Chapter 020

Potter & Perry: Fundamentals of Nursing, 7th Edition
Test Bank
Chapter 20: Evaluation
MULTIPLE CHOICE
1. The client smokes two packs of cigarettes per day. The nurse works with the client, and
they agree that he will smoke one cigarette less each week until he is down to one pack
per day. In 3 weeks, the client is smoking two and a half packs of cigarettes per day. This
is an example of:
1. A realistic goal
2. A compliant client
3. A negative evaluation
4. A nonmeasurable goal
ANS: 3
This is an example of a negative evaluation. During evaluation, the nurse is able to
determine that the client has not met the expected outcome of decreasing smoking by one
cigarette each week but rather has increased his smoking. This is not an example of a
realistic goal. It is an example of the evaluation step of the nursing process. The client is
noncompliant. The goal is measurable. During evaluation, the nurse determines if
expected outcomes are met in order to judge if goals have been met.
DIF: A
REF: 291
OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX test plan designation: Safe, Effective Care Environment
2. The nurse formulates a diagnosis of knowledge deficit related to complications of
pregnancy. One outcome criterion is that the client can state five symptoms that indicate
a possible problem that should be reported. The client is able to tell the nurse three
symptoms. The evaluation statement would be:
1. Goal met; client able to state three symptoms
2. Goal not met; client able to list three symptoms
3. Goal not met; client unable to list five symptoms
4. Goal partially met; client able to state three symptoms
ANS: 4
The client is showing changes but does not yet meet criteria set; therefore, the goal is
partially met. The clients response, being able to state three symptoms, does not meet or
exceed the outcome criteria of being able to state five symptoms. The clients response,
being able to list three symptoms, demonstrates some change. If the client were showing
no progress, then the goal would not be met. If the client were showing no progress, then
the goal would not be met. However, this clients response does indicate some change.
DIF: A
REF: 296
OBJ: Comprehension
Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
20-2
3. The nurse begins to auscultate the clients lungs. While listening, the nurse notices fresh
bloody drainage oozing from the abdominal dressing. The nurse stops auscultating and
applies direct pressure to the wound site. This is an example of:
1. Performing a nursing assessment
2. Reorganizing the nursing diagnoses
3. Implementing nursing interventions
4. Critically analyzing client assessment data
ANS: 4
The nurse who stops auscultating lung sounds to take measures to stop noticeable
bleeding is analyzing data presented. This is demonstrated by the nurse setting priorities
and effectively implementing the safest nursing action. The nurse is doing more than
performing a nursing assessment. The nurse is taking action based on new assessment
data. The nurse is not reorganizing nursing diagnoses. The nurse is implementing the
priority nursing action. This is not an example of setting realistic goals and implementing
nursing interventions. Applying direct pressure to a wound site to stop bleeding
demonstrates critical analysis of the data and implementation of the safest nursing action.
DIF: A
REF: 298
OBJ: Comprehension
4. The client is able to ambulate without signs or symptoms of shortness of breath. Which
statement by the nurse is the best example of an objective evaluation of the clients goal
attainment?
1. Client has no pain after ambulating.
2. Client has no manifestations of nausea while up in hall.
3. Client walked well and did not have any problem when up.
4. Client has no evidence of respiratory distress when ambulating.
ANS: 4
Client has no evidence of respiratory distress when ambulating is the best example of
an objective evaluation of the clients goal attainment. It uses the same evaluative
measures gathered during assessment and clearly describes objective data. Client has no
pain after ambulating does not use the same evaluative measure gathered during
assessment. The assessment measure concerned respiratory changes during ambulation,
not pain. If the clients pain level were going to be used as an evaluative measure, it
would be optimal to have the client report the pain using a pain scale to make it more
measurable for comparison. Client has no manifestations of nausea while up in hall is
not the best example of an objective evaluation of the clients goal attainment. It does not
use the same evaluative measure gathered during assessment. The assessment measure
concerned respiratory changes during ambulation, not nausea. Also, nausea is more
subjective. Client walked well and did not have any problem when up is not the best
example of an objective evaluation. It includes the nurses interpretation rather than
documentation of objective data.
Test Bank
20-3
DIF: A
REF: 294
OBJ: Comprehension
5. When modifying a care plan to meet a client whose status has changed significantly over
the past few days, the nurse should:
1. Redevelop the entire client care plan
2. Focus on changing the nursing diagnoses and goals
3. Perform a complete reassessment of all client factors
4. Add more nursing interventions from a standardized plan of care
ANS: 3
A complete reassessment of all client factors relating to the nursing diagnosis and
etiology is necessary when modifying a plan. After reassessment the nurse will determine
what components of the care plan are accurate for the situation. It may not require
redoing the entire care plan. The nurse should not only focus on the nursing diagnoses
and goals that have changed. Interventions may also need revising to meet new goals.
Adding more nursing interventions may or may not be necessary. The nurse adjusts
