1. A nurse is caring for a group of patients. Which evaluative

measures will the nurse use to determine a patient’s responses to nursing

care? (Select all that apply.)

a. Observations of wound healing

b. Daily blood pressure measurements

c. Findings of respiratory rate and depth

d. Completion of nursing interventions

e. Patient’s subjective report of feelings about a new diagnosis of cancer

ANS: A, B, C, E

You examine the results of care by using evaluative measures, which are

assessment skills and techniques (e.g., observations, physiological

measurements, use of measurement scales, and patient interview). Examples of

evaluative measures include assessment of wound healing and respiratory

status, blood pressure measurement, and assessment of patient feelings. You

conduct evaluative measures to determine if your patients met expected

outcomes, not if nursing interventions were completed.

2. Which nursing actions will the nurse perform in the evaluation phase of

the nursing process? (Select all that apply.)

a. Set priorities for patient care.

b. Determine whether outcomes or standards are met.

c. Ambulate patient 25 feet in the hallway.

d. Document results of goal achievement.

e. Use self-reflection and correct errors.

ANS: B, D, E

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