,Chapter 01: Professional Nursing Practice
gg gg gg gg
Lewis: Medical-Surgical Nursing, 10th Edition
gg gg gg gg gg
MULTIPLE CHOICE gg
1. The nurse completes an admission database and explains that the plan of care and
gg gg gg gg gg gg gg gg gg gg gg gg gg
discharge goals will be developed with the patient‘s input. The patient states, ―How is
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
this different from what the doctor does?‖ Which response would be most appropriate
gg gg gg gg gg gg gg gg gg gg gg gg gg
for the nurse to make?
gg gg gg gg gg
a. ―The role of the nurse is to administer medications and other treatments
gg gg gg gg gg gg gg gg gg gg gg
prescribed by your doctor.‖
gg gg gg gg
b. ―The nurse‘s job is to help the doctor by collecting information
gg gg gg gg gg gg gg gg gg gg
and communicating any problems that occur.‖
gg gg gg gg gg gg
c. ―Nurses perform many of the same procedures as the doctor, but nurses are
gg gg gg gg gg gg gg gg gg gg gg gg
with the patients for a longer time thadoctor.‖
gg gg gg gg gg gg gg gg
d. ―In addition to caring for you while you are sick, the nurses will assist
gg gg gg gg gg gg gg gg gg gg gg gg gg
you to develop an individualized plan to maintain your health.‖
gg gg gg gg gg gg gg gg gg gg
ANS: g g D
This response is consistent with the American Nurses Association (ANA) definition of
gg gg gg gg gg gg gg gg gg gg gg
nursing, which describes the role of nurses in promoting health. The other responses
gg gg gg gg gg gg gg gg gg gg gg gg gg
describe some of the dependent and collaborative functions of the nursing role but do not
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
accurately describe the nurse‘s role in the health care system.
gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Understand (comprehension) REF: 3 gg gg gg gg gg
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
g g gg gg g g gg gg gg gg gg
2. The nurse describes to a student nurse how to use evidence-based practice guidelines
gg gg gg gg gg gg gg gg gg gg gg gg
when caring for patients. Which statement, if made by the nurse, would be the most
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
accurate?
gg
a. ―Inferences from clinical research studies are used as a guide.‖ gg gg gg gg gg gg gg gg gg
b. ―Patient care is based on clinical judgment, experience, and traditions.‖
gg gg gg gg gg gg gg gg gg
c. ―Data are evaluated to show that the patient outcomes are consistently met.‖
gg gg gg gg gg gg gg gg gg gg gg
d. ―Recommendations are based on research, clinical expertise, and gg gg gg gg gg gg gg
patient preferences.‖
gg gg
ANS: g g D
Evidence-based practice (EBP) is the use of the best research-based evidence combined
gg gg gg gg gg gg gg gg gg gg gg
with clinician expertise. Clinical judgment based on the nurse‘s clinical experience is part of
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
EBP, but clinical decision making should also incorporate current research and research-
gg gg gg gg gg gg gg gg gg gg gg gg
based guidelines. Evaluation of patient outcomes is important, but interventions should be
gg gg gg gg gg gg gg gg gg gg gg
based on research from randomized control studies with a large number of subjects.
gg gg gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Remember (knowledge) gg gg gg REF: 15 gg gg
TOP: Nursing Process: Planning
g g MSC: gg gg g g NCLEX: Safe and Effective Care Environment
gg gg gg gg gg
3. The nurse teaches a student nurse about how to apply the nursing process when providing
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
patient care. Which statement, if made by the student nurse, indicates that teaching was
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
successful?
gg
a. ―The nursing process is a scientific-based method of diagnosing the patient‘s
gg gg gg gg gg gg gg gg gg gg
, health care problems.‖ gg gg
b. ―The nursing process is a problem-solving tool used to identify and treat
gg gg gg gg gg gg gg gg gg gg gg
patients‘ health care needs.‖
gg gg gg gg
c. ―The nursing process is used primarily to explain nursing interventions to
gg gg gg gg gg gg gg gg gg gg
other health care professionals.‖
gg gg gg gg
d. ―The nursing process is based on nursing theory that incorporates
gg gg gg gg gg gg gg gg gg
the biopsychosocial nature of humans.‖
gg gg gg gg gg
ANS: g g B
The nursing process is a problem-solving approach to the identification and treatment of
gg gg gg gg gg gg gg gg gg gg gg gg
patients‘ problems. Diagnosis is only one phase of the nursing process. The primary use of
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
the nursing process is in patient care, not to establish nursing theory or explain nursing
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
interventions to other health care professionals.
gg gg gg gg gg gg
DIF: Cognitive Level: Understand (comprehension) REF: 5 gg gg gg gg gg
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
g g gg gg g g gg gg gg gg gg
4. A patient has been admitted to the hospital for surgery and tells the nurse, ―I do not
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
feel comfortable leaving my children with my parents.‖ Which action should the nurse
gg gg gg gg gg gg gg gg gg gg gg gg gg
take next?
gg gg
a. Reassure the patient that these feelings are common for parents.
gg gg gg gg gg gg gg gg gg
b. Have the patient call the children to ensure that they are doing well.
gg gg gg gg gg gg gg gg gg gg gg gg
c. Gather more data about the patient‘s feelings about the child-care arrangements.
gg gg gg gg gg gg gg gg gg gg
d. Call the patient‘s parents to determine whether adequate child care is
gg gg gg gg gg gg gg gg gg gg
being provided.
gg gg
ANS: g g C
Because a complete assessment is necessary in order to identify a problem and choose an
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
appropriate intervention, the nurse‘s first action should be to obtain more information. The
gg gg gg gg gg gg gg gg gg gg gg gg gg
other actions may be appropriate, but more assessment is needed before the best
gg gg gg gg gg gg gg gg gg gg gg gg gg
intervention can be chosen.
gg gg gg gg
DIF: Cognitive Level: Apply (application) REF: 6 gg gg gg
OBJ: Special Questions: Prioritization TOP: Nursing Process:
g g gg gg g g gg
Assessment MSC: NCLEX: Psychosocial Integrity
gg gg g g gg gg
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
gg ulcer on the left hip. Which nursing diagnosis is most appropriate?
gg gg gg gg gg gg gg gg gg gg
a. Impaired physical mobility related to left-sided paralysis
gg gg gg gg gg gg
b. Risk for impaired tissue integrity related to left-sided weakness
gg gg gg gg gg gg gg gg
c. Impaired skin integrity related to altered circulation and pressure
gg gg gg gg gg gg gg gg
d. Ineffective tissue perfusion related to inability to move independently
gg gg gg gg gg gg gg gg
ANS: g g C
The patient‘s major problem is the impaired skin integrity as demonstrated by the presence
gg gg gg gg gg gg gg gg gg gg gg gg gg
of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
by frequently repositioning the patient. Although left-sided weakness is a problem for the
gg gg gg gg gg gg gg gg gg gg gg gg gg
patient, the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
for this patient, who already has impaired tissue integrity. The patient does have ineffective
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the
gg gg gg gg gg gg gg gg gg gg gg gg gg
health problem is.
gg gg gg
, DIF: Cognitive Level: Apply (application) REF: 7 gg gg gg
TOP: Nursing Process: Diagnosis
g g MSC: NCLEX: Physiological Integrity
gg gg g g gg gg
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume
gg gg gg gg gg gg gg gg gg gg gg gg gg
related to excessive diaphoresis. Which outcome would the nurse recognize as appropriate
gg gg gg gg gg gg gg gg gg gg gg gg
for this patient?
gg gg gg
a. Patient has a balanced intake and output.
gg gg gg gg gg gg
b. Patient‘s bedding is changed when it becomes damp.
gg gg gg gg gg gg gg
c. Patient understands the need for increased fluid intake.
gg gg gg gg gg gg gg
d. Patient‘s skin remains cool and dry throughout hospitalization.
gg gg gg gg gg gg gg
ANS: g g A
This statement gives measurable data showing resolution of the problem of deficient fluid
gg gg gg gg gg gg gg gg gg gg gg gg
volume that was identified in the nursing diagnosis statement. The other statements would
gg gg gg gg gg gg gg gg gg gg gg gg gg
not indicate that the problem of deficient fluid volume was resolved.
gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Apply (application) REF: 7 gg gg gg
TOP: Nursing Process: Planning
g g MSC: NCLEX: Physiological Integrity
gg gg g g gg gg
7. A nurse asks the patient if pain was relieved after receiving medication. What is the
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
purpose of the evaluation phase of the nursing process?
