MULTIPLE CHOICE
1. Thenurse completes an admission database and explains that the plan of care and discharge
goals will be developed with the patient’s input. The patient states, “How is this different from
what the doctor does?” Which response would be most appropriate for the nurse to make?
“The
role of the nurse is to administer medications and other treatments prescribed by your
a. doctor.”
nurse’s job is to help the doctor by collecting information and communicating any
“The
b. problems that occur.”
“Nursesperform many of the same procedures as the doctor, but nurses are with the patients
c. for a longer time than the doctor.”
“In
addition to caring for you while you are sick, the nurses will assist you to develop an
d. individualized plan to maintain your health.”
ANS: D
This response is consistent with the American Nurses Association (ANA) definition of nursing,
which describes the role of nurses in promoting health. 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: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
2. The nurse describes toa student nurse how to use evidence-based practice guidelines when
caring for patients. Which statement, if made by the nurse, would be the most accurate?
a. “Inferences from clinical research studies are used as a guide.”
b. “Patient care is based on clinical judgment, experience, and traditions.”
,c. “Data are evaluated 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 expertise. Clinical judgment based on the nurse’s clinical experience is part of EBP, but
clinical decision making should also incorporate current research and research-based guidelines.
Evaluation of patient outcomes is important, but interventions should be based on research from
randomized control studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 11
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teachesa student nurse about how to apply the nursing process when providing
patient care. Which statement, if made by the student nurse, indicates that teaching was
successful?
nursing process is a scientific-based method of diagnosing the patient’s health care
“The
a. problems.”
“The nursing process is a problem-solving tool used to identify and treat patients’ health
b. care needs.”
“The
nursing process is based on nursing theory that incorporates the biopsychosocial
c. nature of humans.”
“The nursing process is used primarily to explain nursing interventions to other health care
d. professionals.”
,ANS: B
The nursing process is a problem-solving approach to the identification and treatment of patients’
problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing
process is in patient care, not to establish nursing theory or explain nursing interventions to other
health care professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A
patient has been admitted to the hospital for surgery and tells the nurse, “I do not feel
comfortable leaving my children with my parents.” Which action should the nurse take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patient’s feelings about the child-care arrangements.
d. Call the patient’s parents to determine whether adequate child care is being provided.
ANS: C
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.
DIF: Cognitive Level: Apply (application) REF: 6-7
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer
on the left hip. Which nursing diagnosis is most appropriate?
, a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patient’s major problem is the impaired skin integrity as demonstrated by the presence of a
pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by
frequently repositioning the patient. Although left-sided weakness is a problem for the patient,
the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this patient,
who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but
the impaired skin integrity diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Apply (application) REF: 7-9
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to
excessive diaphoresis. Which outcome would the nurse recognize as most appropriate for this
patient?
a. Patient has a balanced intake and output.
b. Patient’s bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patient’s skin remains cool and dry throughout hospitalization.
1. Thenurse completes an admission database and explains that the plan of care and discharge
goals will be developed with the patient’s input. The patient states, “How is this different from
what the doctor does?” Which response would be most appropriate for the nurse to make?
“The
role of the nurse is to administer medications and other treatments prescribed by your
a. doctor.”
nurse’s job is to help the doctor by collecting information and communicating any
“The
b. problems that occur.”
“Nursesperform many of the same procedures as the doctor, but nurses are with the patients
c. for a longer time than the doctor.”
“In
addition to caring for you while you are sick, the nurses will assist you to develop an
d. individualized plan to maintain your health.”
ANS: D
This response is consistent with the American Nurses Association (ANA) definition of nursing,
which describes the role of nurses in promoting health. 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: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
2. The nurse describes toa student nurse how to use evidence-based practice guidelines when
caring for patients. Which statement, if made by the nurse, would be the most accurate?
a. “Inferences from clinical research studies are used as a guide.”
b. “Patient care is based on clinical judgment, experience, and traditions.”
,c. “Data are evaluated 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 expertise. Clinical judgment based on the nurse’s clinical experience is part of EBP, but
clinical decision making should also incorporate current research and research-based guidelines.
Evaluation of patient outcomes is important, but interventions should be based on research from
randomized control studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 11
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teachesa student nurse about how to apply the nursing process when providing
patient care. Which statement, if made by the student nurse, indicates that teaching was
successful?
nursing process is a scientific-based method of diagnosing the patient’s health care
“The
a. problems.”
“The nursing process is a problem-solving tool used to identify and treat patients’ health
b. care needs.”
“The
nursing process is based on nursing theory that incorporates the biopsychosocial
c. nature of humans.”
“The nursing process is used primarily to explain nursing interventions to other health care
d. professionals.”
,ANS: B
The nursing process is a problem-solving approach to the identification and treatment of patients’
problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing
process is in patient care, not to establish nursing theory or explain nursing interventions to other
health care professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A
patient has been admitted to the hospital for surgery and tells the nurse, “I do not feel
comfortable leaving my children with my parents.” Which action should the nurse take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patient’s feelings about the child-care arrangements.
d. Call the patient’s parents to determine whether adequate child care is being provided.
ANS: C
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.
DIF: Cognitive Level: Apply (application) REF: 6-7
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer
on the left hip. Which nursing diagnosis is most appropriate?
, a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patient’s major problem is the impaired skin integrity as demonstrated by the presence of a
pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by
frequently repositioning the patient. Although left-sided weakness is a problem for the patient,
the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this patient,
who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but
the impaired skin integrity diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Apply (application) REF: 7-9
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to
excessive diaphoresis. Which outcome would the nurse recognize as most appropriate for this
patient?
a. Patient has a balanced intake and output.
b. Patient’s bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patient’s skin remains cool and dry throughout hospitalization.
