C HAPTER 06: I MPLEMENTATION AND
E VALUATION
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. An example of an appropriatel y worded nursing goal or outcome for the
nursing diagnosis of “Risk for falls related t o weakness” would be:
a. nurse will assist the patient to the bathroom every 2 hours.
b. patient will be free of injury from falls.
c. patient will call for assistance when ambulating for the next week.
d. nurse will keep room well lit 24 hours a day.
ANS: C
An appropriatel y worded outcome is a patient centered, measurable,
and time defined goal based on a nursing diagnosis.
DIF: Cognitive Level: Application REF: p. 79|Box 6 -3
OBJ: Theory #5 TOP: Expected Outcomes KEY:
Nursing Process Step: Evaluation MSC: NCLEX:
Physiological Integrity: Basic Care and Comfort
2. Nurses design interventions that are appropriate for a patient that are:
a. based on the primary care provider’s orders and the medical
diagnosis.
, b. expected to help the patient meets the goals most quick l y.
c. used to evaluate whether the nursing care plan should be revised.
d. based on cost effectiveness and staff availabilit y.
ANS: B
Nursing interventions are based on nursing diagnoses and are those
most likel y to assist the patient in meeting outcomes related to those
diagnoses.
DIF: Cognitive Level: Comprehension REF: p. 79|Box 6 -3
OBJ: Theory #2 TOP: Care Delivery KEY: Nursing
Process Step: Planning MSC: NCLEX: Safe, Effective
Care Environment: Coordinated Care
3. Before performing a cathete rization, the inexperienced nurse should:
a. close the door or curtains to provide the patient with privacy.
b. provide necessary education and explanation of the procedure to the
patient.
c. observe rules of Standard Precautions to protect herself from
exposure to blood or body fluids.
d. review the agency’s procedure manual for the accepted way of
performing the procedure.
ANS: D
Reviewing the procedure manual should occur before the inexperienced
nurse explains to the patient, provides privacy, or observes Standar d
Precautions.
, DIF: Cognitive Level: Application REF: p. 75 OBJ:
Clinical Practice #2 TOP: Standards for All Nursing
Procedures KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrit y: Basic Care and
Comfort
4. During mornin g care in a skilled nursing facilit y, the student nurse notices
that the patient who is at risk for impaired skin integrit y has developed a
small open area on his sacrum. To best address this situation, the student
would first:
a. position the patient to lie on his side, document it, and inform the
head nurse.
b. position the patient on his side and encourage him to massage
around the area.
c. report to the primary care provider so that the nursing care plan can
be revised.
d. tell the nursing assistant to change the patient’s position every 2
hours.
ANS: A
This change in the patient’s position with documentation is the initial
intervention. The discovery of an open lesion requires a change in the
nursing plan.
DIF: Cognitive Level: Anal ysis REF: p. 77 OBJ:
Theory #2 TOP: Care Delivery KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrit y: Basic Care and Comfort
E VALUATION
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. An example of an appropriatel y worded nursing goal or outcome for the
nursing diagnosis of “Risk for falls related t o weakness” would be:
a. nurse will assist the patient to the bathroom every 2 hours.
b. patient will be free of injury from falls.
c. patient will call for assistance when ambulating for the next week.
d. nurse will keep room well lit 24 hours a day.
ANS: C
An appropriatel y worded outcome is a patient centered, measurable,
and time defined goal based on a nursing diagnosis.
DIF: Cognitive Level: Application REF: p. 79|Box 6 -3
OBJ: Theory #5 TOP: Expected Outcomes KEY:
Nursing Process Step: Evaluation MSC: NCLEX:
Physiological Integrity: Basic Care and Comfort
2. Nurses design interventions that are appropriate for a patient that are:
a. based on the primary care provider’s orders and the medical
diagnosis.
, b. expected to help the patient meets the goals most quick l y.
c. used to evaluate whether the nursing care plan should be revised.
d. based on cost effectiveness and staff availabilit y.
ANS: B
Nursing interventions are based on nursing diagnoses and are those
most likel y to assist the patient in meeting outcomes related to those
diagnoses.
DIF: Cognitive Level: Comprehension REF: p. 79|Box 6 -3
OBJ: Theory #2 TOP: Care Delivery KEY: Nursing
Process Step: Planning MSC: NCLEX: Safe, Effective
Care Environment: Coordinated Care
3. Before performing a cathete rization, the inexperienced nurse should:
a. close the door or curtains to provide the patient with privacy.
b. provide necessary education and explanation of the procedure to the
patient.
c. observe rules of Standard Precautions to protect herself from
exposure to blood or body fluids.
d. review the agency’s procedure manual for the accepted way of
performing the procedure.
ANS: D
Reviewing the procedure manual should occur before the inexperienced
nurse explains to the patient, provides privacy, or observes Standar d
Precautions.
, DIF: Cognitive Level: Application REF: p. 75 OBJ:
Clinical Practice #2 TOP: Standards for All Nursing
Procedures KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrit y: Basic Care and
Comfort
4. During mornin g care in a skilled nursing facilit y, the student nurse notices
that the patient who is at risk for impaired skin integrit y has developed a
small open area on his sacrum. To best address this situation, the student
would first:
a. position the patient to lie on his side, document it, and inform the
head nurse.
b. position the patient on his side and encourage him to massage
around the area.
c. report to the primary care provider so that the nursing care plan can
be revised.
d. tell the nursing assistant to change the patient’s position every 2
hours.
ANS: A
This change in the patient’s position with documentation is the initial
intervention. The discovery of an open lesion requires a change in the
nursing plan.
DIF: Cognitive Level: Anal ysis REF: p. 77 OBJ:
Theory #2 TOP: Care Delivery KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrit y: Basic Care and Comfort