gg gg gg gg gg gg gg gg gg
a. To determine if interventions have been effective in meeting patient outcomes
gg gg gg gg gg gg gg gg gg gg
b. To document the nursing care plan in the progress notes of the medical record
gg gg gg gg gg gg gg gg gg gg gg gg gg
c. To decide whether the patient‘s health problems have been completely resolved
gg gg gg gg gg gg gg gg gg gg
d. To establish if the patient agrees that the nursing care provided was satisfactory
gg gg gg gg gg gg gg gg gg gg gg gg
ANS: g g A
Evaluation consists of determining whether the desired patient outcomes have been met
gg gg gg gg gg gg gg gg gg gg gg
and whether the nursing interventions were appropriate. The other responses do not
gg gg gg gg gg gg gg gg gg gg gg gg
describe the evaluation phase.
gg gg gg gg
DIF: Cognitive Level: Understand (comprehension) REF: 5 gg gg gg
TOP: Nursing Process: Evaluation
g g MSC: NCLEX: Safe and Effective Care Environment
gg gg g g gg gg gg gg gg
8. The nurse interviews a patient while completing the health history and physical
gg gg gg gg gg gg gg gg gg gg gg
examination. What is the purpose of the assessment phase of the nursing process?
gg gg gg gg gg gg gg gg gg gg gg gg gg
a. To teach interventions that relieve health problems
gg gg gg gg gg gg
b. To use patient data to evaluate patient care outcomes
gg gg gg gg gg gg gg gg
c. To obtain data with which to diagnose patient problems
gg gg gg gg gg gg gg gg
d. To help the patient identify realistic outcomes for health problems
gg gg gg gg gg gg gg gg gg
ANS: g g C
During the assessment phase, the nurse gathers information about the patient to diagnose
gg gg gg gg gg gg gg gg gg gg gg gg
patient problems. The other responses are examples of the planning, intervention, and
gg gg gg gg gg gg gg gg gg gg gg gg
evaluation phases of the nursing process.
gg gg gg gg gg gg
DIF: Cognitive Level: Understand (comprehension) REF: 5 gg gg gg
TOP: Nursing Process: Assessment
g g MSC: NCLEX: Safe and Effective Care Environment
gg gg g g gg gg gg gg gg
gg gg gg gg
Lewis: Medical-Surgical Nursing, 10th Edition
gg gg gg gg gg
MULTIPLE CHOICE gg
1. The nurse completes an admission database and explains that the plan of care and
gg gg gg gg gg gg gg gg gg gg gg gg gg
discharge goals will be developed with the patient‘s input. The patient states, ―How is
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
this different from what the doctor does?‖ Which response would be most appropriate
gg gg gg gg gg gg gg gg gg gg gg gg gg
for the nurse to make?
gg gg gg gg gg
a. ―The role of the nurse is to administer medications and other treatments
gg gg gg gg gg gg gg gg gg gg gg
prescribed by your doctor.‖
gg gg gg gg
b. ―The nurse‘s job is to help the doctor by collecting information
gg gg gg gg gg gg gg gg gg gg
and communicating any problems that occur.‖
gg gg gg gg gg gg
c. ―Nurses perform many of the same procedures as the doctor, but nurses are
gg gg gg gg gg gg gg gg gg gg gg gg
with the patients for a longer time thadoctor.‖
gg gg gg gg gg gg gg gg
d. ―In addition to caring for you while you are sick, the nurses will assist
gg gg gg gg gg gg gg gg gg gg gg gg gg
you to develop an individualized plan to maintain your health.‖
gg gg gg gg gg gg gg gg gg gg
ANS: g g D
This response is consistent with the American Nurses Association (ANA) definition of
gg gg gg gg gg gg gg gg gg gg gg
nursing, which describes the role of nurses in promoting health. The other responses
gg gg gg gg gg gg gg gg gg gg gg gg gg
describe some of the dependent and collaborative functions of the nursing role but do not
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
accurately describe the nurse‘s role in the health care system.
gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Understand (comprehension) REF: 3 gg gg gg gg gg
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
g g gg gg g g gg gg gg gg gg
2. The nurse describes to a student nurse how to use evidence-based practice guidelines
gg gg gg gg gg gg gg gg gg gg gg gg
when caring for patients. Which statement, if made by the nurse, would be the most
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
accurate?
gg
a. ―Inferences from clinical research studies are used as a guide.‖ gg gg gg gg gg gg gg gg gg
b. ―Patient care is based on clinical judgment, experience, and traditions.‖
gg gg gg gg gg gg gg gg gg
c. ―Data are evaluated to show that the patient outcomes are consistently met.‖
gg gg gg gg gg gg gg gg gg gg gg
d. ―Recommendations are based on research, clinical expertise, and gg gg gg gg gg gg gg
patient preferences.‖
gg gg
ANS: g g D
Evidence-based practice (EBP) is the use of the best research-based evidence combined
gg gg gg gg gg gg gg gg gg gg gg
with clinician expertise. Clinical judgment based on the nurse‘s clinical experience is part of
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
EBP, but clinical decision making should also incorporate current research and research-
gg gg gg gg gg gg gg gg gg gg gg gg
based guidelines. Evaluation of patient outcomes is important, but interventions should be
gg gg gg gg gg gg gg gg gg gg gg
based on research from randomized control studies with a large number of subjects.
gg gg gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Remember (knowledge) gg gg gg REF: 15 gg gg
TOP: Nursing Process: Planning
g g MSC: gg gg g g NCLEX: Safe and Effective Care Environment
gg gg gg gg gg
3. The nurse teaches a student nurse about how to apply the nursing process when providing
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
patient care. Which statement, if made by the student nurse, indicates that teaching was
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
successful?
gg
a. ―The nursing process is a scientific-based method of diagnosing the patient‘s
gg gg gg gg gg gg gg gg gg gg
, health care problems.‖ gg gg
b. ―The nursing process is a problem-solving tool used to identify and treat
gg gg gg gg gg gg gg gg gg gg gg
patients‘ health care needs.‖
gg gg gg gg
c. ―The nursing process is used primarily to explain nursing interventions to
gg gg gg gg gg gg gg gg gg gg
other health care professionals.‖
gg gg gg gg
d. ―The nursing process is based on nursing theory that incorporates
gg gg gg gg gg gg gg gg gg
the biopsychosocial nature of humans.‖
gg gg gg gg gg
ANS: g g B
The nursing process is a problem-solving approach to the identification and treatment of
gg gg gg gg gg gg gg gg gg gg gg gg
patients‘ problems. Diagnosis is only one phase of the nursing process. The primary use of
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
the nursing process is in patient care, not to establish nursing theory or explain nursing
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
interventions to other health care professionals.
gg gg gg gg gg gg
DIF: Cognitive Level: Understand (comprehension) REF: 5 gg gg gg gg gg
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
g g gg gg g g gg gg gg gg gg
4. A patient has been admitted to the hospital for surgery and tells the nurse, ―I do not
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
feel comfortable leaving my children with my parents.‖ Which action should the nurse
gg gg gg gg gg gg gg gg gg gg gg gg gg
take next?
gg gg
a. Reassure the patient that these feelings are common for parents.
gg gg gg gg gg gg gg gg gg
b. Have the patient call the children to ensure that they are doing well.
gg gg gg gg gg gg gg gg gg gg gg gg
c. Gather more data about the patient‘s feelings about the child-care arrangements.
gg gg gg gg gg gg gg gg gg gg
d. Call the patient‘s parents to determine whether adequate child care is
gg gg gg gg gg gg gg gg gg gg
being provided.
gg gg
ANS: g g C
Because a complete assessment is necessary in order to identify a problem and choose an
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
appropriate intervention, the nurse‘s first action should be to obtain more information. The
gg gg gg gg gg gg gg gg gg gg gg gg gg
other actions may be appropriate, but more assessment is needed before the best
gg gg gg gg gg gg gg gg gg gg gg gg gg
intervention can be chosen.
gg gg gg gg
DIF: Cognitive Level: Apply (application) REF: 6 gg gg gg
OBJ: Special Questions: Prioritization TOP: Nursing Process:
g g gg gg g g gg
Assessment MSC: NCLEX: Psychosocial Integrity
gg gg g g gg gg
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
gg ulcer on the left hip. Which nursing diagnosis is most appropriate?
