Chapter 20: Evaluation

Question 1

A nurse determines that the patient’s condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?

Answer 1

Evaluation

Question 2

A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next?

Answer 2

Evaluation

Question 3

A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate?

Answer 3

“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 for the patient’s headache. Which action by the nurse is priority for this patient?

Answer 4

Reassess the patient’s pain level in 30 minutes.

Question 5

A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient’s plan of care?

Answer 5

Evaluate whether patient goals and outcomes have been met.

Question 6

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

Answer 6

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?

Answer 7

Absence of skin breakdown

Question 8

A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?

Answer 8

Reassess the patient and situation.

Question 9

A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate?

Answer 9

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

Question 10

The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?

Answer 10

Measure the wound and observe for redness, swelling, or drainage.

Question 11

The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse’s next action?

Answer 11

Revise the plan of care and change the dressing now.

Question 12

A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome?

Answer 12

States feels better after talking with family and friends

Question 13

A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate?

Answer 13

Health behavior

Question 14

A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal?

Answer 14

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

Question 15

A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion?

Answer 15

Patient correctly states names of family members in the room.

Question 16

A nurse identifies a fall risk 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. Which action is the nurse’s priority when evaluating the patient?

Answer 16

Identify factors interfering with goal achievement.

Question 17

A patient was recently diagnosed with 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 evaluative measure will the nurse use to demonstrate progress toward this goal?

Answer 17

Lungs clear to auscultation following use of inhaler

Question 18

A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met?

Answer 18

Heart rate 78 beats/min on 12/3

Question 19

A nurse is modifying a patient’s care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks?

1. Revise nursing diagnosis.
2. Reassess blood pressure reading.
3. Retake blood pressure after medication.
4. Administer new blood pressure medication.
5. Change goal to blood pressure less than 140/90.

Answer 19

2, 1, 5, 4, 3

Question 20

A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient’s responses to nursing care? (Select all that apply.)

a. Observations of wound healing
b. Daily blood pressure measurements
c. Findings of respiratory rate and depth
d. Completion of nursing interventions
e. Patient’s subjective report of feelings about a new diagnosis of cancer

Answer 20

A, B, C, E

Question 21

Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)

a. Set priorities for patient care.
b. Determine whether outcomes or standards are met.
c. Ambulate patient 25 feet in the hallway.
d. Document results of goal achievement.
e. Use self-reflection and correct errors.

Answer 21

B, D, E