Chapter 14: Implementing and Evaluating Nursing Care

Question 1

In which step of the nursing process does the nurse determine whether the patient’s condition
has improved and whether the patient has met expected outcomes?
a. Assessment.
b. Planning.
c. Implementation.
d. Evaluation.

Answer 1

d. Evaluation.

Question 2

After assembling a thorough database and carrying out nursing interventions based on priority
diagnoses, the nurse proceeds to which step of the nursing process?
a. Assessment.
b. Planning.
c. Implementation.
d. Evaluation.

Answer 2

d. Evaluation.

Question 3

A nursing student asks her nursing instructor to describe the primary purpose of evaluation.
Which of the following statements made by the nursing instructor is most accurate?
a. “During evaluation, 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.”

Answer 3

c. “Nurses use evaluation to determine the effectiveness of nursing care.”

Question 4

After assessing the patient and identifying the need for headache relief, the nurse administers
acetaminophen (Tylenol) for the patient’s headache. What is the nurse’s next priority action
for this patient?
a. Eliminate Acute pain from the nursing care plan.
b. Direct the nursing assistant to ask whether the patient’s headache is relieved.
c. Reassess the patient’s pain level in 30 minutes.
d. Revise the plan of care

Answer 4

c. Reassess the patient’s pain level in 30 minutes.

Question 5

A nurse is getting ready to discharge to home a patient who has a nursing diagnosis of
Impaired physical mobility. Before discontinuing the patient’s plan of care, what does the
nurse need to do?
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

Answer 5

b. Evaluate whether patient goals and outcomes have been met.

Question 6

6. The nurse is evaluating whether patient goals and outcomes have been met. Of the following,
   which is an expected outcome for a patient with a diagnosis of Impaired physical mobility?
   a. The patient is able to ambulate in the hallway with crutches.
   b. The patient’s level of mobility will improve.
   c. The nurse provides assistance while the patient is walking in the hallways.
   d. The patient will deny pain while walking in the hallway.

Answer 6

a. The patient is able to ambulate in the hallway with crutches.

Question 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. Absence of skin breakdown.
c. Presence of redness only on the heels of the patient.
d. Patient’s eating 100% of all meals.

Answer 7

b. Absence of skin breakdown.

Question 8

A new nurse states that she is confused about using evaluative measures when caring for
patients and asks the charge nurse for examples and an explanation. Which of the following is
the most accurate response from the charge nurse?
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 of incident reports.”

Answer 8

b. “Evaluative measures include assessment data used to determine whether patients
have met their expected outcomes and goals.”

Question 9

The nurse is caring for a patient who has an open wound. For evaluating the progress of
wound healing, what is the nurse’s priority action?
a. Ask the unregulated care providers whether the wound looks better.
b. Documenting the progress of wound healing as “better” in the patient’s chart.
c. Measuring the wound and observe for redness, swelling, or drainage.
d. Leaving the dressing off the wound for easier access and more frequent
assessments.

Answer 9

c. Measuring the wound and observe for redness, swelling, or drainage.

Question 10

The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600
and 1800 hours. At 1400 hours, the nurse notices that the dressing is saturated. 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 1 hour.
d. Discontinue the plan of care.

Answer 10

b. Revise the plan of care and change the dressing now.

Question 11

A goal for a patient with a nursing diagnosis of Ineffective coping is to demonstrate effective
coping skills. Which of these patient behaviours indicates that interventions performed to
meet this outcome have been successful?
a. Stating he feels better after talking with his family and friends.
b. Continuing to consume several alcoholic beverages a day.
c. Disliking the support group meetings.
d. Spending most of the day in bed.

Answer 11

a. Stating he feels better after talking with his family and friends.

Question 12

A nurse is providing education to a patient about self-administering subcutaneous injections.
Which of these patient statements indicates that the patient understands the instructions?
a. “I need to use a needle 1/2 inch (1.3 cm) longer than my thumb.”
b. “I will give the medicine deep into my deltoid.”
c. “My belly is a good place to give my injection.”
d. “I need to throw the syringe and needle into the garbage when I am done giving
myself my shot.”

Answer 12

c. “My belly is a good place to give my injection.”

Question 13

Which of these statements made by a patient who has a nursing diagnosis of Disturbed body
image is the best indicator of the patient’s early acceptance of body image?
a. “I just won’t go to the pool this summer.”
b. “I’m worried about what those other girls will think of me.”
c. “I can’t wear that colour. It makes my hips stick out.”
d. “I’ll wear the blue dress. It matches my eyes.”

Answer 13

d. “I’ll wear the blue dress. It matches my eyes.”

Question 14

Which of these options is a patient outcome indicating positive progress toward resolving the
nursing diagnosis of Acute confusion?
a. Side rails are up with bed alarm activated.
b. Patient denies pain while ambulating with assistance.
c. Patient wanders halls at night.
d. Patient correctly states names of family members in the room.

