Chapter 20 Review Qs book Flashcards
A nurse admits a 32-year-old patient for treatment of acute asthma. The patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds with bilateral wheezing. The nurse
makes the patient comfortable and starts an ordered intravenous infusion to administer medication that will relax the patient’s airways. The patient tells the nurse after the first medication infusion, “I feel as if I can breathe better.” The nurse auscultates the patient’s lungs and notes decreased wheezing with a respiratory
rate of 22 per minute. Which of the following is an evaluative measure? (Select all that apply.)
1. Asking patient to breathe deeply during auscultation
2. Counting respirations per minute
3. Asking the patient to describe how his breathing feels
4. Starting the intravenous infusion
5. Auscultating lung sounds
2,3,5
A patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds that reveal wheezing bilaterally. The nurse starts an ordered intravenous infusion to administer medication that will relax the patient’s airways. When the nurse asks how the
patient feels, he responds by saying, “I feel as if I can breathe better.” The nurse auscultates the patient’s lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the
following evaluative measures may not reflect change in a patient’s condition?
1. Counting respirations per minute
2. Asking the patient to describe how his breathing feels
3. Observing breathing pattern
4. Auscultating lung sounds
2
Which of the following statements correctly describes the evaluation process? (Select all that apply.)
- Evaluation involves reflection on the approach to care.
- Evaluation involves determination of the completion of a nursing intervention.
- Evaluation involves making clinical decisions.
- Evaluation requires the use of assessment skills.
- Evaluation
1,3,4
A nurse in a community health clinic has been caring for a young female teenager with diabetes for several months. The nurse’s goal of care for this patient is to achieve self-management of insulin medication. Identify appropriate evaluative measures for self-management for this patient. (Select all that apply.)
- Quality of life
- Patient satisfaction
- Clinic follow-up visits
- Adherence to self-administration of insulin
- Description of side effects of medications
1,3,4
From the following list of indicators, determine which indicators are goals (G) and which indicators are outcomes (O).
- _____ Will achieve pain relief
- _____ Ambulates 10 feet down hallway
- _____ Will remain free of infection
- _____ Will be afebrile
- _____ Reports pain severity reduced from 6 to a 4 on scale of 0 to 10
- _____ Will gain improved mobility
1G, 2O, 3G, 4G, 5O, 6G
A nurse has been caring for a patient over 2 consecutive days. During that time the patient had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks whether
the patient feels tenderness when the site is palpated. The nurse reviews the medical record from 24 hours ago and finds the catheter site was without redness or tenderness. Which of the activities below reflect the nurse’s ability to perform patient evaluation?
(Select all that apply.)
1. Comparing patient response with previous response
2. Examining results of clinical data
3. Recognizing error
4. Self-reflection
5. Checking medical record for when IV was inserted.
1,2
A nurse asks how a patient’s condition from a serious infection changed since yesterday while receiving a hand-off report. The nurse leaving the shift reports the patient has two priority nursing diagnoses—fluid imbalance and fever. The receiving nurse begins
to provide care by measuring the patient’s body temperature, inspecting the condition of the skin, reviewing the intake and output record, and checking the summary notes describing the patient’s progress since the day before. The nurse asks a technician to measure intake and output during the shift. What critical
thinking indicators reflect the nurse’s ability to perform evaluation? (Select all that apply.)
1. Checking the summary notes
2. Asking the leaving RN about the patient’s condition.
3. Assigning the technician to measure intake and output
4. Comparing current outcomes with those set for the patient’s goals
5. Reflecting on patient’s progress
1,2,4,5
A nurse in the recovery room is monitoring a patient who had a left knee replacement. The patient arrived in recovery 15 minutes ago. The nurse observes the patient to be restless, turning frequently, and groaning; the patient’s heart rate is 92 compared with 76 preoperatively. Blood pressure is stable since admission to the recovery room. The nurse reviews the medical orders for analgesic therapy. The nurse notes that the post-op dose of an ordered analgesic has not yet been given. What is most likely to cause the nurse to reflect on the patient’s situation?
- The patient is recovering normally.
- The symptoms reflecting restlessness
- The patient’s blood pressure trend
- The delay in administration of the analgesic
4
A nurse enters a patient’s room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient’s expectations
of care. Which of the following is appropriate for evaluating a patient’s expectations of care?
1. On a scale of 0 to 10 rate your level of nausea.
2. The nurse weighs the patient.
3. The nurse asks, “Did you believe that you received the information you needed to follow your diet?”
4. The nurse states, “Tell me four different foods included in your
diet.”
3
Which of the following statements correctly describe the evaluation process? (Select all that apply.)
- Evaluation is an ongoing process.
- Evaluation involves the gathering of data for recognizing errors or omissions in care.
- Evaluation involves making clinical decisions.
- Evaluation requires the use of assessment skills.
- Evaluation is done only when a patient’s condition changes.
1,2,3,4
