Nurs 211 Chapter 18 : Evaluating
The nurse should evaluate client outcomes at which time? -As early as possible -The day of discharge -Within 24 hours after identifying them -Several days after discharge
As early as possible
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? -When the client is discharged -At the end of the 6-week therapy -Only when the client shows some progress -As soon as possible
As soon as possible
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? At the completion of each meal On 3/2 On 3/3 At the client's direction
At the completion of each meal
Which is a psychomotor client goal? -By 18AUG2015, the client will value health sufficiently to quit smoking. -By 18AUG2015, the client will demonstrate improved motion in the left arm. -By 18AUG15, the client will list three foods that are low in salt. -By 18AUG2015, the client will learn three exercises designed to strengthen leg muscles.
By 18AUG2015, the client will demonstrate improved motion in the left arm.
Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? -Collaborate with other disciplines to revise the discharge plans. -Instruct the client to make alternate living arrangements. -Communicate with the physician about additional orders. -Inform the family that it is not possible to change the discharge plans.
Collaborate with other disciplines to revise the discharge plans.
Which statement related to the evaluation of outcome attainment for a client is correct? Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria. The nurse should initially evaluate the plan of care at the time of the client's discharge. Celebrating outcome achievement with a client often interferes with attainment of future goals. Evaluation of the client's attainment of outcome goals is determined by the nurse and physician.
Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria.
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? -Report the nurse applying the restraints to the supervisor. -File an incident report and have the second nurse sign it. -Confront the nurse and explain how this could be dangerous for the client. -Contact the physician for an order for the restraints.
Confront the nurse and explain how this could be dangerous for the client.
A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? -Discuss the risks and benefits of a blood transfusion with the client. -Discuss possible alternatives to a blood transfusion with the physician. -Discuss the client's options with other church members. -Discuss the client's refusal with hospital risk managers.
Discuss possible alternatives to a blood transfusion with the physician.
Which is the priority question for the nurse to consider before implementing a new intervention? -Does this treatment make sense for this client? -How much experience do I have with this treatment? -What equipment do I need? -Will I need someone to assist me?
Does this treatment make sense for this client?
Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? Finances of the client The client's condition Time and resources Feedback from the family
Finances of the client
The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client? -Discuss discharge plans with the client. -Inform the client what to expect after the surgery. -Instruct the client and family in wound care. -Teach the client about dietary restrictions during recovery.
Inform the client what to expect after the surgery.
Which statement best explains why continuing data collection is important? -It is difficult to collect complete data in the initial assessment. -It is the most efficient use of the nurse's time. -It enables the nurse to revise the care plan appropriately. -It meets current standards of care.
It enables the nurse to revise the care plan appropriately.
A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? -Nurse manager -Nurse case manager -Physician -Insurance company
Nurse case manager
The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? -Registered nurse -Nursing assistant who is a nursing student -A senior nursing student present for clinical -Licensed practical nurse
Nursing assistant who is a nursing student
Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? -Secure the client's jewelry before surgery. -Reassess the client's sacrum for redness when doing a bed bath. -Provide the client with assistance in transferring to the bedside commode. -Retrieve a unit of blood from the blood bank.
Provide the client with assistance in transferring to the bedside commode.
A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care? -Reassess the client to determine the effectiveness of the interventions. -Instruct the client that pain medication is available at regular intervals. -Notify the physician that the client has required pain medications. -Perform additional nonpharmacological pain interventions.
Reassess the client to determine the effectiveness of the interventions.
A client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action? -Report the findings to the physician for further plans. -Reinforce the instructions for the treatment regimen to the client. -Interview the family to determine if the client is giving accurate information. -Inform the client that the blood pressure medication will have to be changed.
Report the findings to the physician for further plans.
Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? -Revise the care plan to allow the client to ambulate to the bathroom independently. -Continue assisting the client to the bathroom to ensure the client's safety. -Consult with the physical therapist to determine the client's ability. -Instruct the client's family to assist the client to ambulate to the bathroom.
