessment data reflect that the dressing is saturated and needs to be changed now. Data are insufficient to support discontinuing the plan of care. Instead, data at this time indicate the need for revision of the plan of care.

13. A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate? a. Health status b. Health behavior c. Psychological self-control d. Health service utilization

ANS: B Health behavior involves demonstrating a psychomotor skill such as self-injection. Health status is a clinical indicator such as exercise tolerance or blood pressure control. The skill is psychomotor, not psychological self-control. Health service utilization is readmission within 30 days or emergency department use.

19. A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks? 1. Revise nursing diagnosis. 2. Reassess blood pressure reading. 3. Retake blood pressure after medication. 4. Administer new blood pressure medication. 5. Change goal to blood pressure less than 140/90. a. 1, 5, 2, 4, 3 b. 2, 1, 5, 4, 3 c. 4, 3, 1, 5, 2 d. 5, 4, 5, 1, 2

ANS: B If a nursing diagnosis is unresolved or if you determine that a new problem has perhaps developed, reassessment is necessary. A complete reassessment of patient factors relating to an existing nursing diagnosis and etiology is necessary when modifying a plan. After reassessment, determine which nursing diagnoses are accurate for the situation; revise as needed. When revising a care plan, review the goals and expected outcomes for necessary changes after the diagnosis. Then evaluate and revise interventions as needed.

6. The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome? a. The nurse provides assistance while the patient is walking in the hallways. b. The patient is able to ambulate in the hallway with crutches. c. The patient will deny pain while walking in the hallway. d. The patient's level of mobility will improve.

ANS: B The patient's being able to ambulate in the hallway with crutches is an expected outcome of nursing care. The outcomes of nursing practice are the measurable conditions of patient, family or community status, behavior, or perception. These outcomes are the criteria used to judge success in delivering nursing care. The option stating, "The patient's level of mobility will improve" is a broader goal statement. The nurse's assisting a patient to ambulate is an intervention. The patient's denying pain is an expected outcome for pain, not for physical mobility problems.

9. A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? a. "Evaluative measures are multiple-page documents used to evaluate nurse performance." b. "Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals." c. "Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse." d. "Evaluative measures are objective views for completion of nursing interventions."

ANS: B You conduct evaluative measures to determine if your patients met expected outcomes, not if nursing interventions were completed. Evaluative measures are assessment skills and techniques. Evaluative measures are not multiple-page documents, and they are used to assess the patient's status, not the nurse's performance or progress from novice to expert.

5. A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient's plan of care? a. Determine whether the patient has transportation to get home. b. Evaluate whether patient goals and outcomes have been met. c. Establish whether the patient has a follow-up appointment scheduled. d. Ensure that the patient's prescriptions have been filled to take home.

ANS: B You evaluate whether the results of care match the expected outcomes and goals set for a patient before discontinuing a patient's plan of care. The patient needs transportation, but that does not address the patient's mobility status. Whether the patient has a follow-up appointment and ensuring that prescriptions are filled do not evaluate the problem of mobility.

21. Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.) a. Set priorities for patient care. b. Determine whether outcomes or standards are met. c. Ambulate patient 25 feet in the hallway. d. Document results of goal achievement. e. Use self-reflection and correct errors.

ANS: B, D, E The expected outcomes established during planning are the standards against which you judge whether goals have been met and if care is successful. You evaluate whether the results of care match the expected outcomes and goals set for a patient. Documentation and reporting are important parts of evaluation because it is crucial to share information about a patient's progress and current status. Using self-reflection and correcting errors are indicators a nurse is performing evaluation. Setting priorities is part of planning, and ambulating with a patient in the hallway is an intervention, so it is included in the implementation step of the nursing process.

4. After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient's headache. Which action by the nurse is priority for this patient? a. Eliminate headache from the nursing care plan. b. Direct the nursing assistive personnel to ask if the headache is relieved. c. Reassess the patient's pain level in 30 minutes. d. Revise the plan of care.

ANS: C The nurse's priority action for this patient is to evaluate whether the nursing intervention of administering acetaminophen was effective. The nurse does not have enough evaluative data at this point to determine whether headache needs to be discontinued. Assessment is the nurse's responsibility and is not to be delegated to nursing assistive personnel. The nurse does not have enough evaluative data to determine whether the patient's plan of care needs to be revised.

10. The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take? a. Ask the nursing assistive personnel if the wound looks better. b. Document the progress of wound healing as "better" in the chart. c. Measure the wound and observe for redness, swelling, or drainage. d. Leave the dressing off the wound for easier access and more frequent assessments.

ANS: C You examine the results of care by using evaluative measures, which are assessment skills and techniques (e.g., observations, physiological measurements, use of measurement scales, and patient interview). The nurse performs evaluative measures, such as completing a wound assessment, to evaluate wound healing. Nurses do not delegate assessment to nursing assistive personnel. Documenting "better" is subjective and does not objectively describe the wound. Leaving the dressing off for the nurse's benefit of easier access is not a part of the evaluation process.

1. A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting? a. Assessment b. Planning c. Implementation d. Evaluation

ANS: D Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient's condition or well-being improves and if goals have been met. Assessment, the first step of the process, includes data collection. Planning, the third step of the process, involves setting priorities, identifying patient goals and outcomes, and selecting nursing interventions. During implementation, nurses carry out nursing care, which is necessary to help patients achieve their goals.

2. A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next? a. Assessment b. Planning c. Implementation d. Evaluation

ANS: D Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient's condition or well-being improves. Assessment involves gathering information about the patient. During the planning phase, patient outcomes are determined. Implementation involves carrying out appropriate nursing interventions.

17. A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal? a. No sputum or cough present in 4 days b. Congestion throughout all lung fields in 2 days c. Shallow, fast respirations 30 breaths per minute in 1 day d. Lungs clear to auscultation following use of inhaler

ANS: D In this case, the patient's goal is to not experience shortness of breath with activity in 3 days. If the lung sounds are clear following use of inhaler, the nurse can determine that the patient is making progress toward achieving the expected outcome. One way for the nurse to evaluate the expected outcome is to assess the patient's lung sounds. Goals are broad statements that describe changes in a patient's condition or behavior. Expected outcomes are measurable criteria used to evaluate goal achievement. When an outcome is met, you know that the patient is making progress toward goal achievement. The time frame of 4 days in the first option is not appropriate because this time frame exceeds the time frame stated in the goal. Congestion indicates fluid in the lungs, and a respiratory rate of 30 breaths per minute is elevated/abnormal. This indicates that the patient is still probably experiencing shortness of breath and secretions in the lungs.

15. A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion? a. Patient wanders halls at night. b. Patient's side rails are up with bed alarm activated. c. Patient denies pain while ambulating with assistance. d. Patient correctly states names of family members in the room.

ANS: D The goal for this patient would address a decrease or absence of confusion. Thus, one possible sign that a patient's confusion is improving is seen when a patient can correctly state the names of family members in the room. You examine the results of care by using evaluative measures that relate to goals and expected outcomes. Keeping the side rails up and using a bed alarm are interventions to promote patient safety and prevent falls. The patient's denying pain indicates positive progress toward resolving pain. The patient's wandering the halls is a sign of confusion.