A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which of the following is an evaluative measure use...
A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway.
After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates
the patient's lung sounds and gives him a glass of water. Which of the following is an evaluative
measure used by the nurse?
A) Suctioning the airway
B) Sitting patient up in bed
C) Auscultating lung sounds
D) Patient describing type of discomfort - ANS Auscultating lung sounds
A nurse caring for a patient with pneumonia sits the patient up in bed and suctions the patient's
airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse
auscultates the patient's lung sounds and gives him a glass of water. Which of the following
would be appropriate evaluative criteria used by the nurse? (Select all that apply.)
A) Patient drinks contents of water glass.
B) Patient's lungs are clear to auscultation in bases.
C) Patient reports abdominal pain on scale of 0 to 10.
D) Patient's rate and depth of breathing are normal with head of bed elevated. - ANS
Patient's lungs are clear to auscultation in bases.
Patient's rate and depth of breathing are normal with head of bed elevated.
The evaluation process includes interpretation of findings as one of its five elements. Which of
the following is an example of interpretation?
A) Evaluating the patient's response to selected nursing interventions
B) Selecting an observable or measurable state or behavior that reflects goal achievement
C) Reviewing the patient's nursing diagnoses and establishing goals and outcome statements
D) Matching the results of evaluative measures with expected outcomes to determine patient's
status - ANS Matching the results of evaluative measures with expected outcomes to
determine patient's status
A goal specifies the expected behavior or response that indicates:
A) The specific nursing action was completed.
B) The validation of the nurse's physical assessment.
C) The nurse has made the correct nursing diagnoses.
D) Resolution of a nursing diagnosis or maintenance of a healthy state. - ANS Resolution
of a nursing diagnosis or maintenance of a healthy state.
, A patient is recovering from surgery for removal of an ovarian tumor. It is 1 day after her surgery.
Because she has an abdominal incision and dressing and a history of diabetes, the nurse has
selected a nursing diagnosis of risk for infection. Which of the following is an appropriate goal
statement for the diagnosis?
A) Patient will remain afebrile to discharge.
B) Patient's wound will remain free of infection by discharge.
C) Patient will receive ordered antibiotic on time over next 3 days.
D) Patient's abdominal incision will be covered with a sterile dressing for 2 days. - ANS
Patient's wound will remain free of infection by discharge.
Unmet and partially met goals require the nurse to do which of the following? (Select all that
apply.)
A) Redefine priorities
B) Continue intervention
C) Discontinue care plan
D) Gather assessment data on a different nursing diagnosis
E) Compare the patient's response with that of another patient - ANS Redefine priorities
Continue intervention
A patient comes to a medical clinic with the diagnosis of asthma. The nurse practitioner decides
that the patient's obesity adds to the difficulty of breathing; the patient is 5 feet 7 inches tall and
weighs 200 pounds (90.7 kg). Based on the nursing diagnosis of imbalanced nutrition: more
than body requirements, the practitioner plans to place the patient on a therapeutic diet. Which
of the following are evaluative measures for determining if the patient achieves the goal of a
desired weight loss? (Select all that apply.)
A) The patient eats 2000 calories a day.
B) The patient is weighed during each clinic visit.
C) The patient discusses factors that increase the risk of an asthma attack.
D) The patient's food diary that tracks intake of daily meals is reviewed. - ANS The patient
is weighed during each clinic visit.
The patient's food diary that tracks intake of daily meals is reviewed.
The nurse follows a series of steps to objectively evaluate the degree of success in achieving
outcomes of care. Place the steps in the correct order.
1. The nurse judges the extent to which the condition of the skin matches the outcome criteria.
2. The nurse tries to determine why the outcome criteria and actual condition of skin do not
agree.
3. The nurse inspects the condition of the skin.
4. The nurse reviews the outcome criteria to identify the desired skin condition.
5. The nurse compares the degree of agreement between desired and actual condition of the
skin. - ANS The nurse reviews the outcome criteria to identify the desired skin condition.
The nurse inspects the condition of the skin.
The nurse compares the degree of agreement between desired and actual condition of the skin.
The nurse judges the extent to which the condition of the skin matches the outcome criteria.
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