Fundamentals Nursing Vol 1 3rd Edition Wilkinson Treas Test Bank

Fundamentals Nursing Vol 1 3rd Edition Wilkinson Treas Test Bank
Fundamentals Nursing Vol 1 3rd Edition Wilkinson

Treas Test Bank
To download the complete and accurate content document, go to:

https://testbankbell.com/download/fundamentals-nursing-vol-1-3rd-edition-wilkinson-tr
eas-test-bank/
Visit TestBankBell.com to get complete for all chapters

Chapter 7. Nursing Process: Implementation & Evaluation
MULTIPLE CHOICE
1. A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This
medication is unfamiliar to the nurse, and she cannot find it in the hospital formulary or other
references. How should she proceed?
a. Administer the medication as ordered.
b. Hold the medication and notify the prescriber.
c. Consult with a pharmacist before administering it.
d. Ask the patient’s RN for information about the medication.
ANS: C
The nurse must recognize when she does not have the knowledge or skill needed to implement
an order. Because the nurse is unfamiliar with the medication, that does not mean she should
hold it and delay patient treatment. It is wisest to first consult with the pharmacist for
information before administering the medication to ensure safe practice. Administering the
medication as ordered, without knowing its expected actions and side effects, at the least
prevents adequate reassessment; at the most, it is dangerous. Holding the medication and
notifying the prescriber prevents the client from receiving timely treatment—many drugs are
less effective if a consistent schedule is not maintained. Asking another nurse to administer
the medication is also unsafe because it cannot be assumed that the other nurse has the correct
knowledge. In addition, the nurse caring for the client must assess for adverse reactions to the
medication.
Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
Page 122
PTS: 1
2. Which task can be delegated to nursing assistive personnel (NAP)?

a. Turn and reposition the patient every 2 hours.
b. Assess the patient’s skin condition.
c. Change pressure ulcer dressings every shift.
d. Apply hydrocolloid dressing to the pressure ulcer.
ANS: A
The nurse can delegate turning the client every 2 hours to the nursing assistive personnel.
Assessing the client’s skin condition, changing pressure ulcer dressings, and applying a
hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge
and judgment.
Cognitive Level: Application
Pages 126-127
PTS: 1
3. A physician orders an indwelling urinary catheter for a client who is mildly confused and has
been combative. How should the nurse proceed?
a. Ask a colleague for help, because the nurse cannot safely perform the procedure
alone.
b. Gather the equipment and prepare it before informing the client about the
procedure.
c. Obtain an order to restrain the client before inserting the urinary catheter.
d. Inform the primary provider that the nurse cannot perform the procedure because
the client is confused.
ANS: A
Before the nurse begins a procedure, she should review the care plan and look at the orders
critically. Because this client is confused, she should ask a colleague to assist with the
procedure to prevent undue stress for the client and nurse. The client should be informed
about the procedure before the nurse gathers the equipment. Gathering the equipment and
bringing it into the room before explaining the procedure might cause the client anxiety.
Restraining the client should be done only as a last resort and to prevent client injury.
Informing the primary provider that the procedure cannot be performed because the client is
confused is inappropriate because the procedure can very likely be done with assistance.
Pages 122-124
PTS: 1
4. Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client
requires which type of nursing skill?
a. Psychomotor
b. Interpersonal
c. Cognitive
d. Critical thinking
ANS: B
Reassuring the client is an interpersonal skill. Inserting the nasogastric tube requires
psychomotor skills. Checking catheter placement after insertion requires cognitive and
psychomotor skills. Assessing whether there is an indication for the nasogastric tube requires
critical thinking skills.
Client Need: PHI
Cognitive Level: Comprehension
Page 133
PTS: 1
5. The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus.
Which intervention by the nurse best promotes client cooperation with the treatment plan?
a. Teaching the client that he must lose weight to control his blood sugar
b. Informing the client that he must exercise at least three times per week
c. Explaining to the client that he must come to the diabetic clinic weekly
d. Determining the client’s main concerns about his diabetes
ANS: D
Determining the client’s main concerns promotes cooperation with the treatment regimen. For
example, if the client is concerned about paying for diabetic monitoring equipment, he may
disregard any teaching about the procedure. Although it is often important for a diabetic client
to exercise and lose weight to control blood sugar levels, the client must want to do both. He
will not exercise or lose weight simply because he is told to do so. The nurse must assess the
client’s support systems and resources, not merely tell him he must come to the diabetic clinic
weekly. Some clients do not have access to transportation and, therefore, could not come to
the clinic without social service intervention. Remember that knowledge does not necessarily
change behavior.
Nursing Process: Planning Interventions
Client Need: PHSI
Page 125
PTS: 1
6. Which statement accurately describes delegation?

a. Transferring authority to another person to perform a task in a selected situation
b. Collaborating with other caregivers to make decisions and plan care
c. Scheduling treatments and activities with other departments
d. Performing a planned intervention from a critical pathway
ANS: A
Delegation is the transfer to another person of the authority to perform a task in a selected
situation—the person delegating retains accountability for the outcome of the activity.
Collaboration is described as working with other caregivers to plan, make decisions, and
perform interventions. Coordination of care involves scheduling treatments and activities with
other departments. Implementation is the process of performing planned interventions.
Difficulty: Easy
Cognitive Level: Knowledge
Page 126
PTS: 1
7. Which statement by the nurse best demonstrates clear communication to nursing assistive
personnel (NAP) about delegating a task?
a. “Record how the patient’s intake and output of fluids, please”
b. “Take the patient’s temperature, pulse, respirations, and blood pressure every 2
hours today.”
c. “Take the patient’s temperature every 4 hours; notify me if it is greater than
100.5°F (38.1°C).”
d. “Assist the patient with all of her meals so she will take in more calories.”
ANS: C
Clear communication about a task (such as “Take the patient’s temperature . . . ”) tells the
NAP exactly what the task is, the specific time at which it needs to be done, and the method
for reporting the results to the registered nurse. The other options are vague and leave room
for misinterpretation.
Pages 126-127
PTS: 1
8. Who is responsible for evaluating the outcome of a task delegated to the nursing assistive
personnel (NAP)?
a. Nurse who delegated the task
b. LPN working with the NAP
c. Unit nurse manager
d. Charge nurse for the shift
ANS: A
The nurse who delegates the task is responsible for supervising and evaluating the outcomes
of tasks performed by the NAP. Another registered nurse, such as a staff nurse, nurse
manager, or charge nurse, can answer questions and provide help, if necessary.
Difficulty: Easy
Pages 126-127
PTS: 1
9. Which criterion might be used in structure evaluation?

a. “Staff refrains from sharing computer passwords.”
b. “Healthcare provider washes hands with each client contact.”
c. “A defibrillator is present on each client care area.”
d. “Nurse verifies client identification before initiating care.”
ANS: C
The criterion that states “A defibrillator is present on each client care area” is associated with
structure evaluation. “Refrains from sharing computer passwords,” “Washes hands before
each client contact,” and “Verifies client identification before initiating care” are criteria
associated with process evaluation.
Nursing Process: Evaluation
Pages 130-132
PTS: 1
10. Which of the following is a client outcome criterion?

a. Central venous catheter site infection does not occur (90% of cases).
b. Client will sit out of bed in the chair for 20 minutes three times per day.
c. Postoperative phlebitis does not occur (95% of cases).
d. Falls in the facility will reduce by 2% this quarter.
ANS: B
A client outcome criterion states the client health status or behaviors one wishes to effect.
“Client will sit out of bed . . .” is a client outcome criterion. The other options are examples of
organizational criteria used to evaluate the quality of care throughout the institution.
Pages 130-131
PTS: 1
11. When should the nurse collect evaluation data for this expected outcome? “Patient will
maintain urine output of at least 30 mL/hour.”
a. At the end of the shift
b. Every 24 hours
c. Every 4 hours
d. Every hour
ANS: D
The nurse should collect evaluation data as defined in the expected outcome. For instance, in
this case, the nurse would check the patient’s urine output every hour because the goal
statement specifies an hourly rate (30 mL/hour). The unit of measurement in the goal guides
how often the nurse would reassess the patient.
Difficulty: Easy
Client Need: PHSI
Pages 131-132
PTS: 1
12. Which type of client-centered evaluation is performed at specific, scheduled times?

