Nursing Process: Implementation & Evaluation

Identify the choice that best completes the statement or answers the question.

____ 1. A physician prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, and she cannot find it in the hospital formulary or other references. How should she proceed?

1)
Administer the medication as ordered.
2)
Hold the medication and notify the physician.
3)
Consult with a pharmacist before administering it.
4)
Ask the patient’s RN for information about the medication.

____ 2. Which task can be delegated to nursing assistive personnel (NAP)?

1)
Turn and reposition the client every 2 hours.
2)
Assess the client’s skin condition.
3)
Change pressure ulcer dressings every shift.
4)
Apply hydrocolloid dressing to the pressure ulcer.

____ 3. The nurse has just finished documenting that he removed a patient’s nasogastric tube. Which is the next logical step in the nursing process?

1)
Assessment
2)
Planning
3)
Evaluation
4)
Diagnosis

____ 4. Which nursing intervention is best individualized to meet the needs of a specific client?

1)
Suction the client every 2 hours per unit policy.
2)
Use incentive spirometry every hour while awake per postoperative protocols.
3)
Institute swallowing precautions.
4)
Move client out of bed to the chair daily; client prefers to be out of bed for dinner.

____ 5. The physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed?

1)
Ask a colleague for help, because the nurse cannot safely perform the procedure alone.
2)
Gather the equipment and prepare it before informing the client about the procedure.
3)
Obtain an order to restrain the client before inserting the urinary catheter.
4)
Inform the physician that she cannot perform the procedure because the client is confused.

____ 6. A patient underwent surgery 3 days ago for colorectal cancer. The patient’s critical pathway states that he should participate in a teaching session with the wound ostomy nurse to learn colostomy self-care. The patient appears depressed and refuses to look at the colostomy or even make eye contact. How should the nurse proceed?

1)
Postpone the teaching session until the patient is more receptive.
2)
Follow the critical pathway for patient teaching
3)
Administer a prescribed antidepressant and notify the physician.
4)
Explain to the patient the importance of skin care around the ostomy site.

____ 7. Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill?

1)
Psychomotor
2)
Interpersonal
3)
Cognitive
4)
Critical thinking

____ 8. Which intervention depends almost entirely on the client’s adhering to the therapy?

1)
Inserting an intravenous catheter
2)
Turning a client every 2 hours
3)
Shortening a surgical drain
4)
Following a low-fat, low-calorie diet

____ 9. The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan?

1)
Teaching the client that he must lose weight to control his blood sugar
2)
Informing the client he must exercise at least three times per week
3)
Explaining to the client he must come to the diabetic clinic weekly
4)
Determining the client’s main concerns about his diabetes

____ 10. Which statement accurately describes delegation?

1)
Transferring authority to another person to perform a task in a selected situation
2)
Collaborating with other caregivers to make decisions, and plan care
3)
Scheduling treatments and activities with other departments
4)
Performing a planned intervention from a critical pathway

____ 11. Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task?

1)
“Record how much the patient drinks.”
2)
“Take the patient’s vital signs every 2 hours today.”
3)
“Take the patient’s temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C).”
4)
“Assist the patient with her meals.”

____ 12. Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)?

1)
Nurse who delegated the task
2)
Licensed practical nurse working with the NAP
3)
Unit nurse manager
4)
Charge nurse for the shift

____ 13. Which criterion might be used in structure evaluation?

1)
“Staff refrains from sharing computer password.”
2)
“Health care provider washes hands with each client contact.”
3)
“A defibrillator is present on each client care area.”
4)
“Nurse verifies client identification before initiating care.”

____ 14. Which of the following is a client outcome criterion?

1)
Central venous catheter site infection does not occur (90% of cases).
2)
Client will sit out of bed in the chair for 20 minutes three times per day.
3)
Postoperative phlebitis does not occur (95% of cases).
4)
Falls will reduce by 2% this quarter.

____ 15. When should the nurse collect evaluation data for this expected outcome? “Patient will maintain urine output of at least 30 mL/hour.”

1)
At the end of the shift
2)
Every 24 hours
3)
Every 4 hours
4)
Every hour

____ 16. Which type of client-centered evaluation is performed at specific, scheduled times?

1)
Intermittent
2)
Ongoing
3)
Terminal
4)
Process

____ 17. Which of the following is the most valid criterion for determining the status of a patient’s anxiety at discharge? The patient:

1)
Has a relaxed facial expression.
2)
States that he feels more relaxed today.
3)
Shows no physiological signs of anxiety (e.g., pallor).
4)
Has no further questions about home care.

____ 18. The nurse works with the respiratory therapist to administer a patient’s breathing treatments. He reports the patient’s breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of:

1)
Delegation.
2)
Collaboration.
3)
Coordination of care.
4)
Supervision of care.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the medical-surgical floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Choose all that apply.

1)
75-year-old patient newly admitted with dehydration
2)
65-year-old patient hospitalized for a stroke, whose blood pressure is 189/90 mm Hg
3)
92-year-old patient with stable vital signs who was admitted with a urinary tract infection
4)
56-year-old patient with chronic renal failure who has vital signs within his normal range

Chapter 7. Nursing Process: Implementation & Evaluation

Answer Section

MULTIPLE CHOICE

1. ANS: 3

The nurse must recognize when she does not have the knowledge or skill needed to implement an order. Because the nurse is unfamiliar with the medication, that does not mean she should hold it and delay patient treatment. It is wisest to first consult with the pharmacist for information before administering the medication in order to ensure safe practice. Administering the medication as ordered, without knowing its expected actions and side effects, at the least prevents adequate reassessment; at the most, it is dangerous. Holding the medication and notifying the physician prevents the client from receiving timely treatment—many drugs are less effective if a consistent schedule is not maintained. Asking another nurse to administer the medication is also unsafe because it cannot be assumed that the other nurse has the correct knowledge. In addition, the nurse caring for the client must assess for adverse reactions to the medication.

PTS: 1 DIF: Moderate REF: V1, p. 119

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

2. ANS: 1

The nurse can delegate turning the client every 2 hours to the nursing assistive personnel. Assessing the client’s skin condition, changing pressure ulcer dressings, and applying a hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge and judgment.

PTS: 1 DIF: Moderate REF: V1, pp. 123-125

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application

3. ANS: 3

The implementation phase ends when you document nursing actions on the client’s chart. Implementation evolves into the evaluation step when you document the client’s response to your interventions. As a general rule, the steps in order are as follows: assessment diagnosis, planning outcomes, planning interventions, implementation, and evaluation.

PTS: 1 DIF: Easy REF: V1, p. 126

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Comprehension

4. ANS: 4

Positioning the client in the chair for meals considers the client’s desire to be out of bed for dinner, so it is obviously individualized. An intervention performed according to unit policy or protocols is not necessarily individualized. “Institute swallowing precautions” does not provide instructions for the specific actions needed to do that for “this” client.

PTS: 1 DIF: Moderate

REF: V1, p. 119; High-level question; answer not given verbatim

KEY: Nursing process: Planning Interventions | Client need: SECE | Cognitive level: Application

5. ANS: 1

Before the nurse begins a procedure, she should review the care plan and look at the orders critically. Because this client is confused, she should ask a colleague to assist with the procedure to prevent undue stress for the client and nurse. The client should be informed about the procedure before the nurse gathers the equipment. Gathering the equipment and bringing it into the room before explaining the procedure might cause the client anxiety. Restraining the client should be done only as a last resort and to prevent client injury. Informing the physician that the procedure cannot be performed because the client is confused is inappropriate because the procedure can very likely be done with assistance.

PTS: 1 DIF: Moderate REF: V1, p. 119

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

6. ANS: 1

A depressed affect and poor eye contact likely indicate the client is having difficulty coping with the new colostomy. At this time, the client would not be physically and psychologically ready to obtain the most benefit from teaching pertaining to ostomy care. Therefore, the nurse should postpone the teaching session for this client until the client is receptive to receiving the information. The nurse should not perform the teaching session simply because the critical pathway indicates it is appropriate. Simply administering an antidepressant does not address the client’s readiness to participate in a teaching session and ultimately self-care of the ostomy. The nurse should encourage the client to verbalize his feelings. Client education is not effective unless the client is receptive to the information. Readiness to learn is important. Proceeding with teaching when the client is struggling with coping is not sensitive to the client’s individual needs.

PTS: 1 DIF: Moderate REF: V1, p. 120

KEY: Nursing process: Implementation | Client need: PHI | Cognitive level: Application

7. ANS: 2

Reassuring the client is an interpersonal skill. Inserting the nasogastric tube requires psychomotor skills. Checking catheter placement after insertion requires cognitive and psychomotor skills. Assessing whether there is an indication for the nasogastric tube requires critical thinking skills.

PTS: 1 DIF: Moderate REF: V1, p. 122

KEY: Nursing process: Implementation | Client need: PHI | Cognitive level: Comprehension

8. ANS: 4

Instituting and adhering to a low-fat, low-calorie diet is an intervention that depends almost entirely on the client’s adhering to the therapy. Client cooperation is necessary for performing the other interventions, but the interventions do not depend on the client to the same extent.

PTS: 1 DIF: Easy REF: V1, p. 122

KEY: Nursing process: Planning Interventions | Client need: SECE | Cognitive level: Analysis

9. ANS: 4

Determining the client’s main concerns promotes cooperation with the treatment regimen. For example, if the client is concerned about paying for diabetic monitoring equipment, he may disregard any teaching about the procedure. Although it is often important for a diabetic client to exercise and lose weight to control blood sugar levels, the client must want to do both. He will not exercise or lose weight simply because he is told to do so. The nurse must assess the client’s support systems and resources, not just tell him he must come to the diabetic clinic weekly. Some clients do not have access to transportation and, therefore, could not come to the clinic without social service intervention. Remember that behavior is not necessarily based on knowledge.

PTS: 1 DIF: Moderate REF: V1, p. 122

KEY: Nursing process: Planning Interventions | Client need: PHSI | Cognitive level: Analysis

10. ANS: 1

Delegation is the transfer to another person of the authority to perform a task in a selected situation—the person delegating retains accountability for the outcome of the activity. Collaboration is described as working with other caregivers to plan, make decisions, and perform interventions. Coordination of care involves scheduling treatments and activities with other departments. Implementation is the process of performing planned interventions.

PTS: 1 DIF: Easy REF: V1, p. 123

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Knowledge

11. ANS: 3

Clear communication about a task (such as “Take the patient’s temperature”) tells the NAP exactly what the task is, the specific time it needs to be done, and the method for reporting the results to the registered nurse. The other options are vague and leave room for misinterpretation.

PTS: 1 DIF: Moderate REF: V1, p. 124

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

12. ANS: 1

The nurse who delegates the task is responsible for supervising and evaluating the outcomes of tasks performed by the NAP. Another registered nurse, such as a staff nurse, nurse manager, or charge nurse, can answer questions and provide help, if necessary.

PTS: 1 DIF: Easy REF: V1, p. 124

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Recall

13. ANS: 3

The criterion that states “a defibrillator is present on each client care area” is associated with structure evaluation. “Refrains from sharing computer password,” “washes hands before each client contact,” and “verifies client identification before initiating care” are criteria associated with process evaluation.

PTS: 1 DIF: Moderate REF: V1, p. 128

KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis

14. ANS: 2

A client outcome criterion states the client health status or behaviors one wishes to effect. “Client will sit out of bed . . .” is a client outcome criterion. The other options are examples of organizational criteria used to evaluate the quality of care throughout the institution.

PTS: 1 DIF: Moderate REF: V1, pp. 129-130

KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application

15. ANS: 4

The nurse should collect evaluation data as defined in the expected outcome. For instance, in this case, the nurse would check the patient’s urine output every hour because the goal statement specifies an hourly rate (30 mL/hour). The unit of measurement in the goal guides how often the nurse would reassess the patient.

PTS: 1 DIF: Easy REF: V1, pp. 128-129

KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

16. ANS: 1

Intermittent evaluation is performed at specific times; it enables the nurse to judge the progress toward goal achievement and to modify the plan of care as needed. Ongoing evaluation is performed while implementing, immediately after an intervention, or with each client contact; these are not necessarily scheduled events. Terminal evaluation is performed at the time of discharge. It describes the client’s health status and progress toward goals at that time. Process evaluation focuses on the manner in which care is given. It may be performed at specific times, but it is not considered a client-centered evaluation.

PTS: 1 DIF: Easy REF: V1, p. 128

KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Recall

17. ANS: 2

A criterion is considered valid when it measures what it is intended to measure. Because anxiety is subjective (perceived by the patient), the best measure of anxiety is what the patient says about it. A relaxed facial expression and other physiological signs might or might not show the level of anxiety. Relaxation might occur, for example, because the patient is sleeping or falling asleep. The fact that a patient is not asking questions about his surgery could mean that he has adequate knowledge about the topic; it would not indicate the presence or absence of anxiety. All of the options except what the patient states could be measuring something other than anxiety.

PTS: 1 DIF: Difficult REF: V1, p. 127 | V1, pp. 129-130

KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application

18. ANS: 2

Collaboration means working with other caregivers to plan, make decisions, and perform interventions. Delegation is the transfer to another person of the authority to perform a task in a selected situation. Coordination of care involves scheduling treatments and activities with other departments, putting together all the patient data to obtain “the big picture.” Supervision is the process of directing, guiding, and influencing the outcome of an individual’s performance of an activity or task.

PTS: 1 DIF: Moderate REF: V1, pp. 122-123

KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application

MULTIPLE RESPONSE

1. ANS: 1, 3, 4

The nurse should not delegate bathing of a client newly diagnosed with a stroke whose blood pressure is unstable or otherwise abnormal. This client requires the keen assessment and critical thinking skills of a registered nurse. The nurse can safely delegate the care of stable clients, such as the client admitted with dehydration, the client admitted with a urinary tract infection, or the client with chronic renal failure. Any client who is very ill or who requires complex decision making should be cared for by a registered nurse.

PTS: 1 DIF: Difficult REF: V1, pp. 123-124 | V2, p. 61

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis