1. In which step of the nursing process does the nurse determine if the patient’s condition has improved and whether the patient has met expected outcomes? a. Assessment b. Planning c. Implementation d. Evaluation
ANS: D
In the five-step nursing process, the evaluation phase is the final step involving conducting evaluative measures to determine whether nursing interventions have been effective and whether the patient has met expected outcomes. Assessment, the first step of the process, includes data collection, validation, sorting, and documentation. Planning, the third step of the process, involves setting priorities, identifying patient goals and outcomes, and prescribing nursing interventions. During implementation, nurses initiate nursing care, which is necessary to help patients achieve their goals.
2. After completing a thorough database and carrying out nursing interventions based on priority diagnoses, the nurse proceeds to which step of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation
ANS: D
In the five-step nursing process, evaluation is the last step following assessment, diagnosis, planning, and intervening. Assessment involves gathering information about the patient. Next, nursing diagnoses are determined. During the planning phase, patient outcomes are determined. Implementation involves carrying out appropriate nursing interventions.
- A nursing student asks her nursing instructor to describe the primary purpose of evaluation. Which of the following statements made by the nursing instructor is most accurate?
a.
“During evaluation, you determine whether all nursing interventions were completed.”
b.
“During evaluation, you determine when to downsize staffing on nursing units.”
c.
“Nurses use evaluation to determine the effectiveness of nursing care.”
d.
“Evaluation eliminates unnecessary paperwork and care planning.”
ANS: C
The purpose of evaluation is to determine the effectiveness of nursing care. The other options are not true statements. During evaluation, you do not simply determine whether nursing interventions were completed. The evaluation process is not used to determine when to downsize staffing or how to eliminate paperwork and planning.
- After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen (Tylenol) for the patient’s headache. What is the nurse’s next priority action for this patient?
a.
Eliminate Acute pain from the nursing care plan.
b.
Direct the nursing assistant to ask if the patient’s headache is relieved.
c.
Reassess the patient’s pain level in 30 minutes.
d.
Revise the plan of care
ANS: C
The nurse’s next priority action for this patient is to evaluate whether the nursing intervention of administering Tylenol was effective. The nurse does not have enough evaluative data at this point to determine whether the nursing diagnosis of Acute pain needs to be discontinued. Assessment is the nurse’s responsibility and is not to be delegated to a nursing assistant. The nurse does not have enough evaluative data to determine whether the patient’s plan of care needs to be revised.
- A nurse is getting ready to discharge to home a patient who has a nursing diagnosis of Impaired physical mobility. Before discontinuing the patient’s plan of care, what does the nurse need to do?
a.
Determine whether the patient has transportation to get home.
b.
Evaluate whether patient goals and outcomes have been met.
c.
Establish whether the patient has a follow-up appointment scheduled.
d.
Ensure that the patient’s prescriptions have been filled.
ANS: B
The nurse needs to evaluate whether goals and outcomes have been met before revising, continuing, or discontinuing a plan of care. The patient needs transportation, but that does not address the patient’s mobility status. Whether the patient has a follow-up appointment and ensuring that prescriptions are filled do not evaluate the problem of mobility.
- The nurse is evaluating whether patient goals and outcomes have been met. Which option below is an expected outcome for a patient with Impaired physical mobility?
a.
The patient is able to ambulate in the hallway with crutches.
b.
The patient’s level of mobility will improve.
c.
The nurse provides assistance while the patient is walking in the hallways.
d.
The patient will deny pain while walking in the hallway.
ANS: A
An outcome is an expected, favorable, and measurable result of nursing care. The patient’s being able to ambulate in the hallway with crutches is an expected outcome of nursing care. The option stating, “The patient’s level of mobility will improve” is a broader goal statement. The nurse’s assisting a patient to ambulate is an intervention. The patient’s denying pain is an expected outcome for Acute pain, not for Impaired physical mobility.
- 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?
a.
Staff documentation of turning the patient every 2 hours
b.
Absence of skin breakdown
c.
Presence of redness only on the heels of the patient
d.
Patient’s eating 100% of all meals
ANS: B
To determine whether a turning schedule is successful, the nurse needs to assess for the presence of skin breakdown. Redness on any part of the body, including only the patient’s heels, indicates that the turning schedule was not successful. Documentation of interventions does not evaluate whether patient outcomes were met. Eating 100% of meals does not evaluate the effectiveness of a turning schedule.
- What is the primary goal of outcomes management for professional nurses?
a.
To promote purposeful actions focused on improving a patient’s health condition
b.
To fine-tune nursing assessment skills
c.
To support the delegation of more nursing tasks to nursing assistive personnel
d.
To decrease the number of medication errors in nursing
ANS: A
The primary goal of outcomes management is to improve a patient’s health status. Assessment skills probably will be improved if a nurse focuses on improving patient outcomes, but this is not the primary goal. Delegating to nursing assistive personnel is not the primary goal of outcomes management. Reducing medication errors is a possible result of outcomes management, but it is not the primary goal.
- A new nurse states that she is confused about using evaluative measures when caring for patients and asks the charge nurse for examples and an explanation. Which of the following is the most accurate response from the charge nurse?
a.
“Evaluative measures are multiple-page documents used to evaluate nurse performance.”
b.
“Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals.”
c.
“Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse.”
d.
“Evaluative measures are objective views of incident reports.”
ANS: B
You use evaluative measures to determine whether patients have met their goals and outcomes. Evaluative measures are not multiple-page documents, and they are used to assess the patient’s status, not the nurse’s performance. Evaluative measures are not used when you are completing an incident report.
- The nurse is caring for a patient who has an open wound. When evaluating the progress of wound healing, what is the nurse’s priority action?
a.
Ask the nursing assistive personnel if the wound looks better.
b.
Document the progress of wound healing as “better” in the patient’s chart.
c.
Measure the wound and observe for redness, swelling, or drainage.
d.
Leave the dressing off the wound for easier access and more frequent assessments.
ANS: C
The nurse performs evaluative measures, such as completing a wound assessment, to evaluate wound healing. Nurses do not delegate assessment to nursing assistive personnel. Documenting “better” is subjective and does not objectively describe the wound. Leaving the dressing off for the nurse’s benefit of easier access is not a part of the evaluation process.
- 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. What is the nurse’s next action?
a.
Wait and change the dressing at 1800 as ordered.
b.
Revise the plan of care and change the dressing now.
c.
Reassess the dressing and the wound in 1 hour.
d.
Discontinue the plan of care
ANS: B
Based on evaluative data, the nurse revises, discontinues, or continues a patient’s plan of care. Because the dressing is saturated, the nurse needs to revise the plan of care and change the dressing now. Waiting until 1800 or for another hour is not appropriate because assessment data reflect that the dressing is saturated and needs to be changed now. Data are insufficient to support discontinuing the plan of care. Instead, data at this time indicate the need for revision of the plan of care.
- A goal for a patient with a diagnosis of Ineffective coping is to demonstrate effective coping skills. Which of these patient behaviors indicates that interventions performed to meet this outcome have been successful?
a.
States he feels better after talking with his family and friends
b.
Continues to consume several alcoholic beverages a day
c.
Dislikes the support group meetings
d.
Spends most of the day in bed
ANS: A
Evaluative data that show signs of effective coping will help the nurse determine whether the patient has met the outcome. Talking to family and friends is the only positive option. The other patient behavior choices indicate unsuccessful progress toward meeting the patient’s goal.
- A nurse is providing education to a patient about self-administering subcutaneous injections. Which of these patient statements indicates that the patient understands the instructions?
a.
“I need to use a needle 1/2 inch longer than my thumb.”
b.
“I will give the medicine deep into my deltoid.”
c.
“My belly is a good place to give my injection.”
d.
“I need to throw the syringe and needle into the garbage when I am done giving myself my shot.”
ANS: C
Remember from anatomy that the skin is made up of the outer layer, called the epidermis. The second layer of skin is the dermis. The connective tissue under the dermis is called the subcutaneous tissue. This is where subcutaneous injections are given. The abdomen is a good site for subcutaneous injections because this is an area that has a lot of subcutaneous tissue. Using a needle 1/2 inch longer than a person’s thumb is not an evidence-based method for measuring needle length needed for subcutaneous injection. The deltoid is a muscle, not a subcutaneous site. Disposing of needles and syringes into a garbage can creates a biomedical hazard and therefore is not appropriate.
- Which of these statements made by a patient who has Disturbed body image is the best indicator of the patient’s patient early acceptance of body image?
a.
“I just won’t go to the pool this summer.”
b.
“I’m worried about what those other girls will think of me.”
c.
“I can’t wear that color. It makes my hips stick out.”
d.
“I’ll wear the blue dress. It matches my eyes.”
ANS: D
The nurse evaluating interventions for the diagnosis Disturbed body image is assessing for positive comments made by the patient indicating acceptance of the patient’s looks and body image. The only positive comment made is that the patient is wearing the blue dress to match her eyes. The other comments do not reflect positive changes in body image.
- Which of these options is a patient outcome indicating positive progress toward resolving the nursing diagnosis of Acute confusion?
a.
Side rails are up with bed alarm activated.
b.
Patient denies pain while ambulating with assistance.
c.
Patient wanders halls at night.
d.
Patient correctly states names of family members in the room.
ANS: D
The identified nursing diagnosis is Acute confusion. The outcome for this diagnosis would address a decrease or absence of confusion. One sign of orientation is when a patient responds to questions appropriately. Thus, one possible sign that a patient’s confusion is improving is seen when a patient can correctly state the names of family members in the room. Keeping the side rails up and using a bed alarm are interventions to promote patient safety and prevent falls. The patient’s denying pain indicates positive progress toward resolving a diagnosis of Acute or Chronic pain. The patient’s wandering the halls is a sign of confusion.
