Chapter 20: Evaluation Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

MULTIPLE CHOICE

1. The client smokes two packs of cigarettes per day. The nurse works with the client, and they agree that he will smoke one cigarette less each week until he is down to one pack per day. In 3 weeks, the client is smoking two and a half packs of cigarettes per day. This is an example of:

1.

A realistic goal

2.

A compliant client

3.

A negative evaluation

4.

A nonmeasurable goal

ANS: 3

This is an example of a negative evaluation. During evaluation, the nurse is able to determine that the client has not met the expected outcome of decreasing smoking by one cigarette each week but rather has increased his smoking. This is not an example of a realistic goal. It is an example of the evaluation step of the nursing process. The client is noncompliant. The goal is measurable. During evaluation, the nurse determines if expected outcomes are met in order to judge if goals have been met.

DIF: A REF: 291 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

2. The nurse formulates a diagnosis of knowledge deficit related to complications of pregnancy. One outcome criterion is that the client can state five symptoms that indicate a possible problem that should be reported. The client is able to tell the nurse three symptoms. The evaluation statement would be:

1.

Goal met; client able to state three symptoms

2.

Goal not met; client able to list three symptoms

3.

Goal not met; client unable to list five symptoms

4.

Goal partially met; client able to state three symptoms

ANS: 4

The client is showing changes but does not yet meet criteria set; therefore, the goal is partially met. The clients response, being able to state three symptoms, does not meet or exceed the outcome criteria of being able to state five symptoms. The clients response, being able to list three symptoms, demonstrates some change. If the client were showing no progress, then the goal would not be met. If the client were showing no progress, then the goal would not be met. However, this clients response does indicate some change.

DIF: A REF: 296 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

3. The nurse begins to auscultate the clients 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.

DIF: A REF: 298 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

4. The client is able to ambulate without signs or symptoms of shortness of breath. Which statement by the nurse is the best example of an objective evaluation of the clients goal attainment?

1.

Client has no pain after ambulating.

2.

Client has no manifestations of nausea while up in hall.

3.

Client walked well and did not have any problem when up.

4.

Client has no evidence of respiratory distress when ambulating.

ANS: 4

Client has no evidence of respiratory distress when ambulating is the best example of an objective evaluation of the clients goal attainment. It uses the same evaluative measures gathered during assessment and clearly describes objective data. Client has no pain after ambulating does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not pain. If the clients pain level were going to be used as an evaluative measure, it would be optimal to have the client report the pain using a pain scale to make it more measurable for comparison. Client has no manifestations of nausea while up in hall is not the best example of an objective evaluation of the clients goal attainment. It does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not nausea. Also, nausea is more subjective. Client walked well and did not have any problem when up is not the best example of an objective evaluation. It includes the nurses interpretation rather than documentation of objective data.

DIF: A REF: 294 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

5. When modifying a care plan to meet a client whose status has changed significantly over the past few days, the nurse should:

1.

Redevelop the entire client care plan

2.

Focus on changing the nursing diagnoses and goals

3.

Perform a complete reassessment of all client factors

4.

Add more nursing interventions from a standardized plan of care

ANS: 3

A complete reassessment of all client factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. After reassessment the nurse will determine what components of the care plan are accurate for the situation. It may not require redoing the entire care plan. The nurse should not only focus on the nursing diagnoses and goals that have changed. Interventions may also need revising to meet new goals. Adding more nursing interventions may or may not be necessary. The nurse adjusts interventions on the basis of the clients response and previous experience with similar clients. Standards of care are used to determine whether the right interventions have been chosen or whether additional ones are required.

DIF: A REF: 297 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

6. 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 clients 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 clients 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 clients 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.

DIF: A REF: 291 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

7. The nurse has determined the following outcome for a client with a skin impairment: Erythema will be reduced in 3 days. Evaluation will specifically focus on:

1.

Selection of appropriate wound care

2.

Notation of the odor and color of drainage

3.

Inspection of the color and condition of the area

4.

Measurement of the diameter of the ulceration daily

ANS: 3

Erythema is reddening of the skin; therefore, the evaluation should specifically focus on inspection of the color of the skin, as stated in the outcome criterion. Selection of appropriate wound care is an intervention, not an evaluation of a clients behavior or response. The outcome criterion does not state anything about drainage. Noting the color and amount of drainage may be a part of reassessment of the client, but is not what the nurse is evaluating according to this outcome criterion. The outcome criterion states the erythema will be reduced, not the size of the ulceration. During the evaluation step of the nursing process, the clients behavior or response should be compared to the outcome criterion and judged for degree of agreement between the two.