a. Intermittent
b. Ongoing
c. Terminal
d. Process
ANS: A
Intermittent evaluation is performed at specific times; it enables the nurse to judge the
progress toward goal achievement and to modify the plan of care as needed. Ongoing
evaluation is performed while implementing, immediately after an intervention, or with each
client contact; these are not necessarily scheduled events. Terminal evaluation is performed at
the time of discharge. It describes the client’s health status and progress toward goals at that
time. Process evaluation focuses on the manner in which care is given. It may be performed at
specific times, but it is not considered a client-centered evaluation.
Difficulty: Easy
Pages 130-131
PTS: 1
13. Which of the following is the most valid criterion for determining the status of a patient’s
anxiety at discharge? The patient:
a. Has a relaxed facial expression
b. Reports that he feels more relaxed today
c. Shows no physiological signs of anxiety (e.g., pallor)
d. Asks no further questions about home care
ANS: B
A criterion is considered valid when it measures what it is intended to measure. Because
anxiety is subjective (perceived by the patient), the best measure of anxiety is what the patient
says about it. A relaxed facial expression and other physiological signs might or might not
show the level of anxiety. Relaxation might occur, for example, because the patient is sleeping
or falling asleep. The fact that a patient is not asking questions about his surgery could mean
that he has adequate knowledge about the topic; it would not indicate the presence or absence
of anxiety. All of the options except what the patient states could be measuring something
other than anxiety.
Difficulty: Difficult
Client Need: PSI
Pages 131-132
PTS: 1
14. The nurse works with the respiratory therapist to administer a patient’s breathing treatments.
He reports the patient’s breathing status and tolerance of the treatment to the primary care
provider. The nurse then discusses with the patient the options for further treatment. This is an
example of:
a. Delegation
b. Collaboration
c. Coordination of care
d. Supervision of care
ANS: B
Collaboration means working with other caregivers to plan, make decisions, and perform
interventions. Delegation is the transfer to another person of the authority to perform a task in
a selected situation. Coordination of care involves scheduling treatments and activities with
other departments, putting together all the patient data to obtain “the big picture.” Supervision
is the process of directing, guiding, and influencing the outcome of an individual’s
performance of an activity or task.
Page 125
PTS: 1
15. The nurse reviews the patient chart and sees a physician prescription for a new medication.
The nurse is able to clearly read the medication name but the dose is not legible. What is the
best action by the nurse?
a. Contact the physician for clarification.
b. Ask another nurse to read the order.
c. Ask the unit secretary to read the order.
d. Contact the pharmacist to read the order.
ANS: A
As a nurse, you are obligated ethically and legally to clarify or question orders that you
believe to be unclear, incorrect, or inappropriate. In this case, the nurse should contact the
physician to clarify the order, as it is not legible. It is inappropriate to ask the secretary or
another nurse to read the order as they may read it incorrectly.
Page 122
PTS: 1
16. The second-year nursing student is in her clinical rotation on a medical-surgical unit. What is
the most appropriate strategy that the student can use to assist her in organizing and
prioritizing patient care for the day?
a. Ask the nurse what tasks need to be completed for the day
b. Make a time-sequenced “to do” list for her activities for the day
c. Ask the instructor what needs to be completed for the day
d. Ask the patient what needs to be completed for the day
ANS: B
Because a nurse will be providing care for more than one patient on each shift, it is important
to make a time-sequenced work plan or work sheet to prioritize patient care for the day. Many
institutions have forms that can be used or one may need to write his/her own list of “things to
do” in the order of need of completion. This is the best strategy this student can use. Asking
the nurse or instructor will not assist the student in developing her own strategy for the future
or in staying organized throughout the day. The patient is not a reliable source as not every
patient is aware of what needs to be “completed” for the day.
Pages 122-123
PTS: 1
17. The nurse is preparing to insert a Foley catheter for her patient. What is the best strategy for
