Deck 7: Implementation Evaluation

Question 1

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?
1)Turn and reposition the patient every 2 hours.
2)Assess the patient's skin condition.
3)Change pressure injury dressings every shift.
4)Apply hydrocolloid dressing to the pressure injury.

Answer 1

1

Question 2

The nurse is providing care for a patient in an acute care facility. The nurse plans to evaluate the effectiveness of the plan of care. Which action does the nurse need to take to achieve a valid evaluation?
1)Read the documentation by the previous nurse.
2)Collect reassessment data on the patient.
3)Look at the physician's progression notes.
4)Ask the patient's view about each nursing goal.

Answer 2

2

Question 3

Which statement by the registered nurse (RN) best demonstrates clear communication to nursing assistive personnel (NAP) about a delegated task?
1)"Record the patient's intake and output of fluids throughout the shift, please."
2)"Take the patient's temperature, pulse, respirations, and blood pressure every 2 hours today."
3)"Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)."
4)"Assist the patient with all meals so that the patient's intake of calories will increase."

Answer 3

3

Question 4

The nurse receives a postsurgical patient who is prescribed to have vital signs taken every 15 minutes for 2 hours. Which type of client-centered evaluation does the nurse recognize?
1)Intermittent
2)Ongoing
3)Terminal
4)Process

Question 5

The nurse reviews a patient's chart and sees a physician's prescription for a new medication. The nurse is able to clearly read the medication name, but the dose is not legible. Which is the best action by the nurse?
1)Contact the physician for clarification.
2)Ask another nurse to read the order.
3)Ask the unit secretary to read the order.
4)Contact the pharmacist to read the order.

Question 6

The nurse is providing care for a client newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan?
1)Teaching the client that weight must be lost to control blood glucose
2)Informing the client it is necessary to exercise at least three times per week
3)Explaining to the client attendance is mandatory at the diabetic clinic weekly
4)Determining the client's main concerns about the diagnosis of diabetes

Question 7

The nurse is delegating patient care to a nursing assistive personnel (NAP) with whom the nurse has worked before. The nurse provides exact details of which patient, what tasks, what time period, and what feedback is expected; the NAP has no questions. Which responsibility does the nurse retain after completing the delegation assignment?
1)The nurse will determine and evaluate completion of the assignment.
2)The nurse will check the NAP's progress on the assignment every hour.
3)The nurse will immediately document the assigned tasks as being delegated.
4)The nurse periodically checks the accuracy of the NAP's documentation.

Question 8

The nurse is providing care for a patient after joint replacement surgery. The standardized care plan states, "Patient will ambulate 50 feet in the hall with a walker before discharge." Which patient variable affecting this goal is the nurse unable to control?
1)Confusion and lethargy related to pain medication
2)Compromised respiratory function due to severe chronic obstructive pulmonary disease (COPD)
3)Reluctance to ambulate due to pain at level 7
4)Presence of a spouse who pushes the patient to rest

Question 9

The nurse is assigned to participate in a structure evaluation for an acute care facility. Which response on the nurse's structure evaluation form indicates the nurse understood the criteria related to the task?
1)"Staff refrains from sharing computer passwords."
2)"Healthcare provider washes hands with each client contact."
3)"A defibrillator is present in each client care area."
4)"Nurses verify client identification before initiating care."

Question 10

A physician prescribes an indwelling urinary catheter for a client who is mildly confused and combative. In which manner does the nurse proceed?
1)Ask a colleague for help because the nurse cannot safely perform the procedure alone.
2)Gather and prepare the equipment before informing the client about the procedure.
3)Obtain a prescription to restrain the client before inserting the urinary catheter.
4)Inform the physician the nurse cannot perform the procedure because the client is confused.

Question 11

After gathering and analyzing data and identifying patient needs, the nurse begins the implementation phase of developing a plan of care. Which is the best example of the implementation phase of the nursing process?
1)Patient verbalizes pain is reduced from 8 to 3 after receiving pain medication.
2)Nurse observes that patient has a small, quarter-sized skin tear over coccyx area.
3)Nurse writes in the care plan: Patient requires two-person assist with ambulation to bathroom.
4)Nurse inserts urinary catheter after reporting to physician the patient's inability to void.