- A nurse identifies a nursing diagnosis of Risk for falls 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. What is the nurse’s priority action when evaluating the patient’s plan of care?
a.
Counsel the nursing assistive personnel on duty when the patient fell.
b.
Identify factors interfering with goal achievement.
c.
Remove the fall risk sign from the patient’s door because the patient has suffered a fall.
d.
Request that the more experienced charge nurse complete the documentation about the fall.
ANS: B
After a change in the patient’s condition or an untoward event, the nurse attempts to identify factors interfering with goal achievement. In this case, the nurse identifies factors that interfered with goal achievement to determine the cause of the fall. The fall may not have been due to an error by the nursing assistant; therefore, counseling should be reserved until after the cause has been determined. The patient remains a fall risk, so the fall risk sign should remain on the door. The nurse witnessing the fall or the nurse assigned to the patient needs to complete the documentation. The charge nurse can be consulted to review the documentation
- 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 of the following is an appropriate evaluative measure demonstrating progress toward this goal?
a.
Nonproductive cough present in 4 days
b.
Scattered rhonchi throughout all lung fields in 2 days
c.
Respirations 30/minute in 1 day
d.
Lungs clear to auscultation following use of inhaler
ANS: D
Goals are broad statements that describe changes in a patient’s condition or behavior. Expected outcomes are shorter-term measurable criteria used to evaluate goal achievement. When an outcome is met, you know that the patient is making progress toward goal achievement. In this case, the patient’s goal is to not experience shortness of breath with activity in 3 days. One way to achieve this goal is for the patient to experience no respiratory secretions in the airway. One way for the nurse to evaluate the expected outcome is to assess the patient’s lung sounds. If the lung sounds are clear, at least periodically throughout the day, the nurse can determine that the patient is making progress toward achieving the expected outcome. The time frame of 4 days in the first option is not appropriate because this time frame exceeds the time frame stated in the goal. Scattered rhonchi indicate fluid in the lungs, and a respiratory rate of 30 per minute is elevated. This indicates that the patient is still probably experiencing respiratory distress.
- A nurse administrator is at a meeting with nurses on the quality council. Several new members are sitting on the council. They ask the nurse administrator to clarify what a nursing-sensitive outcome is. Which response by the nurse administrator best defines nursing-sensitive outcomes?
a.
“Nursing-sensitive outcomes determine the patient’s progress as a result of prescribed treatments, such as medications.”
b.
“Patient falls is an example of a nursing-sensitive outcome because they are directly affected by nursing interventions.”
c.
“Nursing-sensitive outcomes promote universal health care.”
d.
“We use nursing-sensitive outcomes at this hospital to evaluate nursing tasks and to determine safe staffing ratios.”
ANS: B
A nursing-sensitive outcome is a measurable patient or family state, behavior, or perception that is largely influenced by and sensitive to nursing interventions. Patient falls is one nursing-sensitive outcome because they are a direct measure of nursing care. Because the prescriber determines prescribed treatments, the progress of the patient’s condition as a result of prescribed treatments is not an evaluation of a nursing-sensitive outcome. Promotion of universal health care and determining staffing ratios are not components of nursing-sensitive outcomes.
1. Which of the following are examples of evaluative measures that a nurse should utilize when determining the patient’s response to nursing care? (Select all that apply.) a. Observations of wound healing b. Assessment of respiratory rate and depth c. Blood pressure measurement d. Implementation of nursing interventions e. Patient’s subjective report of feelings about a new diagnosis of cancer
ANS: A, B, C, E
Evaluative measures require the nurse to use assessment skills and techniques to determine the patient’s response to nursing care. Examples of evaluative measures include assessment of wound healing and respiratory status, blood pressure measurement, and assessment of patient feelings. Determining whether nursing interventions were used is not an evaluative measure.
- Identify elements of the evaluation process. (Select all that apply.)
a.
Setting priorities for patient care
b.
Collecting subjective and objective data to determine whether criteria or standards are met
c.
Ambulating 25 feet in the hallway with the patient
d.
Documenting findings
e.
Terminating, continuing, or revising the care plan
ANS: B, D, E
During the evaluation process, you gather and document objective and subjective data to determine whether the patient is meeting expected outcomes and is working toward achievement of goals. The evaluation process requires the use of critical thinking about attitudes and standards to analyze your findings and to determine whether a plan of care needs to be terminated, continued, or revised. Setting priorities is part of planning, and ambulating with a patient in the hallway is an intervention, so it is included in the implementation step of the nursing process.
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Chapter 2: The Health Care Delivery System20
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Chapter 14: Older Adults26
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Chapter 15: Critical Thinking in Nursing Practice20
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Chapter 16: Nursing Assessment20
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Chapter 17: Nursing Diagnosis19
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Chapter 18: Planning Nursing Care20
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Chapter 19: Implementing Nursing Care23
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Chapter 20: Evaluation20
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Chapter 24: Communication28
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Chapter 25: Patient Education32
