Chapter gg
,01: Professional Nursing
gg gg
Harding: Lewis’s Medical-Surgical Nursing, g g g g 12th Edition
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 asks, ―How
gg yy gg gg gg gg gg gg gg gg gg gg gg
is this different from what the physician does?‖ Which response would the
gg gg gg g g yy g g g g g g g g g g g g g g
nurse provide?
g g g g
a. ―The role of the nurse is to administer medications and other
gg gg gg gg gg gg gg gg gg gg
treatments prescribed by your physician.‖
gg gg yy gg g g
b. ―In addition to caring for you while you are sick, the nurses will help
gg gg gg gg gg gg gg gg gg gg gg gg gg
you plan to maintain your health.‖
gg gg gg yy g g g g
c. ―The nurse‗s job is to collect information and communicate any
gg gg gg gg gg gg gg gg gg
problems thatoccur to the physician.‖
gg gg g g g g g g
d. ―Nurses perform many of the same procedures as the physician, but
gg gg gg gg gg gg gg gg gg gg
nurses are with the patients for a longer time than the
gg gg g g g g g g g g g g g g g g g g g g
physician.‖
g g
ANS: g g B
The American Nurses Association (ANA) definition of nursing describes the
g g g g g g g g g g g g g g g g g g
role of nurses inpromoting health. The other responses describe dependent and
g g g g gg gg gg gg gg gg gg gg gg
collaborative functions of the nursing role but do not accurately describe
gg gg g g g g g g g g g g g g g g g g g g
the nurse‗s unique role in the health care system.
g g g g g g g g g g gg gg g g gg
DIF: Cognitive Level: Analyze (Analysis)
g g g g g g gg gg gg
TOP: Nursing Process: Implementation g g g g MSC: NCLEX: g g Safe g g and
g Effective
g Care Environment g g gg
2. Which statement by the nurse accurately describes
gg g g gg g g gg gg g g the use of evidence-based practice
gg gg g g g g
gg (EBP)?
a. ―Patient care is based on clinical judgment, experience, and traditions.‖
gg gg gg gg gg gg gg gg gg
b. ―Data are analyzed later to show that the patient outcomes are consistently met.‖
gg gg gg gg gg gg gg gg gg gg gg gg
c. ―Research from all published articles are used as a guide for planning patient care.‖
gg gg gg gg gg gg gg gg gg gg gg gg gg
d. ―Recommendations are based on research, clinical expertise, gg gg gg gg gg gg
and patient preferences.‖
gg gg g g
ANS: g g D
Evidence-based practice (EBP) is the use of the best research-based g g g g g g g g g g g g g g g g g g
evidence combined with clinician expertise and consideration of patient
g g g g gg yy g g gg gg g g gg
preferences. Clinical judgment based on the nurse‗s clinical experience is
gg g g gg gg gg g g g g g g g g g g
part of EBP, but clinical decision making should also incorporate current
g g g g g g g g g g g g g g g g gg g g gg
research and research-based guidelines. Evaluation of patient outcomes isimportant,
g g gg gg gg gg gg gg gg g g
but data analysis is not required to use EBP. All published articles do
g g g g g g g g g g g g g g g g g g g g g g gg g g
not provide research evidence; interventions should be based on credible research,
g g g g g g gg gg gg gg gg gg gg gg
preferably randomizedcontrolled studies with a large number of subjects.
g g gg g g g g g g g g g g g g g g
DIF: Cognitive Level: Understand (Comprehension) gg g g gg TOP: Nursing g g
Process: Planning MSC:
gg gg yy NCLEX: Safe and g g g g
Effective Care Environment
g g g g g g
3. Which statement by the nurse provides a clear explanation of the nursing process?
gg g g gg g g gg g g g g g g gg gg g g gg
a. ―The nursing process is a research method of diagnosing the patient‗s
gg gg gg gg gg gg gg gg gg gg
health careproblems.‖
gg gg
b. ―The nursing process is used primarily to explain nursing interventions
gg gg gg gg gg gg gg gg gg
to otherhealth care professionals.‖
gg gg g g g g
c. ―The nursing process is a problem-solving tool used to identify and manage the
gg gg gg gg gg gg gg gg gg gg gg gg
, patients‗ health care needs.‖ gg gg gg
d. ―The nursing process is based on nursing theory that
gg gg gg gg gg gg gg gg
incorporates the biopsychosocial nature of humans.‖
gg gg yy g g gg g g
ANS: g g C
The nursing process is a problem-solving approach to the identification and
g g g g g g g g g g g g g g g g g g g g
treatment of patients‗ problems. Nursing process does not require research
g g g g gg g g g g g g g g g g g g g g
methods for diagnosis.
