Chapter 9

What guides professional practice? A) ANA Standards of Nursing Practice B) National Institutes of Health publications C) Nursing Intervention Classification D) Risk Appraisal Index

A) ANA Standards of Nursing Practice *Rationale* Standards of care guide professional practice and serve as the framework for the evaluation practice.

The nurse is discussing dietary options with a client who is upset because the client is unable to have the food the client wants to eat. The nurse states "You may not be able to have steak but can have grilled salmon or grilled chicken. Which do you prefer?" What is the purpose for giving clients options to their care? A) Allowing the client to have options supports decision-making abilities. B) Giving the client options makes him feel that he or she controls his or her care. C) The food choices are available in the menu. D) The client must eat hospital food that is good for him or her.

A) Allowing the client to have options supports decision-making abilities. *Rationale* The intellectual skills used in implementation include problem solving, decision- making, and educating. To solve problems, nurses ask clients pertinent questions, discuss alternatives, and are open to new ideas. To enrich the decision-making abilities of clients, nurses give them opportunities to choose which treatments are performed, when, and in what sequence. Educating requires knowledge about teaching-learning principles and information to convey.

Which nursing action can be categorized as a surveillance or monitoring intervention? A) Auscultating of bilateral lung sounds B) Providing hygiene C) Administering paracetamol tablet D) Use of therapeutic communication skills

A) Auscultating of bilateral lung sounds *Rationale* Surveillance or monitoring nursing interventions includes detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone; detecting odors and comparing them with past experience and knowledge of specific problems; and using touch to assess body temperature, skin condition, clamminess, or diaphoresis. Nurses use all of these surveillance or monitoring activities to determine the current status of clients and changes from previous states. Nurses often detect subtle changes in a client's condition and communicate them to the physician to minimize problems.

Which purpose of the evaluation phase of the nursing process is a priority during client care? A) Examining the client's behavioral response to the care received. B) Providing basis for the revision of plan of care. C) Monitoring the quality and effects of the nursing care. D) Appraising collaboration of the client and family.

A) Examining the client's behavioral response to the care received. *Rationale* Nurses continually assess responses of clients to particular nursing interventions, establish different priorities for nursing diagnoses, and alter plans of care as necessary.

Which is a major premise of a quality improvement program? *Select all that apply.* A) It determines whether nursing standards are being upheld. B) Some governmental agencies mandate quality improvement programs. C) It focuses on processes rather than individuals. D) It should ideally be performed one to two times per year. E) Its focus is on ensuring excellence in care.

A) It determines whether nursing standards are being upheld. B) Some governmental agencies mandate quality improvement programs. C) It focuses on processes rather than individuals. E) Its focus is on ensuring excellence in care. *Rationale* The major premises of quality improvement include a focus on processes and standards that lead to quality care. Numerous governmental agencies either encourage or require quality improvement. It is an ongoing process that is not necessarily an annual or biannual event.

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable? A) Psychosocial background B) Developmental stage C) Research findings D) Current standards of care

A) Psychosocial background *Rationale* The nurse is demonstrating an awareness of the client's psychosocial background, which includes consideration of the client's socioeconomic status. Research findings and current standards of care are examples of nursing variables. Developmental stage is a client variable that addresses the developmental needs of a client.

In the implementation step of the nursing process, a nurse is to utilize certain activities to be effective in the care of a client. Which activity is the priority? A) Reassess client's needs. B) Document nursing care. C) Prioritize evaluation of care. D) Differentiate between subjective and objective data.

A) Reassess client's needs. *Rationale* Competence in intellectual, interpersonal, and technical skills is required to carry out the implementation phase. Nurses can delegate parts of the plan of care to other members of the healthcare team, but the registered nurse (RN) maintains accountability for the supervision and evaluation of these people. Figure 9-1 illustrates the activities of implementation, which include the following: (a) reassess, (b) set priorities, (c) perform nursing interventions, (d) record nursing actions.

Which statement describes the purpose of evaluation? *Select all that apply.* A) To examine the client's behavioral responses to nursing interventions B) To appraise the extent to which client goals were attained or problems resolved C) To appraise involvement and collaboration of the client, family members, nurses, and healthcare team members in healthcare decisions D) To ensure the plan of care was followed as it was originally prepared E) To collect subjective and objective data to make judgments about nursing care delivered

A) To examine the client's behavioral responses to nursing interventions B) To appraise the extent to which client goals were attained or problems resolved C) To appraise involvement and collaboration of the client, family members, nurses, and healthcare team members in healthcare decisions E) To collect subjective and objective data to make judgments about nursing care delivered

After the nursing plan of care has been developed, the nurse knows that: A) each client encounter is an opportunity to reassess and revise the plan if necessary. B) the plan will be followed by other healthcare providers and filed with the client's chart upon discharge. C) the responsibility for the assessment of the client has ended. D) care plans are rigid and do not change.

A) each client encounter is an opportunity to reassess and revise the plan if necessary. *Rationale* During each encounter with clients, nurses assess function, ensuring prompt attention to emerging problems. Because a client's condition can change quickly and dramatically, astute nurses remain alert to subtle cues and inferences. As they initiate the plan of care, nurses must ensure that the planned interventions are still relevant.

The nurse is assessing the client's self-care capabilities for after discharge from the hospital. Which barrier greatly contributes to the nursing goals being unmet? *Select all that apply.* A) The availability of assistive devices B) Poor communication skills C) Inadequate emotional coping skills D) Debilitating illness E) Family's lack of interest in the plan of care

B) Poor communication skills C) Inadequate emotional coping skills D) Debilitating illness E) Family's lack of interest in the plan of care *Rationale* Barriers to goal attainment may involve the client, family members or significant others, and the nurse or other healthcare team members.

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention? A) Supportive B) Surveillance C) Collaborative D) Maintenance

B) Surveillance *Rationale* Surveillance nursing interventions include detecting changes from baseline data and recognizing abnormal responses.

When the nurse prepares to discharge a client, and subsequently evaluates the effectiveness of the nursing care, the nurse should determine whether the: A) physician orders have been completed. B) client's goals have been achieved. C) critical pathways are completed. D) documentation is thorough.

B) client's goals have been achieved. *Rationale* Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals based on the client's behavioral responses. This phase involves a thorough, systematic review of the effectiveness of nursing interventions and a determination of client goal achievement.

A client with a recently fractured left femur has been reluctant to comply with physical therapy for fear of the pain associated with movement. A goal for this client is to attend therapy treatments three times each day. The nurse is evaluating the goal for this client. The client states, "I don't like therapy; it hurts, but I have been going twice a day." The client chart has an entry from the last shift nurse stating the client went to therapy two times with encouragement. The nurse evaluates the goal as: A) goal met. B) goal partially met. C) goal completely unmet. D) goal revision needed.

B) goal partially met. *Rationale* After collecting data, nurses form a comprehensive picture of the client's behavioral responses. The next activity is to make a judgment about goal attainment by comparing the client's actual behavioral responses to the predicted responses or predetermined outcome criteria developed in the planning phase.

The nurse participates in a quality assurance program and reviewing evaluation data from the previous year. Which does the nurse recognize as an example of outcome evaluation? A) A 4% increase in the number of baccalaureate prepared nurses are employed in the facility. B) A 97% bed occupancy rate in the critical care areas; 92% bed occupancy rate in the noncritical care areas. C) A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. D) 98% of all hospital admissions had a nursing history completed within 24 hours of admission.

C) A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. *Rationale* 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 98% of all hospital admissions had a nursing history completed within 24 hours of admission.

What are the two priority nursing diagnoses? *Select all that apply.* A) Risk for infection B) Anxiety C) Acute pain D) Ineffective airway clearance E) Feeding self-care deficit

C) Acute pain D) Ineffective airway clearance *Rationale* While all are important diagnoses, respiratory function and pain are priority.

A client has terminal cancer and the practitioner has ordered a diagnostic imaging test. The client tells the nurse, "I don't want the test performed." So the nurse agrees to dialogue with the practitioner on the client's behalf. The nurse's actions are what type of intervention? A) Surveillance B) Supportive C) Coordinating D) Technical

C) Coordinating *Rationale* Coordination involves acting as a client advocate, making referrals for follow-up care, collaborating with other healthcare team members, and ensuring that the client's schedule is therapeutic. This is not a surveillance or technical type of intervention. The nurse is being supportive of the client, but advocacy is more closely associated with coordinating types of interventions.

The nurse is to delegate certain tasks to unlicensed assistive personnel (UAP). Which task can be appropriately assigned to a UAP? A) Securing the client's jewelry before surgery. B) Reassessing the client's sacrum for redness when doing bed bath. C) Providing client assistance to the bedside commode. D) Requesting the UAP to get the unit of blood from the blood bank.

C) Providing client assistance to the bedside commode. *Rationale* Assisting with toileting is one of the tasks permitted by the state board of nursing for UAP. This task is commonly performed by UAP in health facilities.

A new mother is having difficulty breastfeeding her newborn infant. A goal was established stating 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 that she 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. *Rationale* After collecting data, nurses form a comprehensive picture of the client's behavioral responses. The next activity is to make a judgment about goal attainment by comparing the client's actual behavioral responses to the predicted responses or predetermined outcome criteria developed in the planning phase.

The primary purpose of nursing implementation is to: A) improve the client's postoperative status. B) identify a need for collaborative consults. C) help the client achieve optimal levels of health. D) implement the critical pathway for the client.

C) help the client achieve optimal levels of health. *Rationale* The purpose of the nursing implementation phase is to help the client achieve an optimal level of health.

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. E) goal evaluation.

C) outcome evaluation. *Rationale* 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 nursing supervisor is presenting the staff nurse with the nurse's yearly performance evaluation. This type of evaluation would be called: A) technical evaluation. B) structural evaluation. C) process evaluation. D) goal evaluation.

C) process evaluation. *Rationale* Process evaluation focuses on the nurse's performance and whether the nursing care provided was appropriate and competent. The phases of the nursing process are used as the framework for the evaluation of nursing care.

The client complains of right knee pain of 6/10 on the pain scale and requests for medication. The nurse assesses and flushes the IV site before giving the IV pain medication. Which type of intervention skill is the nurse using? A) Interpersonal skill B) Intellectual skill C) Technical skill D) Mechanical skill

D) Mechanical skill *Rationale* Technical skills are used to carry out treatments and procedures. Nurses learn the specific skills through clinical practice. Technical competence means being able to use equipment, machines, and supplies in a particular specialty.

Which nursing action reflects evaluation? A) The nurse identifies that the client has wound drainage. B) The nurse sets an anxiety level of 3 or less with the client. C) The nurse performs a colostomy irrigation. D) The nurse assesses the client's response to pain medication.

D) The nurse assesses the client's response to pain medication. *Rationale* Examples of evaluation include assessing the client's response to pain medication. The focus of diagnosing is recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as a wound infection. Setting an anxiety rating with the client is an example of planning. Performing colostomy irrigation is an example of implementation.

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 healthcare consultations. D) revise or modify the nursing care plan.

D) revise or modify the nursing care plan. *Rationale* Evaluation using the functional health approach provides a framework for organizing and evaluating data.

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) structure.

D) structure. *Rationale* 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.