,Chapter 01: Professional Nursing Practice
ss ss ss ss
Lewis: Medical-Surgical Nursing, 10th Edition
ss ss ss ss ss
MULTIPLE CHOICE ss
1. The nurse completes an admission database and explains that the plan of care and
ss ss ss ss ss ss ss ss ss ss ss ss ss
discharge goals will be developed with the patient‘s input. The patient states, ―How is this
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
different from what the doctor does?‖ Which response would be most appropriate for the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
nurse to make?
ss ss ss
a. ―The role of the nurse is to administer medications and other treatments
ss ss ss ss ss ss ss ss ss ss ss
prescribed by your doctor.‖
ss ss ss ss
b. ―The nurse‘s job is to help the doctor by collecting information
ss ss ss ss ss ss ss ss ss ss
and communicating any problems that occur.‖
ss ss ss ss ss ss
c. ―Nurses perform many of the same procedures as the doctor, but nurses are
ss ss ss ss ss ss ss ss ss ss ss ss
with the patients for a longer time thadoctor.‖
ss ss ss ss ss ss ss ss
d. ―In addition to caring for you while you are sick, the nurses will assist you
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
to develop an individualized plan to maintain your health.‖
ss ss ss ss ss ss ss ss ss
ANS: s s D
This response is consistent with the American Nurses Association (ANA) definition of
ss ss ss ss ss ss ss ss ss ss ss
nursing, which describes the role of nurses in promoting health. The other responses describe
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
some of the dependent and collaborative functions of the nursing role but do not accurately
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
describe the nurse‘s role in the health care system.
ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 3 ss ss ss ss ss
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
s s ss ss s s ss ss ss ss ss
2. The nurse describes to a student nurse how to use evidence-based practice guidelines
ss ss ss ss ss ss ss ss ss ss ss ss
when caring for patients. Which statement, if made by the nurse, would be the most
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
accurate?
ss
a. ―Inferences from clinical research studies are used as a guide.‖ ss ss ss ss ss ss ss ss ss
b. ―Patient care is based on clinical judgment, experience, and traditions.‖
ss ss ss ss ss ss ss ss ss
c. ―Data are evaluated to show that the patient outcomes are consistently met.‖
ss ss ss ss ss ss ss ss ss ss ss
d. ―Recommendations are based on research, clinical expertise, and ss ss ss ss ss ss ss
patient preferences.‖
ss ss
ANS: s s D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with ss ss ss ss ss ss ss ss ss ss ss ss
clinician expertise. Clinical judgment based on the nurse‘s clinical experience is part of EBP,
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
but clinical decision making should also incorporate current research and research-based
ss ss ss ss ss ss ss ss ss ss ss
guidelines. Evaluation of patient outcomes is important, but interventions should be based on
ss ss ss ss ss ss ss ss ss ss ss ss ss
research from randomized control studies with a large number of subjects.
ss ss ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Remember (knowledge) REF: 15 ss ss ss ss ss
TOP: Nursing Process: Planning
s s MSC: NCLEX: Safe and Effective Care Environment ss ss s s ss ss ss ss ss
3. The nurse teaches a student nurse about how to apply the nursing process when providing
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
patient care. Which statement, if made by the student nurse, indicates that teaching was
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
successful?
ss
a. ―The nursing process is a scientific-based method of diagnosing the patient‘s
ss ss ss ss ss ss ss ss ss ss
, health care problems.‖ ss ss
b. ―The nursing process is a problem-solving tool used to identify and treat
ss ss ss ss ss ss ss ss ss ss ss
patients‘ health care needs.‖
ss ss ss ss
c. ―The nursing process is used primarily to explain nursing interventions to
ss ss ss ss ss ss ss ss ss ss
other health care professionals.‖
ss ss ss ss
d. ―The nursing process is based on nursing theory that incorporates
ss ss ss ss ss ss ss ss ss
the biopsychosocial nature of humans.‖
ss ss ss ss ss
ANS: s s B
The nursing process is a problem-solving approach to the identification and treatment of
ss ss ss ss ss ss ss ss ss ss ss ss
patients‘ problems. Diagnosis is only one phase of the nursing process. The primary use of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the nursing process is in patient care, not to establish nursing theory or explain nursing
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
interventions to other health care professionals.
