Chapter 14 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 14

Question 1

Type: MCSA

The home health nurse must devise a way to administer IV antibiotics to a client who insists on being outside during the infusion. Using creativity and critical thinking, the nurse is able to meet the clients requests. This is an example of which of the following?

1. Technical skill

2. Interpersonal skill

3. Creativity

4. Cognitive skill

Correct Answer: 4

Rationale 1: Technical skills are hands-on skills such as manipulating equipment, giving injections, bandaging, moving, lifting, and repositioning clients.

Rationale 2: Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting directly with one another.

Rationale 3: Creativity is part of cognitive skill.

Rationale 4: Cognitive skills include problem solving, decision making, critical thinking, and creativity. Finding a unique way to provide the treatment while keeping the clients wishes in mind is an example of the nurse using cognitive abilities.

Global Rationale: Page Reference: 237

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 02 Describe three categories of skills used to implement nursing interventions.

Question 2

Type: MCSA

The student nurse must accurately perform a sterile dressing change before completing a unit of the course. This student is being evaluated on which of the following?

1. Technical skill

2. Cognitive skill

3. Interpersonal skill

4. Academic skill

Correct Answer: 1

Rationale 1: Technical skills are hands-on skills such as manipulating equipment, giving injections, bandaging, moving, lifting, and repositioning clients. These skills can also be called tasks, procedures, or psychomotor skills.

Rationale 2: Cognitive skills are intellectual skills that involve problem solving, decision making, critical thinking, and creativity.

Rationale 3: Interpersonal skills are necessary for all nursing activities: caring, comforting, advocating, referring, counseling, and supporting, to name a few.

Rationale 4: Academic skills would fall under the category of cognitive skills.

Global Rationale: Page Reference: 237

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 02 Describe three categories of skills used to implement nursing interventions.

Question 3

Type: MCSA

A nurse works in an acute psychiatric setting and sees clients as they are admitted for inpatient psychiatric care. Many of the clients exhibit paranoid behavior. The most important skill this nurse can utilize for these clients is which of the following?

1. Cognitive skill

2. Interpersonal skill

3. Technical skill

4. Therapeutic skill

Correct Answer: 2

Rationale 1: Cognitive skills are intellectual skills and include problem solving, decision making, critical thinking, and creativity.

Rationale 2: Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting directly with one another. The effectiveness of a nursing action often depends largely on the nurses ability to communicate with others. Interpersonal skills are necessary for all nursing activities including comforting, counseling, and supportingall of which are extremely important in the acute psychiatric setting.

Rationale 3: Technical skills are hands-on skills such as manipulating equipment, giving injections, bandaging, and repositioning clients.

Rationale 4: All nursing skills should be therapeutic.

Global Rationale: Page Reference: 237

Cognitive Level: Understanding

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 02 Describe three categories of skills used to implement nursing interventions.

Question 4

Type: MCMA

During the process of implementing cares and treatments for a client, the nurse realizes there are several entities included in this phase.

1. Evaluating the outcome of the interventions

2. Reassessing the client

3. Documenting the history and physical

4. Supervising delegated care

5. Implementing the nursing interventions

Correct Answer: 2,4,5

Rationale 1: Other components of the implementation process include determining the nurses need for assistance, and documenting nursing activities. Documentation of the history and physical is part of the initial assessment. Evaluating the outcome of the interventions is part of the evaluation phase.

Rationale 2: Other components of the implementation process include determining the nurses need for assistance, and documenting nursing activities. Documentation of the history and physical is part of the initial assessment. Evaluating the outcome of the interventions is part of the evaluation phase.

Rationale 3: Other components of the implementation process include determining the nurses need for assistance, and documenting nursing activities. Documentation of the history and physical is part of the initial assessment. Evaluating the outcome of the interventions is part of the evaluation phase.

Rationale 4: Other components of the implementation process include determining the nurses need for assistance, and documenting nursing activities. Documentation of the history and physical is part of the initial assessment. Evaluating the outcome of the interventions is part of the evaluation phase.

