Test Bank Q Fundamentals of Nursing:
Chapter 20 - Evaluation
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 - ANS ANS: D
Evaluation, 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 and if goals have been met. Assessment, the first step of the process, includes data
collection. Planning, the third step of the process, involves setting priorities, identifying
patient goals and outcomes, and selecting nursing interventions. During implementation,
nurses carry out nursing care, which is necessary to help patients achieve their goals.
A nurse completes a thorough database and carries out nursing interventions based on priority
diagnoses. Which action will the nurse take next?
a. Assessment
b. Planning
c. Implementation
d. Evaluation - ANS ANS: D
Evaluation, 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. Assessment involves gathering information about the patient. During the planning
phase, patient outcomes are determined. Implementation involves carrying out appropriate
nursing interventions.
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."
d. "Evaluation eliminates unnecessary paperwork and care planning." - ANS ANS: C
Evaluation is a methodical approach for determining if nursing implementation was effective
in influencing a patient's progress or condition in a favorable way. 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 care
planning.
, After assessing the patient and identifying the need for headache relief, the nurse administers
acetaminophen for the patient's headache. Which action by the nurse is priority for this
patient?
a. Eliminate headache from the nursing care plan.
b. Direct the nursing assistive personnel to ask if the headache is relieved.
c. Reassess the patient's pain level in 30 minutes.
d. Revise the plan of care. - ANS ANS: C
The nurse's priority action for this patient is to evaluate whether the nursing intervention of
administering acetaminophen was effective. The nurse does not have enough evaluative data
at this point to determine whether headache needs to be discontinued. Assessment is the
nurse's responsibility and is not to be delegated to nursing assistive personnel. 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 a patient who has a problem with physical mobility.
What does the nurse need to do before discontinuing the patient's plan of care?
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 to take home. - ANS ANS: B
You evaluate whether the results of care match the expected outcomes and goals set for a
patient before discontinuing a patient's 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 for a patient with
physical mobility problems due to a fractured leg. Which finding indicates the patient has met
an expected outcome?
a. The nurse provides assistance while the patient is walking in the hallways.
b. The patient is able to ambulate in the hallway with crutches.
c. The patient will deny pain while walking in the hallway.
d. The patient's level of mobility will improve. - ANS ANS: B
The patient's being able to ambulate in the hallway with crutches is an expected outcome of
nursing care. The outcomes of nursing practice are the measurable conditions of patient,
family or community status, behavior, or perception. These outcomes are the criteria used to
judge success in delivering 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 pain, not for physical
mobility problems.
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
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