interventions on the basis of the clients response and previous experience with similar
clients. Standards of care are used to determine whether the right interventions have been
chosen or whether additional ones are required.
DIF: A
REF: 297
OBJ: Comprehension
6. Based on the following outcome criterion determined by the nurse: Client will
independently complete necessary assessments prior to administration of digoxin
(cardiotonic) the nurse will evaluate the clients ability to:
1. Assess the respiratory rate
2. Palpate the radial pulse
3. Review dietary habits
4. Inspect color of the skin
ANS: 2
The nurse should compare the established outcome criteria with the clients behavior or
response. In this case the client is expected to independently complete the necessary
assessments before administration of digoxin. The client should be able to palpate the
radial pulse as an assessment before administration of digoxin. The outcome criterion
does not state anything about exercise. During evaluation, the nurse is to judge the degree
of agreement between the outcome criteria and the clients behavior. The outcome
criterion does not state anything about diet. Evaluating whether the client reviews dietary
habits would not be comparable to necessary assessment before medication
administration. The outcome criterion does not state anything about the skin. The nurse,
who knows that digoxin is a cardiotonic, understands that the client should be assessing
the heart rate.
Test Bank
20-4
DIF: A
REF: 291
OBJ: Comprehension
7. The nurse has determined the following outcome for a client with a skin impairment:
Erythema will be reduced in 3 days. Evaluation will specifically focus on:
1. Selection of appropriate wound care
2. Notation of the odor and color of drainage
3. Inspection of the color and condition of the area
4. Measurement of the diameter of the ulceration daily
ANS: 3
Erythema is reddening of the skin; therefore, the evaluation should specifically focus on
inspection of the color of the skin, as stated in the outcome criterion. Selection of
appropriate wound care is an intervention, not an evaluation of a clients behavior or
response. The outcome criterion does not state anything about drainage. Noting the color
and amount of drainage may be a part of reassessment of the client, but is not what the
nurse is evaluating according to this outcome criterion. The outcome criterion states the
erythema will be reduced, not the size of the ulceration. During the evaluation step of the
nursing process, the clients behavior or response should be compared to the outcome
criterion and judged for degree of agreement between the two.
DIF: A
REF: 294
OBJ: Comprehension
8. The client has a nursing diagnosis of impaired gas exchange as a result of excessive
secretions. An outcome for the client is that the airways will be free of secretions. A
positive evaluation will focus upon the clients:
1. Respiratory rate
2. Complaint of chest pain
3. Lungs clear bilaterally on auscultation
4. Ability to perform incentive spirometry
ANS: 3
Auscultating lung sounds is the best way to determine if airways are clear. A positive
evaluation is that they are clear, as expected in the outcome statement. Respiratory rate
may be an indicator of respiratory status, but it is not the best way to determine if airways
are free of secretions. A complaint of chest pain would be a negative outcome, and it is
not the focus for determining whether airways are free of secretions as written in the
outcome statement. Having the ability to perform incentive spirometry does not
determine whether the airways are clear or not. It is an intervention that may help achieve
clear airways.
DIF: A
REF: 294
OBJ: Comprehension
Test Bank
20-5
9. A client shares with the nurse that they have, almost reached the goal of smoking only
one-half pack of cigarettes a day. The best example of a nursing intervention to correct
this unmet outcome is:
1. Discuss with the client the desire to comply with the ordered therapy
2. Suggest that the client use another smoking cessation tool to achieve the goal
3. Reevaluate the time frame originally decided upon for achievement of the goal
4. Suggest that the strength of the prescribed nicotine patches be increased to 21 mg
ANS: 4
An unmet outcome reveals the client has not responded to interventions as planned. As a
result, the nurse changes the plan of care by trying different therapies or changing the
frequency or approach of existing therapies. The best option is one that adds to the
existing therapy. The remaining options should have been explored as a part of the goalsetting process or exercised if the current therapy proves ineffective.
DIF: C
REF: 296
OBJ: Analysis
10. The primary purpose of the nursing evaluation process is to:
1. Determine the effectiveness of the nursing care provided
2. Identify interventions that are ineffective in achieving client goals
3. Establish the progress the client is making towards health and wellness
4. Critique the nurses ability to implement appropriate nursing interventions
ANS: 1
The evaluation process determines the effectiveness of nursing care. The remaining
options are all examples of evaluation but do not reflect the primary purpose of nursing
evaluation.
DIF: C
REF: 291
OBJ: Analysis
11. Which of the following statements best reflects a goal based on a clinical standard of
practice?
1. Client will lose 10 pounds in 90 days.
2. Client will walk 30 feet with minimal assistance.
3. Clients peripheral intravenous site will be free of redness.
4. Clients chronic pain will be managed with oral medication by discharge.
ANS: 3
Goals often are also based on standards of care or guidelines established for minimal safe
practice. Prevention of acquired infection is a standard of practice; the remaining options
reflect client-specific goals.
DIF:
REF: 293
OBJ: Analysis
Test Bank
20-6