Question 12

The nurse works in an acute care facility, which implements team nursing with each team consisting of members from various levels of healthcare provision. Which statement accurately describes delegation in the nurse's work environment?
1)Transferring authority to perform a task to a qualified person in a selected situation
2)Collaborating with other caregivers to make decisions and plan patient care
3)Scheduling treatments and activities by coordinating with other departments
4)Implementing an appropriate planned intervention from a critical pathway

Question 13

A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, who cannot find it in the hospital formulary or other references. In which manner does the nurse proceed?
1)Administer the medication as ordered.
2)Hold the medication and notify the prescriber.
3)Consult with a pharmacist before administering it.
4)Ask the patient's registered nurse (RN) for information about the medication.

Question 14

The nurse works with the respiratory therapist to administer a patient's breathing treatments. The therapist reports the patient's breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. Which type of implementation process is being used?
1)Delegation
2)Collaboration
3)Coordination of care
4)Supervision of care

Question 15

Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill?
1)Psychomotor
2)Interpersonal
3)Cognitive
4)Critical thinking

Question 16

A second-year nursing student is in a clinical rotation on a medical-surgical unit. Which is the most appropriate strategy for the student to use to assist with organizing and prioritizing patient care for the day?
1)Ask the nurse what tasks need to be completed for the day.
2)Make a time-sequenced "to-do" list for care activities for the day.
3)Ask the instructor what needs to be completed for the day.
4)Ask the patient what needs to be completed for the day.

Question 17

Which client outcome criterion does the nurse use when evaluating client behaviors that affect the client's health status?
1)Central venous catheter site infection does not occur in 90% of cases.
2)Client will sit in the bedside chair for 20 minutes three times per day.
3)Postoperative phlebitis does not occur in 95% of surgical patients.
4)Falls in the facility will be reduced by 2% at the end of the year.

Question 18

The nurse creates a plan of care for a patient diagnosed with severe dehydration. One nursing goal reads, "Patient will maintain urine output of at least 30 mL/hour." Which time frame will the nurse use to collect evaluation data for this expected outcome?
1)At the end of the shift
2)Every 24 hours
3)Every 4 hours
4)Every hour

Question 19

The nurse reviews a nursing order for a patient who is 4 days postoperative after hip surgery, which reads: Assist patient in bathing each morning. The nurse assesses the patient and notes the patient demonstrates the ability to bathe independently. Which action does the nurse do next?
1)Assist with the bath, as ordered.
2)Delegate the bath to the nursing assistant.
3)Discontinue the nursing order on the plan of care.
4)Collaborate with the nurse who originally wrote the order.

Question 20

The certified nursing assistant (CNA) is feeding a patient and notices that the patient is having difficulty swallowing. The CNA reports the observation to the primary registered nurse. Which action does the nurse take first?
1)Assign the task to a more experienced can.
2)Continue patient feeding by the nurse.
3)Assess the patient, and place the patient on NPO (nothing by mouth) status.
4)Call the primary care provider.

Question 21

The nurse is providing care for a patient after abdominal surgery and has just completed a prescribed dressing change. Which activities does the nurse perform soon after this task completed? Select all that apply.
1)Assess the patient's response to the procedure.
2)Provide patient teaching about the procedure.
3)Document the procedure in the nursing progress notes.
4)Ask if the patient is interested in helping with the next dressing change.
5)Provide a handout about the dressing changes after discharge.

Question 22

The nurse is providing care for various patients with the assistance of a licensed practical nurse/licensed vocational nurse (LPN/LVN). Which tasks does the nurse delegate to the LPN/LVN? Select all that apply.
1)Administer oral pain medications.
2)Insert an indwelling urinary catheter.
3)Perform an admission assessment on a patient.
4)Establish a new teaching plan for a patient with diabetes.
5)Call a patient's physician to validate a new prescription.

Question 23

The nurse and the nursing assistive personnel (NAP) are providing care for various clients on a medical-surgical unit. For which clients can the nurse delegate to the NAP the task of bathing? Select all that apply.
1)A 75-year-old client who is newly admitted with a diagnosis of dehydration
2)A 65-year-old client diagnosed with a stroke, whose BP is currently 189/90 mm Hg
3)A 92-year-old client with stable vital signs admitted with a urinary tract infection
4)A 56-year-old client with chronic renal failure, whose vital signs remain stable
5)An 80-year-old client who is 2 days postoperative after repair of a hernia

Question 24

Which nursing activity is most reflective of the evaluation phase of the nursing process?
1)Administering pain medication prior to changing a complex wound dressing
2)Obtaining patient's blood pressure (BP) 30 minutes after administering BP medication
3)Reporting there have been three patient falls in the past month on the nursing unit
4)Teaching the patient how to perform daily finger-sticks for blood glucose readings