Test Bank For Medical-Surgical Nursing,
12th Edition by Mariann M. Harding,
Jeffrey Kwong, Debra Hagler Chapter 1-69
Chapter 01: Professional Nursing
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
MULTIPLE
CHOICE
• The nurse completes an admission database and explains that the plan of care
and discharge goals will be developed with the patient‘s input. The patient
asks, “How is this different from what the physician does?” Which response
would the nurse provide?
A. “The role of the nurse is to administer medications and other
treatments prescribed by your physician.”
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 collect information and communicate
any problems that occur to the physician.”
D. “Nurses perform many of the same procedures as the physician,
but nurses are with the patients for a longer time than the
physician.”
ANS: B
The American Nurses Association (ANA) definition of nursing describes the role
of nurses inpromoting health. The other responses describe dependent and
collaborative functions of the nursing role but do not accurately describe the
nurse‘s unique role in the health care system.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care
Environment
• Which statement by the nurse accurately describes the use of evidence-based
practice (EBP)?
A. “Patient care is based on clinical judgment, experience, and traditions.”
, B. “Data are analyzed later to show that the patient outcomes are consistently
met.”
C. “Research from all published articles are used as a guide for planning patient
care.”
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 withclinician expertise and consideration of patient preferences.
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
data analysis is not required to use EBP. All published articles do not provide
research evidence; interventions should be based on credible research,
preferably randomizedcontrolled studies with a large number of subjects.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing
Process: PlanningMSC: NCLEX: Safe and Effective Care Environment
• Which statement by the nurse provides a clear explanation of the nursing process?
A. “The nursing process is a research method of diagnosing the
patient‘s health careproblems.”
B. “The nursing process is used primarily to explain nursing
interventions to otherhealth care professionals.”
C. “The nursing process is a problem-solving tool used to identify and manage the
patients health record.
D. “The nursing process is based on nursing theory that
incorporates thebiopsychosocial nature of humans.”
ANS: C
The nursing process is a problem-solving approach to the identification and
treatment of patients‘ problems. Nursing process does not require research
methods for diagnosis. The primary use of the nursing process is in patient
care, not to establish nursing theory or explainnursing interventions to other
health care professionals.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing
Process: EvaluationMSC: NCLEX: Safe and Effective Care Environment
• A patient admitted to the hospital for surgery tells the nurse, “I do not
feel comfortable leaving my children with my parents.” Which action
would 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 information on the patient‘s concerns about the child care
arrangements.
, D. Call the patient‘s parents to determine whether adequate
child care is beingprovided.
ANS: C
Because 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 interventioncan be chosen.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
• A patient with a bacterial infection is hypovolemic due to a fever and
excessive diaphoresis. Which expected outcome would the nurse select 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 ofdeficient fluid volume. The other statements would not indicate
that the problem of hypovolemia was resolved.
DIF: Cognitive Level: Apply (Application) TOP: Nursing
Process: PlanningMSC: NCLEX: Physiological Integrity
• Which statement describes the purpose of the evaluation phase of the 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 the nursing interventions were appropriate. The
other responses do not describe the evaluation phase.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing
Process: EvaluationMSC: NCLEX: Safe and Effective Care Environment
, • Which statement describes the purpose of the assessment 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 obtain data to diagnose patient strengths and problems
D. To help the patient identify realistic outcomes for health problems
ANS: C
During the assessment phase, the nurse gathers information about the
patient to diagnosepatient strengths and problems. The other 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
• When developing the plan of care, which components would the nurse include
in the clinicalproblem 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, its pathophysiology, and the expected outcome
ANS: B
When writing clinical problems or nursing diagnoses, the subjective as well as
objective data to support the problem‘s existence should be included. Goals,
outcomes, and interventions arenot included in the problem statement.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing
Process: DiagnosisMSC: NCLEX: Safe and Effective Care Environment
• Which patient care task would the nurse delegate to experienced assistive
personnel (AP)?
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.
D. Determine whether the patient is ready to increase the activity level.
ANS: C
AP education includes accurate vital sign measurement. Assessment and
patient teachingrequire registered nurse education and scope of practice and
cannot be delegated.