12. Which of the following outcomes best reflects a nurse-sensitive client outcome?
1. Client will consume 75% of all meals.
2. Client will perform personal hygiene daily.
3. Client will experience no falls during hospitalization.
4. Client will report lessened anxiety regarding surgical procedure.
ANS: 3
A nurse-sensitive client outcome is a measurable client or family state, behavior, or
perception largely influenced by and sensitive to nursing interventions. The nurse is
instrumental in the prevention of falls while the remaining options are dependent on the
client.
DIF: C
REF: 293
OBJ: Analysis
13. The nurse has identified a nursing diagnosis of knowledge deficit regarding the need to
monitor blood glucose levels daily. Which of the following statements best reflects the
clients understanding of the need for therapy?
1. Client agrees to test blood glucose levels 4 times a day.
2. Client records blood glucose levels for a 3-week period.
3. Client is observed testing his blood glucose level before breakfast.
4. Client is able to demonstrate the proper technique for performing a finger stick.
ANS: 2
During the planning phase of the nursing process it is important for you to select an
observable client state, behavior, or self-reported perception that will reflect goal
achievement. The actual written result of regular blood glucose monitoring is the best
indicator of the clients understanding of the importance of regular testing. The remaining
options may show initial willingness or ability to perform the test but do not show
consistent compliance.
DIF: C
REF: 293
OBJ: Analysis
14. Which of the following nursing notes demonstrates the best evaluation of nursing
interventions regarding the care provided?
1. Pressure ulcer located on left heel has shown improvement.
2. Pressure ulcer located on left heel has responded to treatment.
3. Pressure ulcer on left heel is no longer producing purulent drainage.
4. Pressure ulcer on left heel has not enlarged in size within the last 24 hours.
ANS: 3
Test Bank
20-7
In many clinical situations it is important to collect evaluative measures over a period of

time to determine if a pattern of improvement or change exists. The absence of purulent
drainage indicates successful nursing interventions while the other options either fail to
provide measurable data regarding the wound or indicate no improvement.
DIF: C
REF: 294
OBJ: Analysis
15. Which of the following statements made by a clients family is the most reliable for use
in the evaluation of a clients outcome?
1. Mom has been eating 90% of all of her meals since shes been home.
2. My daughter is in much less pain now that she is going to physical therapy.
3. My husband has been less depressed since hes been on that antidepressant pill.
4. Mom has been so much better since shes been able to get up and walk by
herself.
ANS: 1
Input from the family and other caregivers can be used to evaluate client outcomes but it
is best to use their observations of measurable actions, such as the amount eaten, than to
rely on their subjective opinions of a clients reaction, such as pain, anxiety, or mood.
DIF: C
REF: 294
OBJ: Analysis
16. A nurse is providing care for a client receiving normal saline when the IV infiltrates.
Which of the following nursing actions represents the evaluation phase of the nursing
process?
1. IV is discontinued.
2. Warm compress applied to IV site.
3. Site reinspected for presence of swelling.
4. IV site observed as having significant swelling.
ANS: 3
Evaluation, the final step of the nursing process, is crucial to determine whether, after
application of the nursing process, the clients condition or well-being improves. The
remaining options represent the assessment and implementation phases.
DIF: A
REF: 291
OBJ: Comprehension
17. Which of the following questions, asked by a nurse, best reflects an understanding of
effective evaluation?
1. Do you feel confident in the use of your glucometer?
2. Have you been following your low carbohydrate diet?
Test Bank
20-8
3. Any questions regarding the tests you are scheduled for today?
4. May we review what we discussed earlier about your medications?
ANS: 4
In effective evaluation, the nurse compares client behavior and responses that were
assessed before delivering nursing interventions with behavior and responses that occur
after administering nursing care. The answer shows direct client knowledge related to the
material previously discussed, while the other options reflect close-ended questions that
require only a yes or no answer.
DIF: C
REF: 291
OBJ: Analysis
18. The nurse caring for an immobile client with a pressure ulcer implements an intervention
that requires repositioning the client every 2 hours. Which of the following represents the
best evaluation method for this intervention?
1. No additional pressure ulcers are noted over a 1-week period.
2. Client expresses a decrease in pressure ulcer related pain within 1 week.
3. The clients pressure ulcer shows a decrease in size over a 1-week period.
4. The turning schedule is initiated to reflect appropriate positioning for a 1-week
period.
ANS: 3
You conduct evaluation measures to determine if you met expected outcomes, not if
nursing interventions were completed. The decrease in size of the pressure ulcer best
evaluates the effectiveness of this intervention while the remaining options reflect client
opinion, further skin breakdown, or implementation of the intervention.
DIF: C
REF: 291
OBJ: Analysis
19. Which of the following statements best defines quality improvement (performance
improvement)?
1. The assessment of the delivery system responsible for the implementation of clientoriented interventions
2. Integration of evidence-based practice research into the delivery process used to
implement client-oriented interventions
3. High-priority evaluation process directed towards differentiating between good and
poor intervention delivery by providers
4. An ongoing evaluation of interventions that is used to improve the delivery of
health care for the purpose of managing the clients needs
ANS: 4
Test Bank
20-9
Quality improvement (QI) and performance improvement (PI) are interchangeable terms
that describe an approach to the continuous study and improvement of the processes of
providing health care services to meet the needs of clients and others. The remaining
options reflect individual facets of QI.
DIF: C
REF: 298
OBJ: Analysis
20. The primary reason for documenting discontinued portions of the care plan when a client
goal has been met is to ensure:
1. Effective use of both nursing time and resources
2. Delivery of both timely and relevant nursing care
3. Concrete evidence of successful outcome achievement
4. Minimal ineffective communication among the nursing staff
ANS: 2
Documentation of a discontinued plan ensures that other nurses will not unnecessarily
continue interventions for that portion of the plan of care. Continuity of care assumes that
care provided to clients is relevant and timely. The remaining options refer to the
potential nursing outcomes related to poor documentation of care plan editing.
DIF: C
REF: 297
OBJ: Analysis
21. Which of the following nursing actions should be initiated first when dealing with the
following unmet client goal: Client will lose 10 pounds in 3 months?
1. Interview the client to identify reasons why the goal was not met.
2. Assess the client for possible physical reasons for failure to lose the weight.
3. Discuss with the client whether they were truly motivated to lose the weight.
4. Re-evaluate whether it was realistic for the client to lose 10 pounds in 3 months.
ANS: 1
When goals are not met, the nurse should identify the factors that interfere with goal
achievement. The remaining options reflect actions to be taken after the interview to
further determine how the care plan will be modified.
DIF: C
REF: 297
OBJ: Analysis
22. When a client goal is unmet, which of the following nursing actions is most appropriate?
1. Reevaluation of the original client goal
2. Selection of new but appropriate interventions
3. Evaluation of the clients ability and motivation to be compliant
4. Repetition of the entire nursing process regarding the nursing diagnosis
Test Bank
20-10
ANS: 4
When there is failure to achieve a goal, no matter what the reason, repeat the entire
nursing process sequence for that nursing diagnosis to discover changes the plan needs.
The remaining options reflect individual elements within the nursing process.
DIF: C
REF: 297
OBJ: Analysis
MULTIPLE RESPONSE
1. Which of the following is a recognized focus area for quality improvement (performance
improvement) evaluations? (Select all that apply.)
1. Effective care
2. Delivery of care
3. Client satisfaction
4. Exceeding the standard of care
5. Identification of missed client needs
6. Multidisciplinary approach to client care
ANS: 1, 2, 3, 4
Quality improvement is concerned with exceeding the standard of care, examining ways
to be more efficient, improving client satisfaction, and focusing on service. Although the
remaining options are pertinent, they are not major considerations of QI evaluation.
DIF: C
REF: 298
OBJ: Analysis

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Potter & Perry: Fundamentals of Nursing, 7th Edition

TOP: Nursing Process: Evaluation

In many clinical situations it is important to collect evaluative measures over a period of

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