Rationale 5: Other components of the implementation process include determining the nurses need for assistance, and documenting nursing activities. Documentation of the history and physical is part of the initial assessment. Evaluating the outcome of the interventions is part of the evaluation phase.

Global Rationale: Page Reference: 237

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 02 Describe three categories of skills used to implement nursing interventions.

Question 5

Type: MCSA

Upon entering the room, the client is found crying along with the clients spouse. The nurse decides to sit with both of them, offering presence and listening to their fears instead of the planned education. This is an example of which of the following?

1. Implementing nursing intervention

2. Determining the nurses need for assistance

3. Supervising delegated care

4. Reassessing the client

Correct Answer: 4

Rationale 1: In this case, the client and the spouse are not in a good frame of mind to listen to or retain any kind of teaching/learning experience and so the planned intervention should not be initiated.

Rationale 2: In this situation, the nurse does not need assistance.

Rationale 3: This is not a situation where the nurse must supervise care that has been delegated.

Rationale 4: Just before implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed or to discover if there are new data that indicate a need to change the priorities of care. In this case, the client and the spouse are not in a good frame of mind to listen to or retain any kind of teaching/learning experience. Instead, the nurse reassesses the situation and implements a more appropriate intervention. In this situation, the nurse does not need assistance, nor is this a situation where the nurse must supervise care that has been delegated.

Global Rationale: Page Reference: 237

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Describe the steps involved in reviewing and modifying the clients care plan.

Question 6

Type: MCSA

An action that allows new parents to feel in control when being taught how to bath their infants would be when the nurse:

1. Tells the parents everything the nurse is doing and why.

2. Lets the parents watch a video after the bath.

3. Lets the parents bathe the baby with direction and guidance from the nurse.

4. Gives lots of advice and suggestions about different methods.

Correct Answer: 3

Rationale 1: Explaining is helpful, but does not provide the clients with a sense of independence and control in the situation.

Rationale 2: Active participation enhances a clients sense of independence and control. In this situation, the baby and parents will do best with future bathing times if they are allowed to complete the bath themselves. Watching a video is helpful, but does not provide the clients with a sense of independence and control in the situation.

Rationale 3: Active participation enhances a clients sense of independence and control. In this situation, the baby and parents will do best with future bathing times if they are allowed to complete the bath themselves.

Rationale 4: Giving advice or suggestions is helpful, but does not provide the clients with a sense of independence and control in the situation.

Global Rationale: Page Reference: 239

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Identify guidelines for implementing nursing interventions.

Question 7

Type: MCSA

. The nurse makes sure that the client learning how to administer insulin understands how to activate the safety mechanism on the syringe to prevent needlestick injuries. This is an example of which of the guidelines for implementing interventions?

1. Adapt activities to the individual client.

2. Encourage clients to participate actively in implementing nursing interventions.

3. Base nursing interventions on scientific knowledge, research, and standards of care.

4. Implement safe care.

Correct Answer: 4

Rationale 1: Adapting activities would involve learning the clients beliefs, values, age, health status, and environment as factors that can affect the success of a nursing action.

Rationale 2: Encouraging clients to participate enhances their sense of independence and control.

Rationale 3: The nurse must be aware of scientific rationale, as well as possible side effects or complications of all interventions so that implementing them centers around specific knowledge and care standards.

Rationale 4: Showing the client how to avoid injury with needlesticks is part of implementing safe care.

Global Rationale: Page Reference: 238

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Identify guidelines for implementing nursing interventions.

Question 8

Type: MCSA

On one of the first days working alone, the novice nurse must provide teaching on tracheostomy care to the client as well as the clients spouse. This nurse is not familiar with the teaching aspect. The best action for the nurse is to:

1. Ask the nurse mentor to assist with the teaching after reviewing the procedure.

2. Read the policy and procedure manual before the teaching session.

3. Do the best the nurse can by remembering what was taught in nursing school.

4. Ask for a different assignment until the nurse feels comfortable with this one.

Correct Answer: 1

Rationale 1: When implementing some nursing interventions, the nurse may require assistance. In this case, the nurse lacks the knowledge or skills to implement a particular nursing activity (teaching).

