Geri Exam 1 questions n answers
graded A+ 2025 updated
An elderly diabetic client is admitted to the hospital with a chronic non-healing
ulcer. The nurse inspects the color of the ulcer and measures its diameter daily.
The nurse finds that the ulcer does not have an odor. The client is taking
antibiotics prescribed by the primary healthcare provider. What are the evaluative
measures in relation to the ulcer in this case? Select all that apply.
1. Color of the ulcer
2. Diameter of the ulcer
3. Diabetes
4. Odor in the ulcer
5. Antibiotics - correct answer ✔✔color of the ulcer, diameter of the ulcer, and
odor of the ulcer
What should the nurse know about evaluation in the nursing process?
1. Evaluation is dynamic and ever changing.
2. Evaluation occurs at particular intervals set by the nurse.
3. Evaluation process should not involve the caregivers.
4. Evaluation process is done in a nursing process - correct answer ✔✔1.
Evaluation is dynamic and ever changing
A client has limited mobility as a result of a recent knee replacement. The nurse
identifies that he has altered balance and assists him in ambulation. The client
uses a walker presently as part of his therapy. The nurse notes how far the client is
,able to walk and then assists him back to his room. Which of the following is an
evaluative measure?
1. Uses walker during ambulation
2. Presence of altered balance
3. Limited mobility in lower extremities
4. Observation of distance client is able to walk - correct answer ✔✔Observation
of distance client is able to walk
Final step in the nursing process - correct answer ✔✔Evaluation
A nurse is caring for a client with pneumonia. According to the client's care plan, a
reduction of respiratory rate (RR) from 33 breaths per minute to 20 breaths per
minute (bpm), reduced cough, and reduced sputum production in two days would
indicate successful intervention. On the first day the nurse finds that cough has
reduced following nebulization and the RR is 25 bpm. What should the nurse's
evaluation be?
1. The client's condition is deteriorating.
2. The client can be discharged to home to continue treatments.
3. The client needs continued nebulization therapy.
4. The client needs to be transferred to the ICU immediately. - correct answer
✔✔The client needs continued nebulization therapy
A client is recovering from surgery for removal of an ovarian tumor. It is 1 day after
her surgery. Because she has an abdominal incision and dressing and a history of
diabetes, the nurse has selected a nursing diagnosis of risk for infection. Which of
the following is an appropriate goal statement for the diagnosis?
1. Client will remain afebrile to discharge.
2. Client's wound will remain free of infection by discharge.
,3. Client will receive ordered antibiotic on time over next 3 days.
4. Client's abdominal incision will be covered with a sterile dressing for 2 days. -
correct answer ✔✔Client's wound will remain free of infection by discharge
A nurse is caring for a 40-year-old client undergoing chemotherapy. The client
complains of vomiting. Which statement is an appropriate goal statement for the
client's problem?
1. The client will stop vomiting in 2 hours.
2. Antiemetic should be administered every 6 hours.
3. The client may develop a side-effect of the antiemetic medication.
4. The client will not vomit again. - correct answer ✔✔The client will stop
vomiting in 2 hours
A nurse is assessing a client at home post splenectomy. The client tells the nurse
that he realizes that strain on the incision site could cause tearing of the stitches.
Nevertheless, the nurse finds that some of the client's stitches are pulled out.
What should be the most appropriate nursing action?
1. Advise the client to maintain complete bed rest for at least a month.
2. Immediately make arrangements for admission of the client to the hospital.
3. Report to the caregiver that the client is not following the instructions given.
4. Ask if the client understands which activities can cause strain at the incision
site. - correct answer ✔✔Ask if the client understands which activities can cause
strain at the incision site
An elderly client who has been taking thyroxine for hypothyroidism is diagnosed
with dementia. What should the nurse do in revising the care plan for
hypothyroidism?
1. Do not make any changes.
, 2. Increase the dose of thyroxine.
3. Ask the caregiver to monitor administration of the thyroxine.
4. Advise the caregiver to admit the client to a nursing home. - correct answer
✔✔Ask the caregiver to monitor administration of the thyroxine
A client has a nursing diagnosis of fractured ankle. As a part of the care plan, the
nurse plans to assist the client to walk and provides instruction about the use of
crutches. Later, the nurse finds that the client is already able to walk with the
crutches. What should the nurse do now?
1. Help the client walk.
2. Discontinue the current interventions and develop new ones.
3. Instruct the client to walk without support.
4. Demonstrate the use of crutches instead of instructing. - correct answer
✔✔Discontinue the current interventions and develop new ones
A nurse is preparing a client for discharge from the hospital. One of the important
outcome measures before discharge is that the client's surgical wound is aseptic.
What is the most probable evaluative measure in this case?
1. The absence of redness or tenderness at the site of the incision
2. The client identifying the symptoms of wound infection
3. The client's caregiver identifying the signs of wound infection
4. The client reporting no fever three days after surgery - correct answer ✔✔The
absence of redness or tenderness at the site of the incision
A nurse caring for a client with pneumonia sits the client up in bed and suctions
his airway. After suctioning, the client describes some discomfort in his abdomen.
The nurse auscultates the client's lung sounds and gives him a glass of water.