Revise the care plan to allow the client to ambulate to the bathroom independently.
The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include? -Medications used to treat diabetes mellitus -Risk factors for and prevention of diabetes mellitus -The severity of the client's disease -The cellular metabolism of glucose
Risk factors for and prevention of diabetes mellitus
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? -Supportive -Surveillance -Collaborative -Maintenance
Surveillance
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? -Educational -Psychomotor -Maintenance -Surveillance
Surveillance
The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply. -The client is male. -The client is married. -The client is blind. -The client is an architect. -The client denies the need for education.
The client is blind. The client denies the need for education.
Which characteristic is the most important indicator of high-quality nursing practice? The nurse is organized and efficient in client care. The nurse follows the policies and procedures of the institution. The nurse takes measures to ensure accurate medication administration. The nurse considers the individual needs of clients.
The nurse considers the individual needs of clients.
The primary purpose of nursing implementation is to: -improve the client's postoperative status. -identify a need for collaborative consults. -help the client achieve optimal levels of health. -implement the critical pathway for the client.
help the client achieve optimal levels of health.
When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate? -"Inadequate skills" -"Great response" -"Extremely well-mannered" -"Demonstrated steps"
"Demonstrated steps"
A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? -A client with a high fever receiving intravenous fluids, antibiotics, and oxygen -An older adult with pneumonia who is being discharged to the son's home tomorrow -A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall -An adult client who is being treated for kidney stones
A client with a high fever receiving intravenous fluids, antibiotics, and oxygen
A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care? -Another nurse manager -Another registered nurse with critical care certification -One of the staff critical care physicians -Another staff nurse from the medical-surgical unit
Another registered nurse with critical care certification
A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client? -Asking whether the client feels less anxious 30 minutes after administering the medicine -Assigning the client a new nursing diagnosis based on the client's controlled anxiety -Devising a plan for the client to practice anti-anxiety exercises at home -Collecting data about the client's history with anxiety
Asking whether the client feels less anxious 30 minutes after administering the medicine
One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action? -Assess the client to determine the cause of the pain. -Consult with the physician for additional pain medication. -Discuss the frequency of pain medication administration with the client. -Assist the client to reposition and splint the incision.
Assess the client to determine the cause of the pain.
An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply. -Initial assessment of the mother after birth of the infant -Assisting the client with personal hygiene needs and ambulation -Assisting and teaching the client to breastfeed the infant -Providing routine discharge instructions related to infant care -Transporting the infant to the mother's room according to hospital policy
Assisting the client with personal hygiene needs and ambulation Transporting the infant to the mother's room according to hospital policy
Which parties are essential for the nurse to include in the implementation of a client's plan of care? -Client, family, and physician -Client, physician, and hospital director -Client, physical therapist, and nursing staff -Client, surgeon, and physician
Client, family, and physician
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? Terminate the plan of care. Continue the plan of care. Promptly modify the plan of care. Suggest increasing the pain medication.
Continue the plan of care
Which action is appropriate when evaluating a client's responses to a plan of care? -Reinforce the plan of care when each expected outcome is achieved. -Terminate the plan if there are difficulties achieving the goals/outcomes. -Terminate the plan of care upon client discharge. -Continue the plan of care if more time is needed to achieve the goals/outcomes.
Continue the plan of care if more time is needed to achieve the goals/outcomes.
A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's mostappropriate action? -Coordinate with the other disciplines to schedule the tests with adequate rest for the client. -Coordinate with the other disciplines to determine if all the tests scheduled are necessary. -Review the physician's progress notes to determine if any of the tests are not indicated. -Instruct the client to refuse the diagnostic tests if the client becomes too fatigued.
Coordinate with the other disciplines to schedule the tests with adequate rest for the client.
A nurse overhears a coworker telling a somewhat offensive joke to a client. Which nursing action is indicated? Report what was overheard to the charge nurse. Discuss the occurrence with the coworker. Apologize to the client for the coworker's behavior. Investigate whether the coworker and client have a previous relationship.