Rationale 2: Reading and reviewing the policy and procedure are important, but should be followed up with asking for assistance.

Rationale 3: Doing the best the nurse can would not be acceptable.

Rationale 4: Asking for a different assignment would not be acceptable.

Global Rationale: Page Reference: 238

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Identify guidelines for implementing nursing interventions.

Question 9

Type: MCSA

One of the clients assigned to the nurses care is to receive a medication that the nurse is not familiar with and is not listed in the drug reference manual. The best action of the nurse is to:

1. Follow the physicians orders as written and give the medication.

2. Call the pharmacy and do further investigating before administering the medication.

3. Ask the client about this medication.

4. Call the physician and ask what the medication is and what it is for.

Correct Answer: 2

Rationale 1: Following the physicians order is important, but the nurse is still responsible to know and understand the medication, its action, and adverse actions as well as interactions with other medications.

Rationale 2: The nurse should clearly understand all nursing interventions to be implemented and question any that are not understood. The nurse is responsible for intelligent implementation of medical and surgical plans of care. The pharmacist would be the most appropriate reference point for this nurse to begin to research this problem.

Rationale 3: The client should be informed about the medications and treatments, but the nurse does not utilize the client for scientific knowledge and professional standards of care.

Rationale 4: The pharmacist would be the most appropriate reference point for this nurse to begin to research this problem.

Global Rationale: Page Reference: 238

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Identify guidelines for implementing nursing interventions.

Question 10

Type: MCSA

The nurse understands that respect for the dignity of the client is extremely important in providing nursing care. Which of the following is an example of this aspect?

1. Allowing clients to complete their own hygienic cares when possible

2. Providing all cares to all clients whenever possible

3. Telling the other staff that the client is demanding, so they are able to meet the clients needs

4. Presenting information to the clients family about the clients condition

Correct Answer: 1

Rationale 1: Respecting the dignity of each client enhances their self-esteem and is an important aspect of implementing interventions. Providing privacy and allowing clients to make their own decisions, or doing their own cares when possible, is a way of respecting dignity and increasing self-esteem.

Rationale 2: It is not necessary, nor appropriate, to provide all cares at all times.

Rationale 3: Telling peers and other staff members that a client is demanding is the nurses opinion and should not be part of the reporting process.

Rationale 4: Information should be presented to other family members only with the consent of the client.

Global Rationale: Page Reference: 239

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Discuss the five activities of the implementing phase.

Question 11

Type: MCSA

A nurse has provided routine morning cares to a client, including all the medications and scheduled treatments. The most appropriate action after this is completed is for the nurse to:

1. Move on to the next assignment to increase the nurses efficiency.

2. Report this to the charge nurse.

3. Document all cares in the progress notes.

4. Get supplies organized for the next clients medications and treatments.

Correct Answer: 3

Rationale 1: This option does not describe the appropriate nursing actions that come at the end of client care activities.

Rationale 2: Reporting to the charge nurse would be done at the end of the shift, unless the clients condition is not stable.

Rationale 3: After carrying out the nursing activities, the nurse completes the implementing phase by recording the interventions and client responses in the progress notes.

Rationale 4: This option does not describe the appropriate nursing actions that come at the end of client care activities.

Global Rationale: Page Reference: 239

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Identify guidelines for implementing nursing interventions.

Question 12

Type: MCSA

In order to differentiate between evaluation and assessment, the student should remember that:

1. Assessment is done at the beginning of the process.

2. Evaluation is completed at the end of the process.

3. They are the same and there is no need to differentiate.

4. The difference is in how the data are used.

Correct Answer: 4

Rationale 1: Though assessment is the first phase of the nursing process it is carried out during all phases.

Rationale 2: Evaluation is carried out the process.

Rationale 3: Though the two processes overlap, there is a difference between the data collected.

Rationale 4: Though the two processes overlap, there is a difference between the data collected. Assessment data are collected for the nurse to make a diagnosis and evaluate desired outcomes. Evaluation data are collected for the purpose of comparing them to prescribed goals and judging the effectiveness of the nursing care.

