Author Question: Which of the following are examples of evaluative measures that a nurse should utilize when ... (Read 58 times)

roselinechinyere27m · **on:** Jul 23, 2018

Which of the following are examples of evaluative measures that a nurse should utilize when determining the patient's response to nursing care? (Select all that apply.)

a. Observations of wound healing
b. Assessment of respiratory rate and depth
c. Blood pressure measurement
d. Implementation of nursing interventions
e. Patient's subjective report of feelings about a new diagnosis of cancer

Question 2

A patient was recently diagnosed with pneumonia.

The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which of the following is an appropriate evaluative measure demonstrating progress toward this goal?
a. Nonproductive cough present in 4 days
b. Scattered rhonchi throughout all lung fields in 2 days
c. Respirations 30/minute in 1 day
d. Lungs clear to auscultation following use of inhaler

Anonymous · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: A, B, C, E
Evaluative measures require the nurse to use assessment skills and techniques to determine the patient's response to nursing care. Examples of evaluative measures include assessment of wound healing and respiratory status, blood pressure measurement, and assessment of patient feelings. Determining whether nursing interventions were used is not an evaluative measure.

Answer to Question 2

ANS: D
Goals are broad statements that describe changes in a patient's condition or behavior. Expected outcomes are shorter-term measurable criteria used to evaluate goal achievement. When an outcome is met, you know that the patient is making progress toward goal achievement. In this case, the patient's goal is to not experience shortness of breath with activity in 3 days. One way to achieve this goal is for the patient to experience no respiratory secretions in the airway. One way for the nurse to evaluate the expected outcome is to assess the patient's lung sounds. If the lung sounds are clear, at least periodically throughout the day, the nurse can determine that the patient is making progress toward achieving the expected outcome. The time frame of 4 days in the first option is not appropriate because this time frame exceeds the time frame stated in the goal. Scattered rhonchi indicate fluid in the lungs, and a respiratory rate of 30 per minute is elevated. This indicates that the patient is still probably experiencing respiratory distress.