Discuss the occurrence with the coworker.
Which action should the nurse take during the evaluation phase of the nursing process? Document reassessment of pain after medication administration. Provide the client with a follow-up appointment after discharge. Have the client give input into plan of care upon admission. Discontinue the indwelling urinary catheter per the provider's order.
Document reassessment of pain after medication administration.
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? Create a new nursing diagnosis to reflect new goals. Evaluate the use of current pain relief measures. Request a stronger analgesic from the provider. Provide additional relief with non-pharmacologic measures.
Evaluate the use of current pain relief measures.
Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? -Finances of the client -The client's condition -Time and resources -Feedback from the family
Finances of the client
All of the activities listed are related to evaluation, but which activity is the priority concern for nurses? -Measuring client outcome achievement Helping targeted groups of clients to achieve their specific outcomes -Measuring the competence of individual nurses -Meeting the care needs of clients
Meeting the care needs of clients
The nursing staff on a hospital unit uses peer review to improve professional performance. Who performs the review? -Unit manager -Nurses -Clients -Visitors
Nurses
A nurse is participating as a team member involved in the facility's evaluation process. The facility is conducting a retrospective evaluation. Which methods should the nurse expect to use to collect data? Select all that apply. -Direct observation of client care -Post-discharge client questionnaires -Client interviews during the client's stay -Chart review -Telephone interviews of discharged clients
Post-discharge client questionnaires Chart review Telephone interviews of discharged clients
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? Cognitive Psychomotor Affective Physiologic
Psychomotor
Before discharge the client will demonstrate aseptic dressing changes. This is an example of which type of evaluative statement? Psychomotor Cognitive Affective Physical changes
Psychomotor
The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted? -Quality assurance -Magnet status -Peer review -Quality improvement
Quality assurance
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? -Quality by inspection -Quality as opportunity -Quality by perception -Quality as initiative
Quality by inspection
The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action? -Teach the content again utilizing the same method. -Reassess the appropriateness of the method of instruction. -Revise the plan to include the inclusion of a support group. -Report the client's inability to learn to the case manager.
Reassess the appropriateness of the method of instruction.
A client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem? -The client is able to explain when and why the client needs to check the blood glucose level. -The client can demonstrate the correct technique for using a new glucometer. -The client has maintained blood glucose levels within acceptable range in the days prior to discharge. -The client expresses a desire to change the way that the client eats and exercises.
The client is able to explain when and why the client needs to check the blood glucose level.
Which nursing action reflects evaluation? -The nurse identifies that the client has wound drainage. -The nurse sets an anxiety level of 3 or less with the client. -The nurse performs colostomy irrigation. -The nurse assesses the client's response to pain medication.
The nurse assesses the client's response to pain medication.
A nurse evaluates clients prior to discharge from a hospital setting. Which action is the mostimportant act of evaluation performed by the nurse? -The nurse evaluates the client's goal/outcome achievement. -The nurse evaluates the plan of care. -The nurse evaluates the competence of nurse practitioners. -The nurse evaluates the types of health care services available to the client.
The nurse evaluates the client's goal/outcome achievement.
"The client will verbalize appropriate cast care on discharge" represents which type of outcome? -Psychomotor -Cognitive -Affective -Physical change
cognitive
"The levels of performance accepted by and expected of nursing staff or other health team members" defines: -criteria. -evaluation. -standards. -evidence-based practice.
standards
Which are components of an evaluative statement? Select all that apply. -Description of how the client outcome was met -Client's health history -Name of the client's physician -Client data that support how the outcome was met -Client's health insurance information
Description of how the client outcome was met Client data that support how the outcome was met
Which is an independent (nurse-initiated) action? -Executing physician orders for a catheter -Meeting with other health care professionals to discuss a client -Helping to allay a client's fears about surgery -Administering medication to a client
Helping to allay a client's fears about surgery
The nursing supervisor visits the emergency department and informs the department manager that tornado victims are expected to arrive within the hour. The department manager indicates the department has been slow and requests information regarding possible numbers of victims. The department manager reports supplies were just fully stocked, but two nurses are ill with influenza and were unable to report for their shift. Which resource does the department manager need to organize to respond to the disaster? -Personnel -Environment -Clients -Equipment
Personnel
Which action should the nurse take when client data indicate that the stated goals have not been achieved? -Collect more data for the database. -Review each preceding step of the nursing process. -Implement a standardized plan of care. -Change the nursing orders.
