Implimentation and Evaluation prep-u

Which nursing actions reflect the evaluation stage of the nursing process? Select all that apply.

1. The nurse identifies that a client's pain is not being adequately treated. 2. The nurse documents the client's response to suctioning. 3. The nurse determines the client did not lose the expected 2 lb (0.90 kg) Examples of evaluation include documenting the client's response to suctioning and making a judgment that the client did not reach the expected outcome of a 2-lb (0.90-kg) loss or adequate pain control. Setting an anxiety rating with the client is an example of planning. Performing tracheostomy care is an example of implementation.

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of:

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.

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?

Evaluate the use of current pain relief measures

The primary purpose of nursing implementation is to:

Help the client achieve optimal levels of health. The purpose of the nursing implementation phase is to help the client achieve an optimal level of health. Improving the client's postoperative status and implementing the critical pathway for the client are too narrow to represent the purpose of the implementation phase, although they are purposes of specific interventions that would be implemented during this phase. Identifying the need for collaborative consults is an action the nurse would perform in the planning phase of the nursing process.

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 evaluating nursing care and client outcomes by using a retrospective evaluation. Which action would the nurse perform in this approach?

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).

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

Outcome Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care, such as an expedited discharge of the client based on the client recovering more quickly due to an intervention. 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. Cost-effectiveness is not a type of evaluation identified by the American Nurses Association.

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

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.

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?

Survillence 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.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

The client with continuous pulse oximetry who requires pharyngeal suctioning The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel.