Lewis Chapter.1 -Test 1 Medical Surgical Nursing
Clinical Problem 12th Edition 2024-2025 Edition.
Real Test Questions & Answers. Already Graded
A+
A home care nurse is planning care for a patient who has just been diagnosed with type
2 diabetes mellitus. Which task is appropriate for the nurse to delegate to the home
health aide?
a. Assist the patient to choose appropriate foods.
b. Help the patient with a daily bath and oral care.
c. Check the patient's feet for signs of breakdown.
d. Teach the patient how to monitor blood glucose. - ANSANS: B
Assisting with patient hygiene is included in home health-aide education and scope of
practice. Assessment of the patient and instructing the patient in new skills, such as diet
and blood glucose monitoring, are complex skills that are included in registered nurse
education and scope of practice.
A nurse asks the patient if pain was relieved after receiving medication. What is the
purpose of the evaluation phase of the nursing process?
a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care plan in the progress notes of the medical record
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 -
ANSANS: A
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.
A nurse is assigned as a case manager for a hospitalized patient with a spinal cord
injury. The patient can expect the nurse functioning in this role to perform which
activity?
a. Care for the patient during hospitalization for the injuries.
b. Assist the patient with home care activities during recovery.
c. Determine what medical care the patient needs for optimal rehabilitation.
d. Coordinate the services that the patient receives in the hospital and at home. -
ANSANS: D
The role of the case manager is to coordinate the patient's care through multiple
settings and levels of care to allow the maximal patient benefit at the least cost. The
case manager does not provide direct care in either the acute or home setting. The
, case manager coordinates and advocates for care but does not determine what medical
care is needed; that would be completed by the health care provider or other provider.
A nurse is caring for a group of patients on the medical-surgical unit with the help of one
float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed
practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse,
would be inappropriate?
a. Measurement of a patient's urine output by UAP
b. Administration of oral medications by LPN/LVN
c. Check for the presence of bowel sounds and flatulence by UAP
d. Care of a patient with diabetes by RN who usually works on the pediatric unit -
ANSANS: C
Assessment requires RN education and scope of practice and cannot be delegated to
an LPN/LVN or UAP. The other assignments made by the RN are appropriate.
A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse
to delegate to experienced unlicensed assistive personnel (UAP)?
a. Monitor for shortness of breath or fatigue after ambulation.
b. Instruct the patient about the need to alternate activity and rest.
c. Obtain the patient's blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level. - ANSANS: C
UAP education includes accurate vital sign measurement. Assessment and patient
teaching require registered nurse education and scope of practice and cannot be
delegated.
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.
- ANSANS: 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.
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
Clinical Problem 12th Edition 2024-2025 Edition.
Real Test Questions & Answers. Already Graded
A+
A home care nurse is planning care for a patient who has just been diagnosed with type
2 diabetes mellitus. Which task is appropriate for the nurse to delegate to the home
health aide?
a. Assist the patient to choose appropriate foods.
b. Help the patient with a daily bath and oral care.
c. Check the patient's feet for signs of breakdown.
d. Teach the patient how to monitor blood glucose. - ANSANS: B
Assisting with patient hygiene is included in home health-aide education and scope of
practice. Assessment of the patient and instructing the patient in new skills, such as diet
and blood glucose monitoring, are complex skills that are included in registered nurse
education and scope of practice.
A nurse asks the patient if pain was relieved after receiving medication. What is the
purpose of the evaluation phase of the nursing process?
a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care plan in the progress notes of the medical record
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 -
ANSANS: A
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.
A nurse is assigned as a case manager for a hospitalized patient with a spinal cord
injury. The patient can expect the nurse functioning in this role to perform which
activity?
a. Care for the patient during hospitalization for the injuries.
b. Assist the patient with home care activities during recovery.
c. Determine what medical care the patient needs for optimal rehabilitation.
d. Coordinate the services that the patient receives in the hospital and at home. -
ANSANS: D
The role of the case manager is to coordinate the patient's care through multiple
settings and levels of care to allow the maximal patient benefit at the least cost. The
case manager does not provide direct care in either the acute or home setting. The
, case manager coordinates and advocates for care but does not determine what medical
care is needed; that would be completed by the health care provider or other provider.
A nurse is caring for a group of patients on the medical-surgical unit with the help of one
float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed
practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse,
would be inappropriate?
a. Measurement of a patient's urine output by UAP
b. Administration of oral medications by LPN/LVN
c. Check for the presence of bowel sounds and flatulence by UAP
d. Care of a patient with diabetes by RN who usually works on the pediatric unit -
ANSANS: C
Assessment requires RN education and scope of practice and cannot be delegated to
an LPN/LVN or UAP. The other assignments made by the RN are appropriate.
A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse
to delegate to experienced unlicensed assistive personnel (UAP)?
a. Monitor for shortness of breath or fatigue after ambulation.
b. Instruct the patient about the need to alternate activity and rest.
c. Obtain the patient's blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level. - ANSANS: C
UAP education includes accurate vital sign measurement. Assessment and patient
teaching require registered nurse education and scope of practice and cannot be
delegated.
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.
- ANSANS: 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.
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