Review each preceding step of the nursing process.
Which action should the nurse perform in the evaluation phase? -Carry out treatment procedures. -Set priorities for care. -Record interventions. -Revise the plan of care.
Revise the plan of care.
A hospital is evaluating its policies and procedures. What type of evaluation is the hospital conducting? -Outcome -Process -Quality -Structure
Structure
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: -process. -outcome. -goal. -subjective. -structure.
Structure
A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action? -Tell the UAP that the RN will assist the UAP with the client's ambulation. -Tell the UAP that a different UAP should ambulate the client. -Tell the UAP not to ambulate the client at this time. -Tell the UAP to ask the client whether the client is comfortable with the UAP assisting ambulation.
Tell the UAP that the RN will assist the UAP with the client's ambulation.
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. Terminate the plan of care Modify the plan of care Continue the plan of care Begin the plan of care Communicate the plan of care
Terminate the plan of care Modify the plan of care Continue the plan of care
A client with a new diagnosis of diabetes will be discharged on insulin therapy. Which client psychomotor outcome does the nurse expect after client education? -The client demonstrates administration of insulin. -The client reports testing blood sugar before meals. -The client identifies signs and symptoms of hypoglycemia. -The client identifies correct insulin injection sites.
The client demonstrates administration of insulin.
The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent? -The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. -The client expresses a desire to learn how to manage the medication regime. -The parents verbalize acceptance of the need to closely monitor their child's condition. -The parents have comprehensive insurance coverage for their family's medical care.
The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.
The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? -The client who needs vital signs taken following infusion of packed red blood cells. -The client who requires assistance dressing in preparation for discharge. -The client with continuous pulse oximetry who requires pharyngeal suctioning. -The client who is pleasantly confused and requires assistance to the bathroom.
The client with continuous pulse oximetry who requires pharyngeal suctioning.
Which client outcome is an example of a physiologic outcome? The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula. The client reports walking for 30 minutes each day. The client demonstrates active range-of-motion exercises with left upper extremity. The client explains how to administer a vaginal cream.
The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula.
Which nurse is using criteria to determine expected standards of performance? -The nurse manager provides the staff nurse feedback regarding job performance for the previous year. -The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education. -The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. -The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation.
The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.
Which of the following best summarizes the evaluation step of the nursing process? The nurse completes a health assessment to establish a database. The client and family have met health care goals and no longer need care. The nurse and client identify nursing diagnoses and appropriate interventions. The nurse and client measure achievement of planned outcomes of care.
The nurse and client measure achievement of planned outcomes of care.
Which purpose of the evaluation phase of the nursing process is a priority during client care? -To examine the client's behavioral response to the care received -To provide basis for the revision of plan of care -To limit assessment to only the beginning phase of the nursing process -To appraise the collaboration of the client and family
To examine the client's behavioral response to the care received
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? Skilled communication Effective decision making True collaboration Appropriate staffing
True collaboration
The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of: -an affective outcome. -a psychomotor outcome. -a physiologic outcome. -a cognitive outcome.
a cognitive outcome.
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: -met. -partially met. -completely unmet. -inappropriately chosen for this client.
completely unmet.
Identifying the kind and amount of nursing services required is a possible solution for: inadequate staffing. clients who fail to communicate their needs. nurses who are bored. nurses frustrated with substandard care.
inadequate staffing
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: outcome evaluation. structure evaluation. process evaluation. nursing audit.
outcome evaluation
"The client will demonstrate cast care prior to discharge" is which type of evaluative statement? -Psychomotor -Cognitive -Affective -Physical changes
psychomotor
Which are psychomotor outcomes? Select all that apply. -Accurately drawing up insulin -The client will safely ambulate using a walker. -The client will identify signs and symptoms of infection. -The client will rate pain as a 2 on a 0 to 10 pain rating scale. -The client will report increased confidence in testing blood glucose level.
Accurately drawing up insulin The client will safely ambulate using a walker.
The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take? -Assess the client's blood pressure to determine if the medication is indicated. -Determine the client's reaction to the medication in the past. -Ask the client to verbalize the purpose of the medication. -Tell the client to report any side effects experienced.
Assess the client's blood pressure to determine if the medication is indicated.
The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? -Registered nurse -Nursing assistant -A senior nursing student present for clinical -Licensed practical nurse
Nursing assistant
Which are cognitive client outcomes? Select all that apply. -The client lists the side effects of digoxin. -The client describes how to perform progressive muscle relaxation. -The client identifies signs and symptoms of hypoglycemia. -The client correctly ambulates with a walker. -The client reports cycling 30 minutes three times each week.
The client lists the side effects of digoxin. The client describes how to perform progressive muscle relaxation. The client identifies signs and symptoms of hypoglycemia.
A client who has been in a vegetative state for years is scheduled for an elective surgery. The nurse is questioning whether the procedure is necessary. What is the nurse's appropriate firstaction? -The nurse should address the concern with the surgeon. -The nurse should address the concern with the hospital attorney. -The nurse should address the concern with the hospital ethics committee. -The nurse should address the concern with the client's family.
The nurse should address the concern with the surgeon.
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? -Planning a strategy using indicators -Implementing a change -Discovering a problem -Assessing the change
discovering a problem
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: -Peer review -Quality and Safety Educatin for Nurses (QSEN) -Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) -American Association of Critical-Care Nurses (AACN)
peer review
The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. -The client's respiratory rate decreases. -The client states, "I can breathe easier now." -The client's oxygen saturation level increases. -The client is watching television. -The client's family asks if the client is going to be okay.
The client states, "I can breathe easier now." The client's oxygen saturation level increases. The client's respiratory rate decreases.
Which nursing action can be categorized as a surveillance or monitoring intervention? -Auscultating of bilateral lung sounds -Providing hygiene -Administering a paracetamol tablet -Use of therapeutic communication skills
Auscultating of bilateral lung sounds
The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? -Continue the education and remind the client that it is essential to learn self-care. -Medicate the client for anxiety and continue the education later. -Discontinue the education and attempt at another time. -Discontinue the education and ask the client for permission to teach a family member.
Discontinue the education and attempt at another time.
During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? -Go to the client and assess the client's pain. -Determine the frequency of pain medication. -Medicate the client with the ordered pain medication. -Instruct the client in nonpharmacologic pain management.
Go to the client and assess the client's pain.
The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? -Medicate the client and wait to ambulate later. -Ambulate the client and medicate later. -Emphasize to the client the importance of following the treatment plan. -Explain to the client the benefits of ambulation.
Medicate the client and wait to ambulate later.
For the second time this week, a nurse reports to the nurse manager failing to perform an ordered dressing change due to a lack of time. The nurse manager recognizes that the nurse normally is very punctual and known to provide good care for clients and that the unit census has been very high this week. However, the nurse manager knows that quality care must be provided and reports this occurrence. Which approach to quality assurance does this scenario represent? Quality by inspection Quality as opportunity Quality by design Quality as promotion
Quality as opportunity
Which client outcomes are psychomotor outcomes? Select all that apply. The client identifies five low-sodium foods. The client describes how to empty a Jackson-Pratt drain. The client measures capillary blood glucose level. The client self-catheterizes using clean technique. The client reports imagery is effective in controlling anxiety.
The client measures capillary blood glucose level. The client self-catheterizes using clean technique.