ss ss ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 5 ss ss ss ss ss
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
s s ss ss s s ss ss ss ss ss
4. A patient has been admitted to the hospital for surgery and tells the nurse, ―I do not feel
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
comfortable leaving my children with my parents.‖ Which action should the nurse take
ss ss ss ss ss ss ss ss ss ss ss ss ss
next?
ss
a. Reassure the patient that these feelings are common for parents. ss ss ss ss ss ss ss ss ss
b. Have the patient call the children to ensure that they are doing well.
ss ss ss ss ss ss ss ss ss ss ss ss
c. Gather more data about the patient‘s feelings about the child-care arrangements.
ss ss ss ss ss ss ss ss ss ss
d. Call the patient‘s parents to determine whether adequate child care is
ss ss ss ss ss ss ss ss ss ss
being provided.
ss ss
ANS: s s C
Because a complete assessment is necessary in order to identify a problem and choose an
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
appropriate intervention, the nurse‘s first action should be to obtain more information. The
ss ss ss ss ss ss ss ss ss ss ss ss ss
other actions may be appropriate, but more assessment is needed before the best intervention
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
can be chosen.
ss ss ss
DIF: Cognitive Level: Apply (application) REF: 6 ss ss ss
OBJ: Special Questions: Prioritization TOP: Nursing Process:
s s ss ss s s ss
Assessment MSC: NCLEX: Psychosocial Integrity
ss ss s s ss ss
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
ss on the left hip. Which nursing diagnosis is most appropriate?
ss ss ss ss ss ss ss ss ss
a. Impaired physical mobility related to left-sided paralysis ss ss ss ss ss ss
b. Risk for impaired tissue integrity related to left-sided weakness
ss ss ss ss ss ss ss ss
c. Impaired skin integrity related to altered circulation and pressure
ss ss ss ss ss ss ss ss
d. Ineffective tissue perfusion related to inability to move independently ss ss ss ss ss ss ss ss
ANS: s s C
The patient‘s major problem is the impaired skin integrity as demonstrated by the presence
ss ss ss ss ss ss ss ss ss ss ss ss ss
of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
frequently repositioning the patient. Although left-sided weakness is a problem for the
ss ss ss ss ss ss ss ss ss ss ss ss
patient, the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate for
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
this patient, who already has impaired tissue integrity. The patient does have ineffective tissue
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health
ss ss ss ss ss ss ss ss ss ss ss ss ss
problem is.
ss ss
, DIF: Cognitive Level: Apply (application) REF: 7 ss ss ss
TOP: Nursing Process: Diagnosis
s s MSC: NCLEX: Physiological Integrity ss ss s s ss ss
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
to excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this
ss ss ss ss ss ss ss ss ss ss ss ss ss
patient?
ss
a. Patient has a balanced intake and output. ss ss ss ss ss ss
b. Patient‘s bedding is changed when it becomes damp. ss ss ss ss ss ss ss
c. Patient understands the need for increased fluid intake.
ss ss ss ss ss ss ss
d. Patient‘s skin remains cool and dry throughout hospitalization.
ss ss ss ss ss ss ss
ANS: s s A
This statement gives measurable data showing resolution of the problem of deficient fluid
ss ss ss ss ss ss ss ss ss ss ss ss
volume that was identified in the nursing diagnosis statement. The other statements would not
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
indicate that the problem of deficient fluid volume was resolved.
ss ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Apply (application) REF: 7 ss ss ss
TOP: Nursing Process: Planning
s s MSC: NCLEX: Physiological Integrity ss ss s s ss ss
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
of the evaluation phase of the nursing process?