the nurse to use to perform this insertion in a timely and efficient manner?
a. Call another nurse to assist with the procedure
b. Gather all supplies and equipment before entering the patient room
c. Instruct and explain the procedure to the patient
d. Check the patient’s schedule for the day for the most convenient time
ANS: B
Gathering all the supplies and equipment before entering a patient’s room is the best strategy
to ensure that work is completed in an efficient and timely manner. This strategy will also
help in preventing stress to the patient that may occur when a nurse is interrupted by needing
to go to a supply room to get a needed item. Healthcare resources are scarce and staffing may
not be conducive or feasible in having extra personnel available. Instructing and explaining a
procedure to a patient is good practice and usually completed prior to any procedure for the
purpose of patient cooperation and understanding. This is will not usually assist the nurse in
completing a procedure in an efficient and timely manner.
Page 122
PTS: 1
18. The nurse reviews a nursing order for a patient who is 4 days post-operative after hip surgery.
It reads: Assist patient in bathing each morning. The nurse assesses the patient and notes that
the patient is independent in bathing. What should the nurse do next?
a. Assist with the bath as ordered
b. Delegate the bath to the nursing assistant
c. Discontinue the nursing order on the plan of care
d. Collaborate with the nurse who originally wrote the order
ANS: C
After assessing and evaluating patient progress, the nurse will use her conclusions about goal
achievement to decide whether to continue, modify, or discontinue the nursing order on the
plan of care. In this item, the nurse has assessed patient independence and therefore can
discontinue this nursing order from the plan of care.
Client Need: PHI
Page 134
PTS: 1
19. Which of the following is the best example of the implementation phase of the nursing
process?
a. Patient verbalizes pain is reduced from an 8 to a 3 after receiving pain medication.
b. Nurse observes that patient has a small, quarter-sized skin tear over coccyx area.
c. Nurse writes in the care plan: Patient requires 2 person assist with ambulation to
bathroom.
d. Nurse inserts Foley catheter after reporting to physician patient’s inability to void.
ANS: D
Implementation is the action phase of the nursing process. It involves thinking but the
emphasis is on doing. During implementation, the nurse will perform or delegate planned
interventions. In short, implementation is doing, delegating, and documenting. A patient
verbalizing that pain is reduced after receiving pain medication is part of the evaluation phase.
Observing or noticing a skin tear relates to assessment and evaluation of skin condition.
Writing on the care plan of a patient requiring assistance to the bathroom is an example of
assessment and planning.
PTS: 1
20. The certified nursing assistant (CNA) is feeding a patient and notes that the patient is having
difficulty swallowing. She reports this to the primary registered nurse. What should the nurse
do first?
a. Assign the task to a more experienced CNA
b. Feed the patient herself
c. Assess the patient and place on NPO status
d. Call the primary care provider
ANS: C
Feeding a patient is a delegatable task that a CNA can perform. However, once it is reported
to the registered nurse that the patient is having difficulty swallowing, this becomes a safety
issue that the registered nurse must address. This circumstance is then no longer delegatable
for any CNA regardless of experience. The first action by the nurse is to assess the patient and
place the patient on NPO status until a primary provider is notified for further orders.
Page 127
PTS: 1
21. Which of the following nursing activities is most reflective of the evaluation phase of the
nursing process?
a. Administering pain medication prior to changing a complex wound dressing
b. Obtaining patient’s blood pressure 30 minutes after administering blood pressure
medication
c. Reporting that there have been three patient falls in the past month on the nursing
unit
d. Teaching the patient how to perform daily Accu-Cheks for blood sugar readings
ANS: B
Evaluation is the final step of the nursing process. It is a planned, ongoing, systematic activity
in which a nurse will make judgments about patient progress toward desired health outcomes,
effectiveness of the nursing care plan, and the quality of nursing care in the healthcare setting.
Evaluation data are collected after interventions are performed to determine whether patient
goals were achieved. In this item, obtaining a patient’s blood pressure after administering