DIF: A REF: 294 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

8. The client has a nursing diagnosis of impaired gas exchange as a result of excessive secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus upon the clients:

1.

Respiratory rate

2.

Complaint of chest pain

3.

Lungs clear bilaterally on auscultation

4.

Ability to perform incentive spirometry

ANS: 3

Auscultating lung sounds is the best way to determine if airways are clear. A positive evaluation is that they are clear, as expected in the outcome statement. Respiratory rate may be an indicator of respiratory status, but it is not the best way to determine if airways are free of secretions. A complaint of chest pain would be a negative outcome, and it is not the focus for determining whether airways are free of secretions as written in the outcome statement. Having the ability to perform incentive spirometry does not determine whether the airways are clear or not. It is an intervention that may help achieve clear airways.

DIF: A REF: 294 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

9. 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.

DIF: C REF: 296 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

10. The primary purpose of the nursing evaluation process is to:

1.

Determine the effectiveness of the nursing care provided

2.

Identify interventions that are ineffective in achieving client goals

3.

Establish the progress the client is making towards health and wellness

4.

Critique the nurses ability to implement appropriate nursing interventions

ANS: 1

The evaluation process determines the effectiveness of nursing care. The remaining options are all examples of evaluation but do not reflect the primary purpose of nursing evaluation.

DIF: C REF: 291 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

11. Which of the following statements best reflects a goal based on a clinical standard of practice?

1.

Client will lose 10 pounds in 90 days.

2.

Client will walk 30 feet with minimal assistance.

3.

Clients peripheral intravenous site will be free of redness.

4.

Clients chronic pain will be managed with oral medication by discharge.

ANS: 3

Goals often are also based on standards of care or guidelines established for minimal safe practice. Prevention of acquired infection is a standard of practice; the remaining options reflect client-specific goals.

DIF: C REF: 293 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

12. Which of the following outcomes best reflects a nurse-sensitive client outcome?

1.

Client will consume 75% of all meals.

2.

Client will perform personal hygiene daily.

3.

Client will experience no falls during hospitalization.

4.

Client will report lessened anxiety regarding surgical procedure.

ANS: 3

A nurse-sensitive client outcome is a measurable client or family state, behavior, or perception largely influenced by and sensitive to nursing interventions. The nurse is instrumental in the prevention of falls while the remaining options are dependent on the client.

DIF: C REF: 293 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

13. The nurse has identified a nursing diagnosis of knowledge deficit regarding the need to monitor blood glucose levels daily. Which of the following statements best reflects the clients understanding of the need for therapy?

1.

Client agrees to test blood glucose levels 4 times a day.

2.

Client records blood glucose levels for a 3-week period.

3.

Client is observed testing his blood glucose level before breakfast.

4.

Client is able to demonstrate the proper technique for performing a finger stick.

ANS: 2

During the planning phase of the nursing process it is important for you to select an observable client state, behavior, or self-reported perception that will reflect goal achievement. The actual written result of regular blood glucose monitoring is the best indicator of the clients understanding of the importance of regular testing. The remaining options may show initial willingness or ability to perform the test but do not show consistent compliance.

DIF: C REF: 293 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

14. Which of the following nursing notes demonstrates the best evaluation of nursing interventions regarding the care provided?

1.

Pressure ulcer located on left heel has shown improvement.

2.

Pressure ulcer located on left heel has responded to treatment.

3.

Pressure ulcer on left heel is no longer producing purulent drainage.

4.

Pressure ulcer on left heel has not enlarged in size within the last 24 hours.

ANS: 3

In many clinical situations it is important to collect evaluative measures over a period of time to determine if a pattern of improvement or change exists. The absence of purulent drainage indicates successful nursing interventions while the other options either fail to provide measurable data regarding the wound or indicate no improvement.

DIF: C REF: 294 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

15. Which of the following statements made by a clients family is the most reliable for use in the evaluation of a clients outcome?

1.

Mom has been eating 90% of all of her meals since shes been home.

2.

My daughter is in much less pain now that she is going to physical therapy.

3.

My husband has been less depressed since hes been on that antidepressant pill.

4.

Mom has been so much better since shes been able to get up and walk by herself.

ANS: 1

Input from the family and other caregivers can be used to evaluate client outcomes but it is best to use their observations of measurable actions, such as the amount eaten, than to rely on their subjective opinions of a clients reaction, such as pain, anxiety, or mood.

