Harding: Lewis’s Medical-Surgical Nursing, 11th Edition
MULTIPLE CHOICE
1. The nurse completes an admission database and explains that the plan of care and discharge goals will
patient’s input. The patient asks, “How is this different from what the doctor does?” Which response w
the nurse to make?
a. “The role of the nurse is to administer medications and other treatments
prescribed by your doctor.”
b. “In addition to caring for you while you are sick, the nurses will help you plan to
maintain your health.”
c. “The nurse’s job is to help the doctor by collecting information and
communicating any problems that occur.”
d. “Nurses perform many of the same procedures as the doctor, but nurses are with
the patients for a longer time than the doctor.”
ANS: B
The American Nurses Association (ANA) definition of nursing describes the role of nurses in promotin
responses describe dependent and collaborative functions of the nursing role but do not accurately desc
in the health care system.
DIF: Cognitive Level: Analyze (analysis)
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
2. The nurse describes to a student nurse how to use evidence-based practice (EBP) when caring for patie
nurse accurately describes the use of EBP?
a. “Inferences from all published articles are used as a guide.”
b. “Patient care is based on clinical judgment, experience, and traditions.”
c. “Data are analyzed later to show that the patient outcomes are consistently met.”
d. “Recommendations are based on research, clinical expertise, and patient
preferences.”
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician
of patient preferences. Clinical judgment based on the nurse’s clinical experience is part of EBP, but cl
should also incorporate current research and research-based guidelines. Evaluation of patient outcomes
analysis is not required to use EBP. All published articles do not provide research evidence; interventio
credible research, preferably randomized controlled studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teaches a student nurse about how to apply the nursing process when providing patient care.
student nurse indicates that teaching was successful?
a. “The nursing process is a research method of diagnosing the patient’s health care
problems.”
b. “The nursing process is used primarily to explain nursing interventions to other
health care professionals.”
c. “The nursing process is a problem-solving tool used to identify and treat the
patients’ health care needs.”
d. “The nursing process is based on nursing theory that incorporates the
biopsychosocial nature of humans.”
ANS: C
The nursing process is a problem-solving approach to the identification and treatment of patients’ prob
not require research methods for diagnosis. The primary use of the nursing process is in patient care, no
or explain nursing interventions to other health care professionals.
, 5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis. Which exp
nurse recognize as appropriate for this patient?
a. Patient has a balanced intake and output.
b. Patient’s bedding is kept clean and free of moisture.
c. Patient understands the need for increased fluid intake.
d. Patient’s skin remains cool and dry throughout hospitalization.
ANS: A
Balanced intake and output gives measurable data showing resolution of the problem of deficient fluid
statements would not indicate that the problem of hypovolemia was resolved.
DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
6. After administering medication, the nurse asks the patient if pain was relieved. What is the purpose of
nursing process?
a. To document the nursing care plan in the progress notes of the health record
b. To determine if interventions have been effective in meeting patient outcomes
c. To decide whether the patient’s health problems have been completely resolved
d. To establish if the patient agrees that the nursing care provided was satisfactory
ANS: B
Evaluation consists of determining whether the desired patient outcomes have been met and whether th
appropriate. The other responses do not describe the evaluation phase.
DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
7. The nurse interviews a patient while completing the health history and physical examination. What is t
phase of the nursing process?
a. To teach interventions that relieve health problems
b. To use patient data to evaluate patient care outcomes
c. To help the patient identify realistic outcomes for health problems
d. To obtain data with which to diagnose patient strengths and problems
ANS: D
During the assessment phase, the nurse gathers information about the patient to diagnose patient streng
responses are examples of the planning, intervention, and evaluation phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
8. The nurse admits a patient to the hospital and develops a plan of care. What components should the nu
problem statement?
a. The problem and the suggested patient goals or outcomes
b. The problem, its causes, and the signs and symptoms of the problem
c. The problem with the possible etiology and the planned interventions
d. The problem, the pathophysiology of the problem, and the expected outcome
ANS: B
When writing patient problems or nursing diagnoses, this format should be used: problem, etiology, an
subjective as well as objective data should be included. Goals, outcomes, and interventions are not incl
statement.
DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
9. Which patient care task is appropriate for the nurse to delegate to experienced unlicensed assistive pers
a. Instruct the patient about the need to alternate activity and rest.
b. Monitor level of shortness of breath or fatigue after ambulation.
c. Obtain the patient’s blood pressure and pulse rate after ambulation.