ss ss ss ss ss ss ss ss
a. To determine if interventions have been effective in meeting patient outcomes
ss ss ss ss ss ss ss ss ss ss
b. To document the nursing care plan in the progress notes of the medical record
ss ss ss ss ss ss ss ss ss ss ss ss ss
c. To decide whether the patient‘s health problems have been completely resolved
ss ss ss ss ss ss ss ss ss ss
d. To establish if the patient agrees that the nursing care provided was satisfactory
ss ss ss ss ss ss ss ss ss ss ss ss
ANS: s s A
Evaluation consists of determining whether the desired patient outcomes have been met
ss ss ss ss ss ss ss ss ss ss ss
and whether the nursing interventions were appropriate. The other responses do not
ss ss ss ss ss ss ss ss ss ss ss ss
describe the evaluation phase.
ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 5 ss ss ss
TOP: Nursing Process: Evaluation
s s MSC: NCLEX: Safe and Effective Care Environment
ss ss s s ss ss ss ss ss
8. The nurse interviews a patient while completing the health history and physical
ss ss ss ss ss ss ss ss ss ss ss
examination. What is the purpose of the assessment phase of the nursing process?
ss ss ss ss ss ss ss ss ss ss ss ss ss
a. To teach interventions that relieve health problems
ss ss ss ss ss ss
b. To use patient data to evaluate patient care outcomes
ss ss ss ss ss ss ss ss
c. To obtain data with which to diagnose patient problems
ss ss ss ss ss ss ss ss
d. To help the patient identify realistic outcomes for health problems
ss ss ss ss ss ss ss ss ss
ANS: s s C
During the assessment phase, the nurse gathers information about the patient to diagnose
ss ss ss ss ss ss ss ss ss ss ss ss
patient problems. The other responses are examples of the planning, intervention, and
ss ss ss ss ss ss ss ss ss ss ss ss
evaluation phases of the nursing process.
ss ss ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 5 ss ss ss
TOP: Nursing Process: Assessment
s s MSC: NCLEX: Safe and Effective Care Environment
ss ss s s ss ss ss ss ss
ss ss ss ss
Lewis: Medical-Surgical Nursing, 10th Edition
ss ss ss ss ss
MULTIPLE CHOICE ss
1. The nurse completes an admission database and explains that the plan of care and
ss ss ss ss ss ss ss ss ss ss ss ss ss
discharge goals will be developed with the patient‘s input. The patient states, ―How is this
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
different from what the doctor does?‖ Which response would be most appropriate for the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
nurse to make?
ss ss ss
a. ―The role of the nurse is to administer medications and other treatments
ss ss ss ss ss ss ss ss ss ss ss
prescribed by your doctor.‖
ss ss ss ss
b. ―The nurse‘s job is to help the doctor by collecting information
ss ss ss ss ss ss ss ss ss ss
and communicating any problems that occur.‖
ss ss ss ss ss ss
c. ―Nurses perform many of the same procedures as the doctor, but nurses are
ss ss ss ss ss ss ss ss ss ss ss ss
with the patients for a longer time thadoctor.‖
ss ss ss ss ss ss ss ss
d. ―In addition to caring for you while you are sick, the nurses will assist you
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
to develop an individualized plan to maintain your health.‖
ss ss ss ss ss ss ss ss ss
ANS: s s D
This response is consistent with the American Nurses Association (ANA) definition of
ss ss ss ss ss ss ss ss ss ss ss
nursing, which describes the role of nurses in promoting health. The other responses describe
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
some of the dependent and collaborative functions of the nursing role but do not accurately
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
describe the nurse‘s role in the health care system.
ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 3 ss ss ss ss ss
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
s s ss ss s s ss ss ss ss ss
2. The nurse describes to a student nurse how to use evidence-based practice guidelines
ss ss ss ss ss ss ss ss ss ss ss ss
when caring for patients. Which statement, if made by the nurse, would be the most
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
accurate?
ss
a. ―Inferences from clinical research studies are used as a guide.‖ ss ss ss ss ss ss ss ss ss
b. ―Patient care is based on clinical judgment, experience, and traditions.‖
ss ss ss ss ss ss ss ss ss
c. ―Data are evaluated to show that the patient outcomes are consistently met.‖
ss ss ss ss ss ss ss ss ss ss ss
d. ―Recommendations are based on research, clinical expertise, and ss ss ss ss ss ss ss
patient preferences.‖
ss ss
ANS: s s D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with ss ss ss ss ss ss ss ss ss ss ss ss
clinician expertise. Clinical judgment based on the nurse‘s clinical experience is part of EBP,
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
but clinical decision making should also incorporate current research and research-based
ss ss ss ss ss ss ss ss ss ss ss
guidelines. Evaluation of patient outcomes is important, but interventions should be based on
ss ss ss ss ss ss ss ss ss ss ss ss ss
research from randomized control studies with a large number of subjects.
ss ss ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Remember (knowledge) REF: 15 ss ss ss ss ss
TOP: Nursing Process: Planning
s s MSC: NCLEX: Safe and Effective Care Environment ss ss s s ss ss ss ss ss
3. The nurse teaches a student nurse about how to apply the nursing process when providing
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
patient care. Which statement, if made by the student nurse, indicates that teaching was
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
successful?
ss
a. ―The nursing process is a scientific-based method of diagnosing the patient‘s
ss ss ss ss ss ss ss ss ss ss
, health care problems.‖ ss ss
b. ―The nursing process is a problem-solving tool used to identify and treat
ss ss ss ss ss ss ss ss ss ss ss
patients‘ health care needs.‖
ss ss ss ss
c. ―The nursing process is used primarily to explain nursing interventions to
ss ss ss ss ss ss ss ss ss ss
other health care professionals.‖
ss ss ss ss
d. ―The nursing process is based on nursing theory that incorporates
ss ss ss ss ss ss ss ss ss
the biopsychosocial nature of humans.‖
ss ss ss ss ss
ANS: s s B
The nursing process is a problem-solving approach to the identification and treatment of
ss ss ss ss ss ss ss ss ss ss ss ss
patients‘ problems. Diagnosis is only one phase of the nursing process. The primary use of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the nursing process is in patient care, not to establish nursing theory or explain nursing
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
interventions to other health care professionals.
ss ss ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 5 ss ss ss ss ss
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
s s ss ss s s ss ss ss ss ss
4. A patient has been admitted to the hospital for surgery and tells the nurse, ―I do not feel
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
comfortable leaving my children with my parents.‖ Which action should the nurse take
ss ss ss ss ss ss ss ss ss ss ss ss ss
next?
ss
a. Reassure the patient that these feelings are common for parents. ss ss ss ss ss ss ss ss ss
b. Have the patient call the children to ensure that they are doing well.
ss ss ss ss ss ss ss ss ss ss ss ss
c. Gather more data about the patient‘s feelings about the child-care arrangements.
ss ss ss ss ss ss ss ss ss ss
d. Call the patient‘s parents to determine whether adequate child care is
ss ss ss ss ss ss ss ss ss ss
being provided.
ss ss
ANS: s s C
Because a complete assessment is necessary in order to identify a problem and choose an
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
appropriate intervention, the nurse‘s first action should be to obtain more information. The
ss ss ss ss ss ss ss ss ss ss ss ss ss
other actions may be appropriate, but more assessment is needed before the best intervention
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
can be chosen.
ss ss ss
DIF: Cognitive Level: Apply (application) REF: 6 ss ss ss
OBJ: Special Questions: Prioritization TOP: Nursing Process:
s s ss ss s s ss
Assessment MSC: NCLEX: Psychosocial Integrity
ss ss s s ss ss
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
ss on the left hip. Which nursing diagnosis is most appropriate?
