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A nurse forgets to raise the railings of the bed of a patient who is confused after taking pain medications. The patient attempts to get out of bed, and suffers a minor fall. The nurse asks a colleague who witnessed the fall not to mention it to anyone because the patient only had minor bruises. What would be the appropriate action of the colleague?
- A. No other steps need to be taken, since the patient was not seriously injured.
- B. The colleague should inform the nurse that a full report of the incident needs to be made.
- C. The colleague should monitor the patient closely for any adverse effects of the fall.
- D. The colleague should report the incident in a peer review of the nurse.
Correct Answer: B
Rationale: Reporting the incident ensures patient safety and compliance with ethical and legal standards, regardless of injury severity.
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A nurse has developed a plan of care for the nursing diagnosis Risk for Loneliness for a recently widowed man. When evaluating the plan, the man tells the nurse new information about his active social life. What would the nurse do next?
- A. Continue with the plan.
- B. Delete the nursing diagnosis.
- C. Tell the patient he is lonely.
- D. Adjust the time criteria.
Correct Answer: B
Rationale: New information indicating an active social life negates the risk for loneliness, so the diagnosis should be removed.
Which of the following would not be part of the nurses decision about care after evaluating the patients responses to the plan of care?
- A. terminate the plan of care
Correct Answer: D
Rationale: The options are incomplete, but based on standard nursing practice, transferring medical orders (D) is not part of evaluation decisions, which focus on continuing, modifying, or terminating the plan.
Patient lost 2 of the 5 pound/month goal. How should the nurse alter the plan of care in response to this new data?
- A. The nurse should not alter the plan of care.
- B. The nurse should change the diet.
- C. The nurse should delete the nursing diagnosis.
- D. The nurse should modify the time criteria.
Correct Answer: D
Rationale: Since the patient made progress but didn't meet the goal, adjusting the time criteria allows for continued effort toward the outcome.
A nurse is teaching a patient how to administer insulin, with the expected outcome that the patient will be able to self-administer the insulin injection. How would this outcome be evaluated?
- A. asking the patient to verbally repeat the steps of the injection
- B. asking the patient to demonstrate self-injection of insulin
- C. asking family members how much trouble the patient is having with injections
- D. asking the patient how comfortable he or she is with injections
Correct Answer: B
Rationale: Demonstration of the skill (self-injection) directly evaluates the psychomotor outcome of insulin administration.
What is the purpose of evaluation in the nursing process?
- A. to direct future nursing interventions
- B. to formulate a database of nursing diagnoses
- C. to complete an initial plan of care
- D. to transfer medical orders to the plan of care
Correct Answer: A
Rationale: Evaluation determines the effectiveness of the care plan, guiding future interventions based on patient responses.