Global Rationale: Page Reference: 239

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 05 Explain how evaluating relates to other phases of the nursing process.

Question 13

Type: MCSA

A client had an outcome goal stated as follows: Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic. Which statement by the client will the nurse use to evaluate this goal?

1. Im getting really sleepy from that medication. I think Ill take a nap.

2. My pain is a 4.

3. I still have some pain.

4. Will the pain ever go away?

Correct Answer: 2

Rationale 1: This option does not address the clients pain level.

Rationale 2: The nurse collects data so that conclusions can be drawn about whether goals have been met. If the goal is clearly stated, precise, and measurable, it will be easy to evaluate. If the goal was a pain level of 3, the client should be able to give a numerical rating to the pain in order for the nurse to evaluate it.

Rationale 3: This option does not clearly define the level of the clients pain so that effectiveness of the treatment is not possible.

Rationale 4: This option does not address the clients pain level.

Global Rationale: Page Reference: 240

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 06 Describe five components of the evaluation process.
08 Describe three components of quality evaluation: structure, process, and outcomes.

Question 14

Type: MCSA

The goal statement for a clients care plan read as follows: Client will be able to state two positive aspects of rehab therapy by the end of the week. Which of the following is an appropriately written evaluation statement?

1. Goal not met, client able to state one positive aspect by the end of the week.

2. Goal met, client able to state one positive aspect by the end of the week.

3. Goal met, client able to state two positive aspects of therapy by weeks end.

4. Goal incomplete, client not able to positively state anything about rehab.

Correct Answer: 3

Rationale 1: If the client can only state one or it takes longer than a week, then the goal could be partially met.

Rationale 2: If the client can only state one or it takes longer than a week, then the goal could be partially met.

Rationale 3: An evaluation statement consists of two parts: a conclusion and supporting data. The conclusion is a statement that the goal/desired outcome was met, partially met, or not met. The supporting data are the list of the client responses that support the conclusion. In this situation, the goal was met if the client was able to state two positive aspects of rehab by the end of the week and the evaluation statement should reveal that.

Rationale 4: Using the word incomplete is not appropriate for the evaluation statement.

Global Rationale: Page Reference: 240

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 08 Describe three components of quality evaluation: structure, process, and outcomes.

Question 15

Type: MCSA

The written goal statement in a clients care plan is: Client will have clear lung sounds bilaterally within 3 days. One of the interventions to meet this goal is that the nurse will teach the client to cough and deep breathe and have the client do this several times every 2 hours. At the end of the third day, the clients lungs are indeed clear. In order to relate the intervention to the outcome, the nurse should:

1. Ask how many times per day the client practiced the coughing and deep breathing exercises.

2. Tell the client that the lungs are clear.

3. Document the assessment findings to show the effectiveness of the intervention.

4. Write this evaluation statement: Goal met, lung sounds clear by third day.

Correct Answer: 1

Rationale 1: Part of the evaluating process is determining whether the nursing activities had any relation to the outcomes. Did the lungs clear because the client actually did the coughing and deep breathing? In order to know for sure, the nurse must collect more data and not assume that this particular nursing intervention had any relation to the outcome.

Rationale 2: Telling the client that his/her lungs are clear is not evrelating intervention to outcome since no mention of the intervention is made.

Rationale 3: Documenting does not show effectiveness of the intervention.

Rationale 4: Writing an evaluation statement does not show effectiveness of the intervention.

Global Rationale: Page Reference: 240

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 05 Explain how evaluating relates to other phases of the nursing process.

Question 16

Type: MCSA

A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was that the clients symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. The nurse should:

1. Keep the problem on the care plan, in case the symptoms return.

2. Document that the problem has been resolved and discontinue the care for the problem.

3. Assume that whatever the cause was, the symptoms may return, but document that the goal was met.

4. Document that the potential problem is being prevented since the symptoms have stopped.

Correct Answer: 2

Rationale 1: In this case, the risk factors no longer exist because the causative factors have stopped. The nurse should document that the goal has been met and discontinue the care for the problem. If the problem returns, it can be implemented again and addressed at that time.