DIF: Cognitive Level: Apply (Application) TOP: Nursing
Process: PlanningMSC: NCLEX: Safe and Effective Care Environment
12th Edition by Mariann M. Harding,
Jeffrey Kwong, Debra Hagler Chapter 1-69
Chapter 01: Professional Nursing
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
MULTIPLE
CHOICE
• The nurse completes an admission database and explains that the plan of care
and discharge goals will be developed with the patient‘s input. The patient
asks, “How is this different from what the physician does?” Which response
would the nurse provide?
A. “The role of the nurse is to administer medications and other
treatments prescribed by your physician.”
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 collect information and communicate
any problems that occur to the physician.”
D. “Nurses perform many of the same procedures as the physician,
but nurses are with the patients for a longer time than the
physician.”
ANS: B
The American Nurses Association (ANA) definition of nursing describes the role
of nurses inpromoting health. The other responses describe dependent and
collaborative functions of the nursing role but do not accurately describe the
nurse‘s unique role in the health care system.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care
Environment
• Which statement by the nurse accurately describes the use of evidence-based
practice (EBP)?
A. “Patient care is based on clinical judgment, experience, and traditions.”
, B. “Data are analyzed later to show that the patient outcomes are consistently
met.”
C. “Research from all published articles are used as a guide for planning patient
care.”
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 withclinician expertise and consideration of patient preferences.
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
data analysis is not required to use EBP. All published articles do not provide
research evidence; interventions should be based on credible research,
preferably randomizedcontrolled studies with a large number of subjects.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing
Process: PlanningMSC: NCLEX: Safe and Effective Care Environment
• Which statement by the nurse provides a clear explanation of the nursing process?
A. “The nursing process is a research method of diagnosing the
patient‘s health careproblems.”
B. “The nursing process is used primarily to explain nursing
interventions to otherhealth care professionals.”
C. “The nursing process is a problem-solving tool used to identify and manage the
patients health record.
D. “The nursing process is based on nursing theory that
incorporates thebiopsychosocial nature of humans.”
ANS: C
The nursing process is a problem-solving approach to the identification and
treatment of patients‘ problems. Nursing process does not require research
methods for diagnosis. The primary use of the nursing process is in patient
care, not to establish nursing theory or explainnursing interventions to other
health care professionals.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing
Process: EvaluationMSC: NCLEX: Safe and Effective Care Environment
• A patient admitted to the hospital for surgery tells the nurse, “I do not
feel comfortable leaving my children with my parents.” Which action
would 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 information on the patient‘s concerns about the child care
arrangements.
, D. Call the patient‘s parents to determine whether adequate
child care is beingprovided.
ANS: C
Because 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 interventioncan be chosen.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
• A patient with a bacterial infection is hypovolemic due to a fever and
excessive diaphoresis. Which expected outcome would the nurse select 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 ofdeficient fluid volume. The other statements would not indicate
that the problem of hypovolemia was resolved.
DIF: Cognitive Level: Apply (Application) TOP: Nursing
Process: PlanningMSC: NCLEX: Physiological Integrity
• Which statement describes the purpose of the evaluation phase of the 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 the nursing interventions were appropriate. The
other responses do not describe the evaluation phase.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing
Process: EvaluationMSC: NCLEX: Safe and Effective Care Environment
, • Which statement describes the purpose of the assessment 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 obtain data to diagnose patient strengths and problems
D. To help the patient identify realistic outcomes for health problems
ANS: C
During the assessment phase, the nurse gathers information about the
patient to diagnosepatient strengths and problems. The other 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
• When developing the plan of care, which components would the nurse include
in the clinicalproblem 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, its pathophysiology, and the expected outcome
ANS: B
When writing clinical problems or nursing diagnoses, the subjective as well as
objective data to support the problem‘s existence should be included. Goals,
outcomes, and interventions arenot included in the problem statement.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing
Process: DiagnosisMSC: NCLEX: Safe and Effective Care Environment
• Which patient care task would the nurse delegate to experienced assistive
personnel (AP)?
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.
D. Determine whether the patient is ready to increase the activity level.
ANS: C
AP education includes accurate vital sign measurement. Assessment and
patient teachingrequire registered nurse education and scope of practice and
cannot be delegated.
DIF: Cognitive Level: Apply (Application) TOP: Nursing
Process: PlanningMSC: NCLEX: Safe and Effective Care Environment