Which of the following is an evaluative measure used by the nurse?
graded A+ 2025 updated
An elderly diabetic client is admitted to the hospital with a chronic non-healing
ulcer. The nurse inspects the color of the ulcer and measures its diameter daily.
The nurse finds that the ulcer does not have an odor. The client is taking
antibiotics prescribed by the primary healthcare provider. What are the evaluative
measures in relation to the ulcer in this case? Select all that apply.
1. Color of the ulcer
2. Diameter of the ulcer
3. Diabetes
4. Odor in the ulcer
5. Antibiotics - correct answer ✔✔color of the ulcer, diameter of the ulcer, and
odor of the ulcer
What should the nurse know about evaluation in the nursing process?
1. Evaluation is dynamic and ever changing.
2. Evaluation occurs at particular intervals set by the nurse.
3. Evaluation process should not involve the caregivers.
4. Evaluation process is done in a nursing process - correct answer ✔✔1.
Evaluation is dynamic and ever changing
A client has limited mobility as a result of a recent knee replacement. The nurse
identifies that he has altered balance and assists him in ambulation. The client
uses a walker presently as part of his therapy. The nurse notes how far the client is
,able to walk and then assists him back to his room. Which of the following is an
evaluative measure?
1. Uses walker during ambulation
2. Presence of altered balance
3. Limited mobility in lower extremities
4. Observation of distance client is able to walk - correct answer ✔✔Observation
of distance client is able to walk
Final step in the nursing process - correct answer ✔✔Evaluation
A nurse is caring for a client with pneumonia. According to the client's care plan, a
reduction of respiratory rate (RR) from 33 breaths per minute to 20 breaths per
minute (bpm), reduced cough, and reduced sputum production in two days would
indicate successful intervention. On the first day the nurse finds that cough has
reduced following nebulization and the RR is 25 bpm. What should the nurse's
evaluation be?
1. The client's condition is deteriorating.
2. The client can be discharged to home to continue treatments.
3. The client needs continued nebulization therapy.
4. The client needs to be transferred to the ICU immediately. - correct answer
✔✔The client needs continued nebulization therapy
A client is recovering from surgery for removal of an ovarian tumor. It is 1 day after
her surgery. Because she has an abdominal incision and dressing and a history of
diabetes, the nurse has selected a nursing diagnosis of risk for infection. Which of
the following is an appropriate goal statement for the diagnosis?
1. Client will remain afebrile to discharge.
2. Client's wound will remain free of infection by discharge.
,3. Client will receive ordered antibiotic on time over next 3 days.
4. Client's abdominal incision will be covered with a sterile dressing for 2 days. -
correct answer ✔✔Client's wound will remain free of infection by discharge
A nurse is caring for a 40-year-old client undergoing chemotherapy. The client
complains of vomiting. Which statement is an appropriate goal statement for the
client's problem?
1. The client will stop vomiting in 2 hours.
2. Antiemetic should be administered every 6 hours.
3. The client may develop a side-effect of the antiemetic medication.
4. The client will not vomit again. - correct answer ✔✔The client will stop
vomiting in 2 hours
A nurse is assessing a client at home post splenectomy. The client tells the nurse
that he realizes that strain on the incision site could cause tearing of the stitches.
Nevertheless, the nurse finds that some of the client's stitches are pulled out.
What should be the most appropriate nursing action?
1. Advise the client to maintain complete bed rest for at least a month.
2. Immediately make arrangements for admission of the client to the hospital.
3. Report to the caregiver that the client is not following the instructions given.
4. Ask if the client understands which activities can cause strain at the incision
site. - correct answer ✔✔Ask if the client understands which activities can cause
strain at the incision site
An elderly client who has been taking thyroxine for hypothyroidism is diagnosed
with dementia. What should the nurse do in revising the care plan for
hypothyroidism?
1. Do not make any changes.
, 2. Increase the dose of thyroxine.
3. Ask the caregiver to monitor administration of the thyroxine.
4. Advise the caregiver to admit the client to a nursing home. - correct answer
✔✔Ask the caregiver to monitor administration of the thyroxine
A client has a nursing diagnosis of fractured ankle. As a part of the care plan, the
nurse plans to assist the client to walk and provides instruction about the use of
crutches. Later, the nurse finds that the client is already able to walk with the
crutches. What should the nurse do now?
1. Help the client walk.
2. Discontinue the current interventions and develop new ones.
3. Instruct the client to walk without support.
4. Demonstrate the use of crutches instead of instructing. - correct answer
✔✔Discontinue the current interventions and develop new ones
A nurse is preparing a client for discharge from the hospital. One of the important
outcome measures before discharge is that the client's surgical wound is aseptic.
What is the most probable evaluative measure in this case?
1. The absence of redness or tenderness at the site of the incision
2. The client identifying the symptoms of wound infection
3. The client's caregiver identifying the signs of wound infection
4. The client reporting no fever three days after surgery - correct answer ✔✔The
absence of redness or tenderness at the site of the incision
A nurse caring for a client with pneumonia sits the client up in bed and suctions
his airway. After suctioning, the client describes some discomfort in his abdomen.
The nurse auscultates the client's lung sounds and gives him a glass of water.
Which of the following is an evaluative measure used by the nurse?