Rationale 2: In this case, the risk factors no longer exist because the causative factors have stopped. The nurse should document that the goal has been met and discontinue the care for the problem. If the problem returns, it can be implemented again and addressed at that time.

Rationale 3: In this case, the risk factors no longer exist because the causative factors have stopped. The nurse should document that the goal has been met and discontinue the care for the problem. If the problem returns, it can be implemented again and addressed at that time.

Rationale 4: In this case, the risk factors no longer exist because the causative factors have stopped. The nurse should document that the goal has been met and discontinue the care for the problem. If the problem returns, it can be implemented again and addressed at that time.

Global Rationale: Page Reference: 241

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 07 Describe the steps involved in reviewing and modifying the clients care plan.

Question 17

Type: MCSA

A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is as follows: Client will be free of pain within 48 hours. As an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What is the flaw in this plan?

1. The goal statement is written inaccurately.

2. The interventions are dependent of nursing.

3. The goal is unrealistic.

4. The interventions are not clear enough.

Correct Answer: 3

Rationale 1: The goal statement is written accurately inclusive of all required components.

Rationale 2: Dependent interventions would be appropriate in this situation.

Rationale 3: When a care plan needs to be modified, discontinued, or changed in some manner, several decisions need to be made. If the nursing diagnosis is accurate, as it is in this case, the nurse should check to see if the goals are attainable and realisticthe flaw in this plan. A client with terminal cancer is not going to be pain-free, regardless of the amount of medication delivered. To think otherwise is inappropriate.

Rationale 4: The interventions are clearly written.

Global Rationale: Page Reference: 240

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 04 Identify guidelines for implementing nursing interventions.

Question 18

Type: MCSA

A teenage client has been having problems with peer support, school performance, and parental expectations, all of which have led to an eating disorder. After gathering this assessment data, the nurse formulate the diagnosisActivity Intolerance related to weakness. After evaluating this information, the nurse should realize which of the following?

1. The data collected would support the diagnosis.

2. The diagnosis is directly related to the data presented.

3. The nursing diagnosis is not relevant to the data.

4. The data are not sufficient enough to support this diagnosis.

Correct Answer: 4

Rationale 1: Perhaps this diagnosis is appropriate for this client, but there are not enough data presented to know that for sure.

Rationale 2: Once data are complete, the diagnosis and information need to be directly related to each other.

Rationale 3: Once data are complete, the diagnosis and information need to be relevant to each other.

Rationale 4: An incomplete database influences all steps of the nursing process and care plan. The nurse must complete the assessment before formulating a diagnosis about weakness and fatigue. Perhaps this diagnosis is appropriate for this client, but there are not enough data presented to know that for sure.

Global Rationale: Page Reference: 236-239

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 04 Identify guidelines for implementing nursing interventions.

Question 19

Type: MCSA

A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of Risk for Falls related to unsteady gait, secondary to neurologic dysfunction has been formulated. A goal for this client is not to sustain any injuries for the next month. The client however, has fallen several times. In this situation, the nurse should do which of the following?

1. Review the data and make sure that the diagnosis is relevant.

2. Investigate whether the best nursing interventions were selected.

3. Modify the whole nursing plan.

4. Discard the nursing plan and start over from the assessment phase.

Correct Answer: 2

Rationale 1: The data presented are relevant for the diagnosis selected in this case.

Rationale 2: Even if all sections of the care plan appear to be satisfactory, the manner in which the plan was implemented may have interfered with goal achievement. The nurse needs to check and see if the interventions were appropriate for the client. If the interventions selected did not help the client achieve the goal, then rearranging or implementing new ones may be necessary.

Rationale 3: The data presented are relevant for the diagnosis selected in this case, and it is not necessary to modify the whole plan.

Rationale 4: The data presented are relevant for the diagnosis selected in this case, and it is not necessary to discard the whole plan and start over. Modifications may be the key to a successful outcome for the client.

Global Rationale: Page Reference: 241

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 07 Describe the steps involved in reviewing and modifying the clients care plan.