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? -Psychomotor -Cognitive -Affective -Physical changes
physical changes
Prior to the first visit following gastrectomy, the client will have a weight loss of 10 lb (4.5 kg). This is an example of which type of evaluative statement? -Cognitive -Psychomotor -Physical changes -Affective
physical changes
The primary purpose for evaluating data about a client's care according to a functional health approach is to: -meet accreditation standards. -determine implementation of medical orders. -evaluate the need for health care consultations. -revise or modify the client care plan.
revise or modify the client care plan.
The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? -Remind the client that the client is responsible for the client's own health care decisions. -Ask the client whether the client is afraid that the spouse will be angry. -Ask the surgeon to wait until the client has had a chance to talk to the spouse. -Inform the surgeon that the nurse will not sign the informed consent form.
Ask the surgeon to wait until the client has had a chance to talk to the spouse.
A nurse finds that a client is not achieving the set outcomes for care and reviews the plan. Which are appropriate actions for the nurse to take while reviewing the plan of care? Select all that apply. Modify the nursing diagnosis. Make the outcome statement more realistic. Adjust the time limits on the outcome statement. Make no changes to the plan of care Increase the complexity of the outcome statement.
Modify the nursing diagnosis. Make the outcome statement more realistic. Adjust the time limits on the outcome statement. Increase the complexity of the outcome statement.
Which nursing action reflects evaluation? -The nurse identifies that the client does not tolerate activity. -The nurse sets a tolerable pain rating with the client. -The nurse auscultates the client's lungs and abdomen. -The nurse assesses urine output following administration of a diuretic.
The nurse assesses urine output following administration of a diuretic.
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 4% increase in the number of baccalaureate-prepared nurses employed in the facility Bed occupancy rates of 97% in the critical care areas and 92% in the non-critical care areas A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery A rate of 98% of clients admitted to the hospital who had a nursing history completed within 24 hours after admission
A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery
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? -Develop a process for periodic review of care plans that focuses on deleting and updating the nursing diagnoses. -Request that a staff development nurse instruct the nurses on concept mapping to use instead of care planning. -Provide an in-service on interviewing and physical assessment skills; discuss the importance of these skills with the staff. -Delegate the updating of nursing diagnoses for all clients on the unit to one nurse for each shift.
Develop a process for periodic review of care plans that focuses on deleting and updating the nursing diagnoses.
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 directly observes the nursing care being provided. -The nurse reviews the client chart while the client is being cared for. -The nurse interviews the client while the client is receiving the care. -The nurse devises a postdischarge questionnaire to evaluate client satisfaction.
The nurse devises a postdischarge questionnaire to evaluate client satisfaction.
A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action? -Ask the gastroenterologist to explain the treatment plan to the client and family again. -Ask the client to verbalize the medication regimen and diet modifications required. -Ask the nutritionist to give the client strict meal plans to follow. -Refer the client to available community resources and support groups.
Ask the client to verbalize the medication regimen and diet modifications required.
A mother brings an infant into the clinic for a well-baby visit. The mother reports being concerned at discharge from the hospital after giving birth about being able to get the infant to latch on for breastfeeding. Now, however, the mother reports success with breastfeeding. and the nurse finds that the baby is gaining weight appropriately. Which is an appropriate evaluative statement for this client? -"Goal met" -"8FEB2016. Goal met." -"Goal met. Mother reports that breastfeeding is going well with the infant eating every 2-3 hours and attaching to the nipple easily. Infant is gaining weight." -"8FEB2016. Goal met. Mother reports that breastfeeding is going well with the infant eating every 2-3 hours and attaching to the nipple easily. Infant is gaining weight."
"8FEB2016. Goal met. Mother reports that breastfeeding is going well with the infant eating every 2-3 hours and attaching to the nipple easily. Infant is gaining weight."
Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? -"I provide indirect care to my clients by coordinating their treatment with other disciplines." -"Even though I do not provide care to clients, my work is very important." -"I provide a critical service that is necessary for financial reimbursement." -"Moving away from client care is a necessary step to advancing my career."
"I provide indirect care to my clients by coordinating their treatment with other disciplines."
A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? -Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. -Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. -Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. -Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure.
Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization.