DIF: C REF: 294 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

16. 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 clients condition or well-being improves. The remaining options represent the assessment and implementation phases.

DIF: A REF: 291 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

17. Which of the following questions, asked by a nurse, best reflects an understanding of effective evaluation?

1.

Do you feel confident in the use of your glucometer?

2.

Have you been following your low carbohydrate diet?

3.

Any questions regarding the tests you are scheduled for today?

4.

May we review what we discussed earlier about your medications?

ANS: 4

In effective evaluation, the nurse compares client behavior and responses that were assessed before delivering nursing interventions with behavior and responses that occur after administering nursing care. The answer shows direct client knowledge related to the material previously discussed, while the other options reflect close-ended questions that require only a yes or no answer.

DIF: C REF: 291 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

18. The nurse caring for an immobile client with a pressure ulcer implements an intervention that requires repositioning the client every 2 hours. Which of the following represents the best evaluation method for this intervention?

1.

No additional pressure ulcers are noted over a 1-week period.

2.

Client expresses a decrease in pressure ulcer related pain within 1 week.

3.

The clients pressure ulcer shows a decrease in size over a 1-week period.

4.

The turning schedule is initiated to reflect appropriate positioning for a 1-week period.

ANS: 3

You conduct evaluation measures to determine if you met expected outcomes, not if nursing interventions were completed. The decrease in size of the pressure ulcer best evaluates the effectiveness of this intervention while the remaining options reflect client opinion, further skin breakdown, or implementation of the intervention.

DIF: C REF: 291 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

19. Which of the following statements best defines quality improvement (performance improvement)?

1.

The assessment of the delivery system responsible for the implementation of client-oriented interventions

2.

Integration of evidence-based practice research into the delivery process used to implement client-oriented interventions

3.

High-priority evaluation process directed towards differentiating between good and poor intervention delivery by providers

4.

An ongoing evaluation of interventions that is used to improve the delivery of health care for the purpose of managing the clients needs

ANS: 4

Quality improvement (QI) and performance improvement (PI) are interchangeable terms that describe an approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others. The remaining options reflect individual facets of QI.

DIF: C REF: 298 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

20. The primary reason for documenting discontinued portions of the care plan when a client goal has been met is to ensure:

1.

Effective use of both nursing time and resources

2.

Delivery of both timely and relevant nursing care

3.

Concrete evidence of successful outcome achievement

4.

Minimal ineffective communication among the nursing staff

ANS: 2

Documentation of a discontinued plan ensures that other nurses will not unnecessarily continue interventions for that portion of the plan of care. Continuity of care assumes that care provided to clients is relevant and timely. The remaining options refer to the potential nursing outcomes related to poor documentation of care plan editing.

DIF: C REF: 297 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

21. Which of the following nursing actions should be initiated first when dealing with the following unmet client goal: Client will lose 10 pounds in 3 months?

1.

Interview the client to identify reasons why the goal was not met.

2.

Assess the client for possible physical reasons for failure to lose the weight.

3.

Discuss with the client whether they were truly motivated to lose the weight.

4.

Re-evaluate whether it was realistic for the client to lose 10 pounds in 3 months.

ANS: 1

When goals are not met, the nurse should identify the factors that interfere with goal achievement. The remaining options reflect actions to be taken after the interview to further determine how the care plan will be modified.

DIF: C REF: 297 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

22. When a client goal is unmet, which of the following nursing actions is most appropriate?

1.

Reevaluation of the original client goal

2.

Selection of new but appropriate interventions

3.

Evaluation of the clients ability and motivation to be compliant

4.

Repetition of the entire nursing process regarding the nursing diagnosis

ANS: 4

When there is failure to achieve a goal, no matter what the reason, repeat the entire nursing process sequence for that nursing diagnosis to discover changes the plan needs. The remaining options reflect individual elements within the nursing process.

DIF: C REF: 297 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

MULTIPLE RESPONSE

1. Which of the following is a recognized focus area for quality improvement (performance improvement) evaluations? (Select all that apply.)

1.

Effective care

2.

Delivery of care

3.

Client satisfaction

4.

Exceeding the standard of care

5.

Identification of missed client needs

6.

Multidisciplinary approach to client care

ANS: 1, 2, 3, 4

Quality improvement is concerned with exceeding the standard of care, examining ways to be more efficient, improving client satisfaction, and focusing on service. Although the remaining options are pertinent, they are not major considerations of QI evaluation.

DIF: C REF: 298 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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