Question 20

Type: MCSA

A nurse manager has been charged with implementing a quality assurance program at the hospital. Quality assurance requires evaluation of several components of care. Select those that apply:

1. Methods

2. Structure

3. Finances

4. Process

5. Outcome

Correct Answer: 2,4,5

Rationale 1: Quality assurance is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. It requires evaluation of three consistent components of care. Each type of evaluation requires different criteria and methods.

Rationale 2: Quality assurance is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. It requires evaluation of three components of care: with structure being one of them.

Rationale 3: Quality assurance is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. It requires evaluation of three components of care; finance is not one of them.

Rationale 4: Quality assurance is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. It requires evaluation of three components of care with process Being one of them.

Rationale 5: Quality assurance is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. It requires evaluation of three components of care with outcome being one of them.

Global Rationale: Page Reference: 243

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 08 Describe three components of quality evaluation: structure, process, and outcomes.

Question 21

Type: MCSA

A nursing unit has been short staffed for the past month with a heavy client load and high acuity. The nurses on this unit have been working extra as well as double shifts and often do not have time to make sure that properly working equipment is cleaned, returned, and stored in the appropriate areas. This unit should be evaluated at which level?

1. Management

2. Structure

3. Process

4. Outcome

Correct Answer: 2

Rationale 1: Management is not one of the three components of quality assurance evaluation.

Rationale 2: Structure evaluation focuses on the setting in which care is given. Structural standards describe desirable environmental and organizational characteristics that influence care, such as equipment and staffing. Process evaluation focuses on how the care was given.

Rationale 3: Process evaluation focuses on how the care was given.

Rationale 4: Outcome evaluation focuses on demonstrable changes in the clients health status as a result of nursing care.

Global Rationale: Page Reference: 243

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 08 Describe three components of quality evaluation: structure, process, and outcomes.

Question 22

Type: MCSA

A nursing unit has had a large number of negative client responses about various aspects of their care in the previous quarter. The quality assurance officer is evaluating this unit, paying particular attention to which of the components of care?

1. Competency

2. Structure

3. Process

4. Outcome

Correct Answer: 3

Rationale 1: Process evaluation focuses on how the care was given. Is the care relevant to the clients needs? Is it appropriate, complete, and timely? Process standards focus on the manner in which the nurse uses the nursing process. Competency is not one of the components of quality assurance evaluation. Structure evaluation focuses on the setting in which the care is given. Outcome evaluation focuses on demonstrable changes in the clients health status as a result of nursing care.

Rationale 2: Process evaluation focuses on how the care was given. Is the care relevant to the clients needs? Is it appropriate, complete, and timely? Process standards focus on the manner in which the nurse uses the nursing process. Competency is not one of the components of quality assurance evaluation. Structure evaluation focuses on the setting in which the care is given. Outcome evaluation focuses on demonstrable changes in the clients health status as a result of nursing care.

Rationale 3: Process evaluation focuses on how the care was given. Is the care relevant to the clients needs? Is it appropriate, complete, and timely? Process standards focus on the manner in which the nurse uses the nursing process. Competency is not one of the components of quality assurance evaluation. Structure evaluation focuses on the setting in which the care is given. Outcome evaluation focuses on demonstrable changes in the clients health status as a result of nursing care.

Rationale 4: Process evaluation focuses on how the care was given. Is the care relevant to the clients needs? Is it appropriate, complete, and timely? Process standards focus on the manner in which the nurse uses the nursing process. Competency is not one of the components of quality assurance evaluation. Structure evaluation focuses on the setting in which the care is given. Outcome evaluation focuses on demonstrable changes in the clients health status as a result of nursing care.

Global Rationale: Page Reference: 243

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 08 Describe three components of quality evaluation: structure, process, and outcomes.

Question 23

Type: MCSA

A nursing units records of client care have been reviewed for accuracy in documentation. This type of review is which of the following?