gg gg gg gg gg gg gg gg gg gg
a. Impaired physical mobility related to left-sided paralysis
gg gg gg gg gg gg
b. Risk for impaired tissue integrity related to left-sided weakness
gg gg gg gg gg gg gg gg
c. Impaired skin integrity related to altered circulation and pressure
gg gg gg gg gg gg gg gg
d. Ineffective tissue perfusion related to inability to move independently
gg gg gg gg gg gg gg gg
ANS: g g C
The patient‘s major problem is the impaired skin integrity as demonstrated by the presence
gg gg gg gg gg gg gg gg gg gg gg gg gg
of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
by frequently repositioning the patient. Although left-sided weakness is a problem for the
gg gg gg gg gg gg gg gg gg gg gg gg gg
patient, the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
for this patient, who already has impaired tissue integrity. The patient does have ineffective
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the
gg gg gg gg gg gg gg gg gg gg gg gg gg
health problem is.
gg gg gg
, DIF: Cognitive Level: Apply (application) REF: 7 gg gg gg
TOP: Nursing Process: Diagnosis
g g MSC: NCLEX: Physiological Integrity
gg gg g g gg gg
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume
gg gg gg gg gg gg gg gg gg gg gg gg gg
related to excessive diaphoresis. Which outcome would the nurse recognize as appropriate
gg gg gg gg gg gg gg gg gg gg gg gg
for this patient?
gg gg gg
a. Patient has a balanced intake and output.
gg gg gg gg gg gg
b. Patient‘s bedding is changed when it becomes damp.
gg gg gg gg gg gg gg
c. Patient understands the need for increased fluid intake.
gg gg gg gg gg gg gg
d. Patient‘s skin remains cool and dry throughout hospitalization.
gg gg gg gg gg gg gg
ANS: g g A
This statement gives measurable data showing resolution of the problem of deficient fluid
gg gg gg gg gg gg gg gg gg gg gg gg
volume that was identified in the nursing diagnosis statement. The other statements would
gg gg gg gg gg gg gg gg gg gg gg gg gg
not indicate that the problem of deficient fluid volume was resolved.
gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Apply (application) REF: 7 gg gg gg
TOP: Nursing Process: Planning
g g MSC: NCLEX: Physiological Integrity
gg gg g g gg gg
7. A nurse asks the patient if pain was relieved after receiving medication. What is the
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
purpose of the evaluation phase of the nursing process?
gg gg gg gg gg gg gg gg gg
a. To determine if interventions have been effective in meeting patient outcomes
gg gg gg gg gg gg gg gg gg gg
b. To document the nursing care plan in the progress notes of the medical record
gg gg gg gg gg gg gg gg gg gg gg gg gg
c. To decide whether the patient‘s health problems have been completely resolved
gg gg gg gg gg gg gg gg gg gg
d. To establish if the patient agrees that the nursing care provided was satisfactory
gg gg gg gg gg gg gg gg gg gg gg gg
ANS: g g A
Evaluation consists of determining whether the desired patient outcomes have been met
gg gg gg gg gg gg gg gg gg gg gg
and whether the nursing interventions were appropriate. The other responses do not
gg gg gg gg gg gg gg gg gg gg gg gg
describe the evaluation phase.
gg gg gg gg
DIF: Cognitive Level: Understand (comprehension) REF: 5 gg gg gg
TOP: Nursing Process: Evaluation
g g MSC: NCLEX: Safe and Effective Care Environment
gg gg g g gg gg gg gg gg
8. The nurse interviews a patient while completing the health history and physical
gg gg gg gg gg gg gg gg gg gg gg
examination. What is the purpose of the assessment phase of the nursing process?
gg gg gg gg gg gg gg gg gg gg gg gg gg
a. To teach interventions that relieve health problems
gg gg gg gg gg gg
b. To use patient data to evaluate patient care outcomes
gg gg gg gg gg gg gg gg
c. To obtain data with which to diagnose patient problems
gg gg gg gg gg gg gg gg
d. To help the patient identify realistic outcomes for health problems
gg gg gg gg gg gg gg gg gg
ANS: g g C
During the assessment phase, the nurse gathers information about the patient to diagnose
gg gg gg gg gg gg gg gg gg gg gg gg
patient problems. The other responses are examples of the planning, intervention, and
gg gg gg gg gg gg gg gg gg gg gg gg
evaluation phases of the nursing process.
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DIF: Cognitive Level: Understand (comprehension) REF: 5 gg gg gg
TOP: Nursing Process: Assessment
g g MSC: NCLEX: Safe and Effective Care Environment
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