Answer 14

d. Patient correctly states names of family members in the room

Question 15

A nurse identifies a nursing diagnosis of Risk for falls 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. What is the nurse’s priority action
when evaluating the patient’s plan of care?
a. Counsel the unregulated care provider on duty when the patient fell.
b. Identify factors interfering with goal achievement.
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.

Answer 15

b. Identify factors interfering with goal achievement.

Question 16

A patient recently received a diagnosis of 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 of the following is an appropriate evaluative measure demonstrating progress toward
this goal?
a. Nonproductive cough present in 4 days.
b. Scattered rhonchi throughout all lung fields in 2 days.
c. Respirations 30/minute in 1 day.
d. Lungs clear to auscultation after use of inhaler.

Answer 16

d. Lungs clear to auscultation after use of inhaler.

Question 17

A nurse administrator is at a meeting with nurses on the quality council. Several new
members are sitting on the council. They ask the nurse administrator to clarify what a
nursing-sensitive outcome is. Which response by the nurse administrator best defines
nursing-sensitive outcomes?
a. “Nursing-sensitive outcomes determine the patient’s progress as a result of
prescribed treatments, such as medications.”
b. “Patient falls is an example of a nursing-sensitive outcome because they are
directly affected by nursing interventions.”
c. “Nursing-sensitive outcomes promote universal health care.”
d. “We use nursing-sensitive outcomes at this hospital to evaluate nursing tasks and
to determine safe staffing ratios.”

Answer 17

b. “Patient falls is an example of a nursing-sensitive outcome because they are
directly affected by nursing interventions.”

Question 18

Which scenario best illustrates the use of data validation when an independent nursing clinical
decision is made?
a. The nurse determines that she needs to remove a wound dressing when the patient
reveals the time of the last dressing change, and she notices that the present
dressing is saturated with fresh and old blood.
b. The nurse administers pain medicine due at 1700 hours at 1600 hours because the
patient complains of increased pain.
c. The nurse removes a leg cast when the patient complains of decreased mobility.
d. The nurse administers potassium when a patient complains of leg cramps

Answer 18

a. The nurse determines that she needs to remove a wound dressing when the patient
reveals the time of the last dressing change, and she notices that the present
dressing is saturated with fresh and old blood.

Question 19

Another term for a collaborative nursing intervention is which of the following?
a. Dependent intervention.
b. Independent intervention.
c. Interdependent intervention.
d. Physician-initiated intervention.

Answer 19

c. Interdependent intervention

Question 20

A registered nurse administers pain medication to a patient suffering from fractured ribs.
What type of nursing intervention is this nurse implementing?
a. Collaborative.
b. Independent.
c. Interdependent.
d. Dependent.

Answer 20

d. Dependent.

Question 21

Which intervention is most appropriate for the nursing diagnosis Impaired verbal
communication related to loss of facial motor control and decreased sensation?
a. Obtain an interpreter for the patient as soon as possible.
b. Assist the patient in performing swallowing exercises each shift.
c. Ask the family to provide a sitter to remain with the patient at all times.
d. Provide the patient with a writing board each shift.

Answer 21

d. Provide the patient with a writing board each shift.

Question 22

Which intervention is most appropriate for the nursing diagnosis Impaired skin integrity
related to shearing forces?
a. Administer pain medication every 4 hours as needed.
b. Perform the ordered dressing change twice daily.
c. Do not document the wound appearance in the chart.
d. Keep the bed side rails up at all times

Answer 22

b. Perform the ordered dressing change twice daily.

Question 23

A patient has reduced muscle strength after a left-sided stroke and is at risk for falling. Which
intervention is most appropriate for the nursing diagnosis Risk for falls?
a. Encouraging the patient to remain in bed most of the shift.
b. Keeping all side rails down at all times.
c. Placing the patient in a room away from the nurses’ station if possible.
d. Assisting patient into and out of bed every 6 hours or as tolerated.

Answer 23

d. Assisting patient into and out of bed every 6 hours or as tolerated.

Question 24

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The
patient needs many nursing interventions, including a dressing change, several intravenous
antibiotics, and a walk. Which factor does the nurse consider when prioritizing interventions?
a. Putting all of the patient’s physician-initiated interventions as first priority.
b. Considering time as an influencing factor.
c. Setting priorities based solely on physiological factors.
d. Not changing priorities once they’ve been established

Answer 24

b. Considering time as an influencing factor.

Question 25

Which of the following is an element of the evaluation process?
a. Setting priorities for patient care.
b. Collecting subjective and objective data to determine whether criteria or standards
are met.
c. Ambulating 7.6 m (25 feet) in the hallway.
d. Administering oxygen as ordered.

Answer 25

b. Collecting subjective and objective data to determine whether criteria or standards
are met.