blood pressure medications evaluates the patient’s response to the medication. Administering
pain medication prior to performing a dressing change is an intervention, as is teaching a
patient to perform an Accu-Chek. Reporting patient falls is part of the assessment process.
Page 132
PTS: 1
MULTIPLE RESPONSE
1. The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the
medical-surgical floor. For which of the following patients can the nurse delegate to the NAP
the task of bathing? Select all that apply.
a. 75-year-old patient newly admitted with dehydration
b. 65-year-old patient hospitalized for a stroke, whose blood pressure reading is
189/90 mm Hg
c. 92-year-old patient with stable vital signs who was admitted with a urinary tract
infection
d. 56-year-old patient with chronic renal failure who has vital signs within his normal
range
ANS: A, C, D
The nurse should not delegate bathing of a client newly diagnosed with a stroke whose blood
pressure is unstable or otherwise abnormal. This client requires the keen assessment and
critical thinking skills of a registered nurse. The nurse can safely delegate the care of stable
clients, such as the client admitted with dehydration, the client admitted with a urinary tract
infection, or the client with chronic renal failure. Any client who is very ill or who requires
complex decision making should be cared for by a registered nurse.
Pages 126-127
PTS: 1
2. Which of the following is the most appropriate task(s) to be delegated to the licensed practical
nurse (LPN)? Select all that apply.
a. Administer oral pain medications
b. Insert an indwelling (e.g., Foley) catheter
c. Perform an admission assessment on a new patient
d. Establish a new teaching plan for a diabetic patient
ANS: A, B
The licensed practical nurse (LPN) can administer oral medications and insert a Foley
catheter. LPNs can usually provide care to medically stable patients according to an
established plan of care; they can give you feedback about patient responses for patients who
are expected to respond predictably. Tasks you can usually assign to an LPN include
administering some medications and oral medications, and in some instances, starting an IV
infusion and administering plain IV solutions. Some tasks that cannot be delegated include
creating or modifying nursing care plans. Performing an admission assessment on a newly
admitted patient and establishing a teaching plan are usually the responsibility of the
registered nurse, as these tasks requires professional nursing judgment and critical thinking.
Nursing Process: Planning Implementation
Pages 126-127
PTS: 1
3. The nurse has just completed wound care on her patient who has a large abdominal wound.
What should the nurse do soon after this is completed? Select all that apply.
a. Assess the patient’s response to the procedure
b. Teach the patient about the procedure
c. Document the procedure in the nursing progress notes
Fundamentals Nursing Vol 1 3rd Edition Wilkinson Treas Test Bank
d. Ask the patient to assist in the wound care at the next scheduled dressing change
ANS: A, C
After giving care, the nurse needs to assess and record the nursing activities and the patient’s
responses. This is the final step in the implementation process. Documentation is a mode of
communication among the members of the health team, so it needs to be done soon after
finishing the procedure. It provides the information the nurse needs to evaluate the patient’s
health status and nursing care plan. The implementation phase ends when the nurse
documents the nursing actions and evolves into evaluation as the nurse documents patient
responses to the interventions. Teaching the patient and asking the patient to assist in wound
care as a part of that teaching do not need to be done right away.
Page 128
PTS: 1
Visit TestBankBell.com to get complete for all chapters

Fundamentals Nursing Vol 1 3rd Edition Wilkinson Treas Test Bank

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Fundamentals Nursing Vol 1 3rd Edition Wilkinson Treas Test Bank

Uploaded by

Copyright:

Available Formats

Fundamentals Nursing Vol 1 3rd Edition Wilkinson Treas Test Bank

Fundamentals Nursing Vol 1 3rd Edition Wilkinson

To download the complete and accurate content document, go to:

Visit TestBankBell.com to get complete for all chapters

2. Which task can be delegated to nursing assistive personnel (NAP)?

6. Which statement accurately describes delegation?

9. Which criterion might be used in structure evaluation?

10. Which of the following is a client outcome criterion?

12. Which type of client-centered evaluation is performed at specific, scheduled times?

Visit TestBankBell.com to get complete for all chapters

You might also like