Test Bank For Medical-Surgical Nursing in Canada 4th Edition
By Sharon L. Lewis;
Margaret McLean Heitkemper; Linda Bucher
Complete Test bank, All Chapters are included.
Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
,MULTIPLE CHOICE
1. The nurse is caring for a client with a new diagnosis of pneumonia and explains to the client that
together they will plan the client’s care and set goals for discharge. The client asks, “How is that
different from what the doctor does?” Which response by the nurse is most appropriate?
a. “The role of the nurse is to administer medications and other treatments prescribed by your
doctor.”
b. “The nurse’s job is to help the doctor by collecting data and communicating when there are
problems.”
c. “Nurses perform many of the procedures done by physicians, but nurses are here in the
hospital for a longer time than doctors.”
d. “In addition to caring for you while you are sick, the nurses will assist you to develop an
individualized plan to maintain your health.”
ANS: D
This response is consistent with the Canadian Nurses Association (CNA) definition of
nursing. Registered nurses are self-regulated health care professionals who work
autonomously and in collaboration with others. RNs enable individuals, families, groups,
communities and populations to achieve their optimal level of health. RNs coordinate
health care, deliver direct services, and support clients in their self-care decisions and
actions in situations of health, illness, injury, and disability in all stages of life. The other
responses describe some of the dependent and collaborative functions of the nursing role
but do not accurately describe the nurse’s role in the health care system.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation MSC:
NCLEX: Safe and Effective Care Environment
2. When caring for clients using evidence-informed practice, which of the following does the nurse
use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the client outcomes are met
ANS: C
Evidence-informed nursing practice is a continuous interactive process involving the
explicit, conscientious, and judicious consideration of the best available evidence to
provide care. Four primary elements are: (a) clinical state, setting, and circumstances; (b)
client preferences and actions; (c) best research evidence, and (d) health care resources.
Clinical judgement based on the nurse’s clinical experience is part of EIP, but clinical
decision making also should incorporate current research and research-based guidelines.
Evidence from one clinical research study does not provide an adequate substantiation for
interventions. Evaluation of client outcomes is important, but interventions should be
based on research from randomized control studies with a large number of subjects.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
, MSC: NCLEX: Safe and Effective Care Environment
3. Which of the following best explains the nurses’ primary use of the nursing process
when providing care to clients?
a. To explain nursing interventions to other health care professionals
b. As a problem-solving tool to identify and treat clients’ health care needs
c. As a scientific-based process of diagnosing the client’s health care problems
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
ANS: B
The nursing process is an assertive problem-solving approach to the identification and
treatment of clients’ problems. Diagnosis is only one phase of the nursing process. The
primary use of the nursing process is in client care, not to establish nursing theory or
explain nursing interventions to other health care professionals.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation MSC:
NCLEX: Safe and Effective Care Environment
4. The nurse is caring for a critically ill client in the intensive care unit and plans an every-
2-hour turning schedule to prevent skin breakdown. Which type of nursing function is
demonstrated with this turning schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D
When implementing collaborative nursing actions, the nurse is responsible primarily for
monitoring for complications of acute illness or providing care to prevent or treat
complications. Independent nursing actions are focused on health promotion, illness
prevention, and client advocacy. A dependent action would require a physician order to
implement. Cooperative nursing functions are not described as one of the formal nursing
functions.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX:
Safe and Effective Care Environment
5. The nurse is caring for a client who has been admitted to the hospital for surgery and
tells the nurse, “I do not feel right about leaving my children with my neighbour.” Which
action should the nurse take next?
a. Reassure the client that these feelings are common for parents.
b. Have the client call the children to ensure that they are doing well.
c. Call the neighbour to determine whether adequate childcare is being provided.
d. Gather more data about the client’s feelings about the childcare arrangements.
ANS: D
, Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurse’s first action should be to obtain more information.
The other actions may be appropriate, but more assessment is needed before the best
intervention can be chosen.
MSC: NCLEX: Psychosocial Integrity
6. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the client’s left hip. Which of the following is the most
appropriate nursing diagnosis for this client?
a. Impaired physical mobility related to decrease in muscle control (left-sided
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
protecting tissue integrity
c. Impaired skin integrity related to pressure over bony prominence (impaired
circulation)
d. Ineffective peripheral tissue perfusion related to sedentary lifestyle
ANS: C
The client’s major problem is the impaired skin integrity as demonstrated by the presence
of a pressure injury. The nurse is able to treat the cause of impaired circulation and
pressure over bony prominence by frequently repositioning the client. Although left-sided
weakness is a problem for the client, the nurse cannot treat the weakness. The “risk for”
diagnosis is not appropriate for this client, who already has impaired tissue integrity. The
client does have ineffective peripheral tissue perfusion, but the impaired skin integrity
diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis
MSC: NCLEX: Physiological Integrity
7. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
volume related to excessive fluid loss through normal route (diaphoresis). Which of the
following is an appropriate client outcome?
a. Client has a balanced intake and output.
b. Client’s bedding is changed when it becomes damp.
c. Client understands the need for increased fluid intake.
d. Client’s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid
volume that was identified in the nursing diagnosis statement. The other statements would
not indicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC:
NCLEX: Physiological Integrity
By Sharon L. Lewis;
Margaret McLean Heitkemper; Linda Bucher
Complete Test bank, All Chapters are included.
Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
,MULTIPLE CHOICE
1. The nurse is caring for a client with a new diagnosis of pneumonia and explains to the client that
together they will plan the client’s care and set goals for discharge. The client asks, “How is that
different from what the doctor does?” Which response by the nurse is most appropriate?
a. “The role of the nurse is to administer medications and other treatments prescribed by your
doctor.”
b. “The nurse’s job is to help the doctor by collecting data and communicating when there are
problems.”
c. “Nurses perform many of the procedures done by physicians, but nurses are here in the
hospital for a longer time than doctors.”
d. “In addition to caring for you while you are sick, the nurses will assist you to develop an
individualized plan to maintain your health.”
ANS: D
This response is consistent with the Canadian Nurses Association (CNA) definition of
nursing. Registered nurses are self-regulated health care professionals who work
autonomously and in collaboration with others. RNs enable individuals, families, groups,
communities and populations to achieve their optimal level of health. RNs coordinate
health care, deliver direct services, and support clients in their self-care decisions and
actions in situations of health, illness, injury, and disability in all stages of life. The other
responses describe some of the dependent and collaborative functions of the nursing role
but do not accurately describe the nurse’s role in the health care system.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation MSC:
NCLEX: Safe and Effective Care Environment
2. When caring for clients using evidence-informed practice, which of the following does the nurse
use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the client outcomes are met
ANS: C
Evidence-informed nursing practice is a continuous interactive process involving the
explicit, conscientious, and judicious consideration of the best available evidence to
provide care. Four primary elements are: (a) clinical state, setting, and circumstances; (b)
client preferences and actions; (c) best research evidence, and (d) health care resources.
Clinical judgement based on the nurse’s clinical experience is part of EIP, but clinical
decision making also should incorporate current research and research-based guidelines.
Evidence from one clinical research study does not provide an adequate substantiation for
interventions. Evaluation of client outcomes is important, but interventions should be
based on research from randomized control studies with a large number of subjects.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
, MSC: NCLEX: Safe and Effective Care Environment
3. Which of the following best explains the nurses’ primary use of the nursing process
when providing care to clients?
a. To explain nursing interventions to other health care professionals
b. As a problem-solving tool to identify and treat clients’ health care needs
c. As a scientific-based process of diagnosing the client’s health care problems
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
ANS: B
The nursing process is an assertive problem-solving approach to the identification and
treatment of clients’ problems. Diagnosis is only one phase of the nursing process. The
primary use of the nursing process is in client care, not to establish nursing theory or
explain nursing interventions to other health care professionals.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation MSC:
NCLEX: Safe and Effective Care Environment
4. The nurse is caring for a critically ill client in the intensive care unit and plans an every-
2-hour turning schedule to prevent skin breakdown. Which type of nursing function is
demonstrated with this turning schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D
When implementing collaborative nursing actions, the nurse is responsible primarily for
monitoring for complications of acute illness or providing care to prevent or treat
complications. Independent nursing actions are focused on health promotion, illness
prevention, and client advocacy. A dependent action would require a physician order to
implement. Cooperative nursing functions are not described as one of the formal nursing
functions.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX:
Safe and Effective Care Environment
5. The nurse is caring for a client who has been admitted to the hospital for surgery and
tells the nurse, “I do not feel right about leaving my children with my neighbour.” Which
action should the nurse take next?
a. Reassure the client that these feelings are common for parents.
b. Have the client call the children to ensure that they are doing well.
c. Call the neighbour to determine whether adequate childcare is being provided.
d. Gather more data about the client’s feelings about the childcare arrangements.
ANS: D
, Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurse’s first action should be to obtain more information.
The other actions may be appropriate, but more assessment is needed before the best
intervention can be chosen.
MSC: NCLEX: Psychosocial Integrity
6. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the client’s left hip. Which of the following is the most
appropriate nursing diagnosis for this client?
a. Impaired physical mobility related to decrease in muscle control (left-sided
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
protecting tissue integrity
c. Impaired skin integrity related to pressure over bony prominence (impaired
circulation)
d. Ineffective peripheral tissue perfusion related to sedentary lifestyle
ANS: C
The client’s major problem is the impaired skin integrity as demonstrated by the presence
of a pressure injury. The nurse is able to treat the cause of impaired circulation and
pressure over bony prominence by frequently repositioning the client. Although left-sided
weakness is a problem for the client, the nurse cannot treat the weakness. The “risk for”
diagnosis is not appropriate for this client, who already has impaired tissue integrity. The
client does have ineffective peripheral tissue perfusion, but the impaired skin integrity
diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis
MSC: NCLEX: Physiological Integrity
7. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
volume related to excessive fluid loss through normal route (diaphoresis). Which of the
following is an appropriate client outcome?
a. Client has a balanced intake and output.
b. Client’s bedding is changed when it becomes damp.
c. Client understands the need for increased fluid intake.
d. Client’s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid
volume that was identified in the nursing diagnosis statement. The other statements would
not indicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC:
NCLEX: Physiological Integrity
