ATI RN MATERNAL NEWBORN PROCTORED EXAM 2020 with [ALL CORRECT SOLUTIONS]

1. A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient’s responses to nursing care? (Select all that apply.) a. Observations of wound healing b. Daily blood pressure measurements c. Findings of respiratory rate and depth d. Completion of nursing interventions e. Patient’s subjective report of feelings about a new diagnosis of cancer ANS: A, B, C, E You examine the results of care by using evaluative measures, which are assessment skills and techniques (e.g., observations, physiological measurements, use of measurement scales, and patient interview). Examples of evaluative measures include assessment of wound healing and respiratory status, blood pressure measurement, and assessment of patient feelings. You conduct evaluative measures to determine if your patients met expected outcomes, not if nursing interventions were completed. 2. Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.) a. Set priorities for patient care. b. Determine whether outcomes or standards are met. c. Ambulate patient 25 feet in the hallway. d. Document results of goal achievement. e. Use self-reflection and correct errors. ANS: B, D, E The expected outcomes established during planning are the standards against which you judge whether goals have been met and if care is successful. You evaluate whether the results of care match the expected outcomes and goals set for a patient. Documentation and reporting are important parts of evaluation because it is crucial to share information about a patient’s progress and current status. Using self-reflection and correcting errors are indicators a nurse is performing evaluation. Setting priorities is part of planning, and ambulating with a patient in the hallway is an intervention, so it is included in the implementation step of the nursing process. 1. A nurse encounters a family who experienced the death of their adult child last year. The parents are talking about the upcoming anniversary of their child’s death. The nurse spends time with them discussing their child’s life and death. Which nursing principle does the nurse’s action best demonstrate? a. Facilitation of normal mourning b. Pain-management technique c. Grief evaluation d. Palliative care ANS: A Anniversary reactions can reopen grief processes. A nurse should openly acknowledge the loss and talk about the common renewal of grief feeling around the anniversary of the individual’s death; this facilitates normal 1mourning. The nurse is not attempting to alleviate a physical pain. The actions are of open communication, not evaluation. Palliative care refers to comfort measures for symptom relief.