Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Ex, Exams of Nursing

Download Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Ex and more Exams Nursing in PDF only on Docsity! Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 . Purposes of the Nursing Outcomes Classification (NOC) include which of the following? Select all that apply. A. To identify and label nurse-sensitive patient outcomes B. To test the classification in clinical settings C. To establish health care reimbursement guidelines D. To identify nursing interventions for linked nursing diagnoses E. To define measurement procedures for outcomes - Correct Answers ✅A, B, E Which of the following does a nurse perform when discontinuing a plan of care for a patient? A. Confirms with the patient that expected outcomes and goals have been met Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 B. Talks with the patient about reprioritizing interventions in the plan of care C. Changes the frequency of interventions provided D. Reassesses how goals were met - Correct Answers ✅A Which of the following statements correctly describes the evaluation process? Select all that apply. A. Evaluation is an ongoing process. B. Evaluation usually reveals obvious changes in patients. C. Evaluation involves making clinical decisions. D. Evaluation requires the use of assessment skills. E. Evaluation is only done when a patient's condition changes. - Correct Answers ✅A, C, D Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 C. Use of clinic services D. Adherence to use of inhaler E. Description of side effects of medications - Correct Answers ✅A, C, D A nurse checks an intravenous (IV) solution container for clarity of the solution, noting that it is infusing into the patient's left arm. The IV solution of 9% NS is infusing freely at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room the nurse inspects the condition of the dressing and notes the date on the dressing label. In which ways did the nurse evaluate the condition of the IV site? Select all that apply. A. Checked the IV infusion rate B. Checked the type of IV solution C. Confirmed from nurses' notes the time of dressing change Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 D. Inspected the condition of the IV dressing at the site E. Checked clarity of IV solution - Correct Answers ✅A, D 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 statement is appropriate for evaluating a patient's expectations of care? A. On a scale of 0 to 10 rate your level of nausea. B. The nurse weighs the patient. C. The nurse asks, "Did you believe that you received the information you needed to follow your diet?" D. The nurse states, "Tell me four different foods included in your diet." - Correct Answers ✅C Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 A patient has been febrile and coughing thick secretions; adventitious lung sounds indicate rales in the left lower lobe of the lungs. The nurse decides to perform nasotracheal suction because the patient is not coughing. The nurse inspects the mucus that is suctioned, which is minimal. The nurse again auscultates for lung sounds. Auscultation and mucus inspection are examples of: A. Evaluative measures. B. Expected outcomes. C. Reassessments. D. Reflection. - Correct Answers ✅A A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the nursing diagnosis of Nausea related to effects of postoperative anesthesia. The nurse has been asking the patient to rate his nausea over the last several hours after administering antiemetics and using comfort measures such as oral hygiene. The nurse reviews the patient's responses over the past 10 hours and notes how the patient's self-report of nausea has changed. This review an example of: Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 Select all that apply. A. Number of interventions B. Appropriateness of the intervention for the patient C. The prior use of interventions by other nursing staff D. Correct application of the intervention for the patient care setting E. The time it takes to provide interventions - Correct Answers ✅B, D A patient is being discharged after treatment for colitis (inflammation of the colon). The patient has had no episodes of diarrhea or abdominal pain for 24 hours. Following instruction, the patient identified correctly the need to follow a low-residue diet and the types of food to include if a bout of diarrhea develops at home. These behaviors are examples of: A. Evaluative measures. Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 B. Expected outcomes. C. Reassessments. D. Standards of care. - Correct Answers ✅B A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting? a.Assessment b.Planning c.Implementation d.Evaluation - Correct Answers ✅D A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next? Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 a.Assessment b.Planning c.Implementation d.Evaluation - Correct Answers ✅D A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate? a."An evaluation helps 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." Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 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.Presence of redness only on the heels of the patient c.Patient's eating 100% of all meals d.Absence of skin breakdown - Correct Answers ✅D A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next? a.Reassess the patient and situation. b.Revise the turning schedule to increase the frequency. Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 c.Delegate turning to the nursing assistive personnel. d.Apply medication to the area of skin that is broken down. - Correct Answers ✅A A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? 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 for completion of nursing interventions." - Correct Answers ✅B Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take? a.Ask the nursing assistive personnel if the wound looks better. b.Document the progress of wound healing as "better" in the 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. - Correct Answers ✅C 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 and leaking. 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. Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion? a.Patient wanders halls at night. b.Patient's side rails are up with bed alarm activated. c.Patient denies pain while ambulating with assistance. d.Patient correctly states names of family members in the room. - Correct Answers ✅D A nurse identifies a fall risk 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. Which action is the nurse's priority when evaluating the patient? a.Identify factors interfering with goal achievement. b.Counsel the nursing assistive personnel on duty when the patient fell. Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 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. - Correct Answers ✅A 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 evaluative measure will the nurse use to demonstrate progress toward this goal? a.No sputum or cough present in 4 days b.Congestion throughout all lung fields in 2 days c.Shallow, fast respirations 30 breaths per minute in 1 day d.Lungs clear to auscultation following use of inhaler - Correct Answers ✅D Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met? a.Heart rate 78 beats/min on 12/3 b.Heart rate 78 beats/min on 12/4 c.Heart rate 80 beats/min on 12/3 d.Heart rate 80 beats/min on 12/4 - Correct Answers ✅A A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks? 1. Revise nursing diagnosis. 2. Reassess blood pressure reading. 3. Retake blood pressure after medication. Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 evaluation - Correct Answers ✅the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient's condition or well-being improves. what are the 4 critical thinking indicators reflecting a nurse's ability to perform evaluation? - Correct Answers ✅1. examine the results according to clinical data collected. 2. compare achieved effect with goals and expected outcomes. 3. recognize errors. 4. understand a patient situation, participate in self-reflection, and correct errors. evaluative measures - Correct Answers ✅same as assessment measures, but you perform them at the point of care when you make decisions about a patient's status and progress. self-report - Correct Answers ✅a measure of a patient's own perceptions or beliefs and may not truly reflect if behavior has changed. what are the 3 purposes of Nursing Outcomes Classification (NOC)? - Correct Answers ✅1. to identify, label, validate, and classify nurse- sensitive patient outcomes. Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 2. to field test and validate the classification. 3. to define and test measurement procedures for the outcomes and indicators using clinical data. outcomes - Correct Answers ✅statements of progressive, step-by- step physical, emotional, or behavioral responses that a patient needs to accomplish to achieve the goals of care. what are the 5 steps to objectively evaluate the degree of success in achieving outcomes of care? - Correct Answers ✅1. examine the outcome criteria to identify the exact desired patient behavior or response. 2. evaluate a patient's actual behavior or response. 3. compare the established outcome criteria with the actual behavior or response. 4. judge the degree of agreement between outcome criteria and the actual behavior or response. 5. if there is no agreement between the outcome criteria and the actual behavior or response, what is/are the barrier(s)? why did they not agree? what do you do when a goal is not met? - Correct Answers ✅repeat the nursing process sequence for that nursing diagnosis. Chapter 20 Potter and Perry, Potter Perry Fundamentals of Nursing Chapter 20 Evaluation Exams 2024 standard of care - Correct Answers ✅the minimum level of care accepted to ensure high quality of patient care. self-efficacy - Correct Answers ✅General self-efficacy (GSE) scale, disease-specific self-efficacy scales (e.g., arthritis, cardiac); medication- adherence self-efficacy scale health behavior - Correct Answers ✅Adherence to medication schedule (e.g., pill count), demonstrated psychomotor skill (e.g., dressing change, self-injection), adherence to medical follow-up visits health status - Correct Answers ✅Clinical indicators (e.g., exercise tolerance, blood pressure control, blood glucose control (HgA1C) Health Service Utilization - Correct Answers ✅Readmission to hospital in 30 days Admission to Emergency Department