1. Nursing audit

2. Peer review

3. Individual audit

4. Concurrent audit

Correct Answer: 1

Rationale 1: An audit is an examination or review of records. A nursing audit is a type of peer review that focuses on evaluating nursing care through the review of records. The success of these audits depends on accurate documentation. Peer review is a type of evaluation where nurses functioning in the same capacity perform the audit. Peer review is based on preestablished standards or criteria. An individual audit focuses on the performance of an individual nurse. Concurrent audits are reviews of a clients health care and occur while the client is still receiving the care.

Rationale 2: An audit is an examination or review of records. A nursing audit is a type of peer review that focuses on evaluating nursing care through the review of records. The success of these audits depends on accurate documentation. Peer review is a type of evaluation where nurses functioning in the same capacity perform the audit. Peer review is based on preestablished standards or criteria. An individual audit focuses on the performance of an individual nurse. Concurrent audits are reviews of a clients health care and occur while the client is still receiving the care.

Rationale 3: An audit is an examination or review of records. A nursing audit is a type of peer review that focuses on evaluating nursing care through the review of records. The success of these audits depends on accurate documentation. Peer review is a type of evaluation where nurses functioning in the same capacity perform the audit. Peer review is based on preestablished standards or criteria. An individual audit focuses on the performance of an individual nurse. Concurrent audits are reviews of a clients health care and occur while the client is still receiving the care.

Rationale 4: An audit is an examination or review of records. A nursing audit is a type of peer review that focuses on evaluating nursing care through the review of records. The success of these audits depends on accurate documentation. Peer review is a type of evaluation where nurses functioning in the same capacity perform the audit. Peer review is based on preestablished standards or criteria. An individual audit focuses on the performance of an individual nurse. Concurrent audits are reviews of a clients health care and occur while the client is still receiving the care.

Global Rationale: Page Reference: 244

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 07 Describe the steps involved in reviewing and modifying the clients care plan.

Question 24

Type: MCSA

A nurse has taken a position with an insurance company to review clients records and the care they received while they were inpatient status. Part of the job description requires the nurse to make sure the client (and insurance company) were billed for services and treatment/therapies rendered and that there were no errors in billing. This type of audit is which of the following?

1. Concurrent

2. Peer review

3. Nursing audit

4. Retrospective

Correct Answer: 4

Rationale 1: Concurrent audit is the evaluation of a clients health care while the client is still receiving the care from an agency.

Rationale 2: A nursing audit is a type of peer review, in which the audit focuses on evaluating a specific nurses nursing care through the review of records.

Rationale 3: A nursing audit is a type of peer review, in which the audit focuses on evaluating a specific nurses nursing care through the review of records.

Rationale 4: A retrospective audit is the evaluation of a clients record after discharge from an agency. The word retrospective means relating to the past. If the nurse is reviewing records after the client has been discharged, the information being examined is in the past.

Global Rationale: Page Reference: 244

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 09 Differentiate quality improvement from quality assurance.

Question 25

Type: MCSA

A nurse is working on a medical unit, and assigns a nurses aide to take vital signs for several clients. The aide completes this task and documents them accordingly. One of the clients had a blood pressure reading of 180/110, and it wasnt until the end of the shift that the nurse was apprised of this value. The physician was notified, and orders were received for treatment, but not until much later in the shift. Which responsibility of delegation did the nurse fail to carry out?

1. Delegating to the appropriate staff.

2. Delegating the appropriate task.

3. Selecting the appropriate client.

4. Appropriately supervising care.

Correct Answer: 4

Rationale 1: The nurse did delegate to the appropriate staff, since securing vital signs is within the scope of practice for a nurses aide.

Rationale 2: The nurse did delegate an appropriate task, since securing vital signs is within the scope of practice for a nurses aide.

Rationale 3: There was no indication given that the clients were not appropriately selected for this task.

Rationale 4: The nurse has two responsibilities in delegating and assigning duties: (1) appropriate delegation of duties (that is, giving people duties within their scope of practice) and (2) adequate supervision of personnel to whom work is delegated or assigned. In this situation, the nurse gave an unlicensed person a duty that was appropriate. The aide completed the duty and documented the findings. The nurse is still responsible for analyzing data, planning care, and evaluating outcomes. In this case, the nurse failed to follow up (supervise) after the duty was performed and analyze the findings.