ss ss ss ss ss ss ss ss ss
a. Impaired physical mobility related to left-sided paralysis ss ss ss ss ss ss
b. Risk for impaired tissue integrity related to left-sided weakness
ss ss ss ss ss ss ss ss
c. Impaired skin integrity related to altered circulation and pressure
ss ss ss ss ss ss ss ss
d. Ineffective tissue perfusion related to inability to move independently ss ss ss ss ss ss ss ss
ANS: s s C
The patient‘s major problem is the impaired skin integrity as demonstrated by the presence
ss ss ss ss ss ss ss ss ss ss ss ss ss
of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
frequently repositioning the patient. Although left-sided weakness is a problem for the
ss ss ss ss ss ss ss ss ss ss ss ss
patient, the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate for
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
this patient, who already has impaired tissue integrity. The patient does have ineffective tissue
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health
ss ss ss ss ss ss ss ss ss ss ss ss ss
problem is.
ss ss
, DIF: Cognitive Level: Apply (application) REF: 7 ss ss ss
TOP: Nursing Process: Diagnosis
s s MSC: NCLEX: Physiological Integrity ss ss s s ss ss
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
to excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this
ss ss ss ss ss ss ss ss ss ss ss ss ss
patient?
ss
a. Patient has a balanced intake and output. ss ss ss ss ss ss
b. Patient‘s bedding is changed when it becomes damp. ss ss ss ss ss ss ss
c. Patient understands the need for increased fluid intake.
ss ss ss ss ss ss ss
d. Patient‘s skin remains cool and dry throughout hospitalization.
ss ss ss ss ss ss ss
ANS: s s A
This statement gives measurable data showing resolution of the problem of deficient fluid
ss ss ss ss ss ss ss ss ss ss ss ss
volume that was identified in the nursing diagnosis statement. The other statements would not
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
indicate that the problem of deficient fluid volume was resolved.
ss ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Apply (application) REF: 7 ss ss ss
TOP: Nursing Process: Planning
s s MSC: NCLEX: Physiological Integrity ss ss s s ss ss
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
of the evaluation phase of the nursing process?
ss ss ss ss ss ss ss ss
a. To determine if interventions have been effective in meeting patient outcomes
ss ss ss ss ss ss ss ss ss ss
b. To document the nursing care plan in the progress notes of the medical record
ss ss ss ss ss ss ss ss ss ss ss ss ss
c. To decide whether the patient‘s health problems have been completely resolved
ss ss ss ss ss ss ss ss ss ss
d. To establish if the patient agrees that the nursing care provided was satisfactory
ss ss ss ss ss ss ss ss ss ss ss ss
ANS: s s A
Evaluation consists of determining whether the desired patient outcomes have been met
ss ss ss ss ss ss ss ss ss ss ss
and whether the nursing interventions were appropriate. The other responses do not
ss ss ss ss ss ss ss ss ss ss ss ss
describe the evaluation phase.
ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 5 ss ss ss
TOP: Nursing Process: Evaluation
s s MSC: NCLEX: Safe and Effective Care Environment
ss ss s s ss ss ss ss ss
8. The nurse interviews a patient while completing the health history and physical
ss ss ss ss ss ss ss ss ss ss ss
examination. What is the purpose of the assessment phase of the nursing process?
ss ss ss ss ss ss ss ss ss ss ss ss ss
a. To teach interventions that relieve health problems
ss ss ss ss ss ss
b. To use patient data to evaluate patient care outcomes
ss ss ss ss ss ss ss ss
c. To obtain data with which to diagnose patient problems
ss ss ss ss ss ss ss ss
d. To help the patient identify realistic outcomes for health problems
ss ss ss ss ss ss ss ss ss
ANS: s s C
During the assessment phase, the nurse gathers information about the patient to diagnose
ss ss ss ss ss ss ss ss ss ss ss ss
patient problems. The other responses are examples of the planning, intervention, and
ss ss ss ss ss ss ss ss ss ss ss ss
evaluation phases of the nursing process.
ss ss ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 5 ss ss ss
TOP: Nursing Process: Assessment
s s MSC: NCLEX: Safe and Effective Care Environment
ss ss s s ss ss ss ss ss
