Evaluation Practice Questions
A client shares with the nurse that they have, "almost reached the goal of smoking only
one-half pack of cigarettes a day." The best example of a nursing intervention to correct
this unmet outcome is:
1.Discuss with the client the desire to comply with the ordered therapy
2.Suggest that the client use another smoking cessation tool to achieve the goal
3.Reevaluate the time frame originally decided upon for achievement of the goal
4.Suggest that the strength of the prescribed nicotine patches be increased to 21 mg -
ANS-4
An unmet outcome reveals the client has not responded to interventions as planned. As
a result, the nurse changes the plan of care by trying different therapies or changing the
frequency or approach of existing therapies. The best option is one that adds to the
existing therapy. The remaining options should have been explored as a part of the
goal-setting process or exercised if the current therapy proves ineffective.
A nurse is providing care for a client receiving normal saline when the IV infiltrates.
Which of the following nursing actions represents the evaluation phase of the nursing
process?
1.IV is discontinued.
2.Warm compress applied to IV site.
3.Site reinspected for presence of swelling.
4.IV site observed as having significant swelling. - ANS-3
Evaluation, the final step of the nursing process, is crucial to determine whether, after
application of the nursing process, the client's condition or well-being improves. The
remaining options represent the assessment and implementation phases.
Based on the following outcome criterion determined by the nurse: "Client will
independently complete necessary assessments prior to administration of digoxin
(cardiotonic)" the nurse will evaluate the client's ability to:
, 1.Assess the respiratory rate
2.Palpate the radial pulse
3.Review dietary habits
4.Inspect color of the skin - ANS-2
The nurse should compare the established outcome criteria with the client's behavior or
response. In this case the client is expected to independently complete the necessary
assessments before administration of digoxin. The client should be able to palpate the
radial pulse as an assessment before administration of digoxin. The outcome criterion
does not state anything about exercise. During evaluation, the nurse is to judge the
degree of agreement between the outcome criteria and the client's behavior. The
outcome criterion does not state anything about diet. Evaluating whether the client
reviews dietary habits would not be comparable to necessary assessment before
medication administration. The outcome criterion does not state anything about the skin.
The nurse, who knows that digoxin is a cardiotonic, understands that the client should
be assessing the heart rate.
he nurse begins to auscultate the client's lungs. While listening, the nurse notices fresh
bloody drainage oozing from the abdominal dressing. The nurse stops auscultating and
applies direct pressure to the wound site. This is an example of:
1.Performing a nursing assessment
2.Reorganizing the nursing diagnoses
3.Implementing nursing interventions
4.Critically analyzing client assessment data - ANS-4
The nurse who stops auscultating lung sounds to take measures to stop noticeable
bleeding is analyzing data presented. This is demonstrated by the nurse setting
priorities and effectively implementing the safest nursing action. The nurse is doing
more than performing a nursing assessment. The nurse is taking action based on new
assessment data. The nurse is not reorganizing nursing diagnoses. The nurse is
implementing the priority nursing action. This is not an example of setting realistic goals
and implementing nursing interventions. Applying direct pressure to a wound site to stop
bleeding demonstrates critical analysis of the data and implementation of the safest
nursing action.
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