Global Rationale: Page Reference: 237-238

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Identify guidelines for implementing nursing interventions.

Question 26

Type: MCMA

During the process of implementing care and treatments for a client, the nurse realizes there are several entities included in which phase?

Standard Text: Select all that apply.

1. Evaluating the outcome of the interventions.

2. Reassessing the client.

3. Documenting the history and physical.

4. Supervising delegated care.

5. Implementing the nursing intervention.

Correct Answer: 2,4,5

Rationale 1: Evaluating the outcome of the interventions is part of the evaluation phase.

Rationale 2: This is a component of the implementation process.

Rationale 3: Documentation of the history and physical is part of the initial assessment.

Rationale 4: This is a component of the implementation process.

Rationale 5: This is a component of the implementation process.

Global Rationale: Page Reference: 237

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Discuss the five activities of the implementing phase.
04 Identify guidelines for implementing nursing interventions

Question 27

Type: MCMA

After implementing interventions and reassessing the clients response, the nurse completes the process by evaluating. Evaluation includes which of the following attributes?

Standard Text: Select all that apply.

1. Purposeful activity.

2. Nursing accountability.

3. Continuous.

4. Judgments.

5. Opinion.

Correct Answer: 1,2,3,4

Rationale 1: Evaluating is a planned, ongoing, purposeful activity in which clients and healthcare professionals determine the clients progress toward achievement of goals/outcomes and the effectiveness of the nursing care plan.

Rationale 2: Through evaluating, nurses demonstrate responsibility and accountability for their actions.

Rationale 3: Evaluation is continuous, and done while or immediately after implementing a nursing order.

Rationale 4: To evaluate is to judge or appraise. Through evaluation, the nurse is able to establish whether nursing interventions should be terminated, continued, or changed.

Rationale 5: Evaluation does not rest on opinion.

Global Rationale: Page Reference: 239

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 06 Describe five components of the evaluation process.

Question 28

Type: MCMA

The nurse shows an understanding of the relationship of evaluation to the other phases of the nursing process when:

Standard Text: Select all that apply.

1. Being careful to effectively assess the clients needs.

2. Selecting the appropriate nursing diagnosis related to the clients needs.

3. Collecting client-focused data with a specific need in mind.

4. Evaluating by using assessment data to determine effective achievement of goals and outcomes.

5. Basing evaluation on assessment data collected during the admission phase.

Correct Answer: 1,2,3,4

Rationale 1: Successful evaluation depends on the effectiveness of the steps that precede it. Assessment data must be accurate and complete so that the nurse can proceed with the nursing process.

Rationale 2: Successful evaluation depends on the effectiveness of the steps that precede it so that the nurse can formulate appropriate nursing diagnoses.

Rationale 3: Data are collected for different purposes at different points in the nursing process.

Rationale 4: During the evaluation step, the nurse collects data for the purpose of comparing it with preselected goals/outcomes and judging the effectiveness of the nursing care.

Rationale 5: During the assessment phase, the nurse collects data for the purpose of making diagnoses.

Global Rationale: Page Reference: 239

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 01 Explain how implementing relates to other phases of the nursing process.

Question 29

Type: MCMA

When assessment data show a change in the clients condition, the nursebefore changing the care planasks:

Standard Text: Select all that apply.

1. How difficult will it be to change the care plan?

2. Are the new data complete?

3. Are the new data accurate?

4. Do the new data require a change in the care plan?

5. Will the primary medical provider agree with the need to alter the care plan?

Correct Answer: 2,3,4

Rationale 1: The degree of difficulty in changing the care plan is not a consideration for its change.

Rationale 2: This condition must be met before consideration is given to altering a clients care plan.

Rationale 3: This condition must be met before consideration is given to altering a clients care plan.

Rationale 4: This condition must be met before consideration is given to altering a clients care plan.

Rationale 5: The medical provider is generally not involved in the formation or alteration of a nursing care plan.

Global Rationale: Page Reference: 241

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 07 Describe the steps involved in reviewing and modifying the clients care plan.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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