g g g g g g
The primary use of the nursing process is in patient care, not to establish
g g gg gg g g gg gg g g g g gg g g g g gg gg
nursing theory or explain nursing interventions to other health care professionals.
gg gg gg gg yy gg g g g g gg g g g g
DIF: Cognitive Level: Understand (Comprehension) gg g g gg TOP: Nursing g g
Process: EvaluationMSC:
gg gg NCLEX: Safe and g g g g
Effective Care Environment
g g g g g g
4. A patient admitted to the hospital for surgery tells the nurse, ―I do not
gg gg gg gg gg gg gg gg gg gg gg gg gg
feel comfortableleaving my children with my parents.‖ Which action
gg gg gg gg g g g g gg g g g g
would the nurse take next?
g g g g gg g g g g
a. Reassure the patient that these feelings are common for parents.
gg gg gg g g gg gg gg gg gg
b. Have the patient call the children to ensure that they are doing well.
gg gg g g g g g g g g gg gg g g gg gg gg
c. Gather information on the patient‗s concerns 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
gg gg gg gg gg gg gg gg
care is being provided.
gg gg gg yy
ANS: g g C
Because a complete assessment is necessary in order to identify a problem
g g g g g g g g g g g g g g g g g g g g g g
and choose an appropriate intervention, the nurse‗s first action should be
g g g g gg g g g g g g g g g g g g g g g g
to obtain more information. The other actions may be appropriate, but more
g g g g g g gg g g g g gg gg gg gg gg g g
assessment is needed before the best intervention can be chosen.
gg gg gg g g gg gg gg yy g g g g
DIF: Cognitive Level: Analyze (Analysis) gg gg gg
TOP: Nursing Process: Assessment MSC: gg g g g g g g NCLEX: Psychosocial Integrity gg gg
5. A patient with a bacterial infection is hypovolemic due to a fever and
gg gg gg gg g g gg gg g g gg gg gg gg
excessive diaphoresis.Which expected outcome would the nurse select
g g gg g g g g g g g g g g g g
for this patient?
g g g g g g
a. Patient has a balanced intake and output.
gg gg gg gg gg g g
b. Patient‗s bedding is kept clean and free of moisture.
gg 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
Balanced intake and output gives measurable data showing resolution of the problem
gg g g gg gg gg gg g g gg g g gg gg
ofdeficient fluid volume. The other statements would not indicate that the
gg g g g g g g g g g g g g g g g g g g g g
problem of hypovolemia was resolved.
g g g g gg g g g g
DIF: Cognitive Level: Apply (Application) gg g g gg TOP: Nursing g g
Process: Planning MSC:
gg gg yy NCLEX:
Physiological Integrity
g g g g
6. Which statement describes the purpose of the evaluation phase of the nursing
gg g g gg gg gg gg gg g g gg gg gg
process?
gg
a. To document the nursing care plan in the progress notes of the health record
gg g g gg g g gg g g g g gg g g gg gg gg g g
b. To determine if interventions have been effective in meeting patient outcomes
gg gg gg gg gg gg gg gg gg g g
c. To decide whether the patient‗s health problems have been completely resolved
gg gg gg gg gg gg g g gg g g gg
d. To establish if the patient agrees that the nursing care provided was satisfactory
gg gg gg gg g g gg gg gg gg gg g g g g
ANS: g g B
, Evaluation consists of determining whether the desired patient outcomes
g g g g g g g g g g g g g g g g
have been
g g met andwhether the nursing interventions were appropriate.
g g g g g g g g g g g g g g g g
The other responses do not describe theevaluation phase.
g g g g g g g g g g g g g g g g
DIF: Cognitive Level: Understand (Comprehension) TOP:
g g g g Nursing gg g g g g Process:
gg
Evaluation MSC:
gg NCLEX: Safe and Effective Care Environment
yy g g g g g g g g g g g g
7. Which statement describes the purpose of the assessment phase of the nursing
gg g g gg g g gg gg gg g g gg gg gg
process?
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 g g gg gg gg g g gg
c. To obtain data to diagnose patient strengths and problems
gg gg gg gg gg gg g g gg
d. To help the patient identify realistic outcomes for health problems
gg g g gg g g gg gg g g gg gg
ANS: g g C
During the assessment phase, the nurse gathers information about the patient to
gg gg gg gg gg gg gg g g g g gg g g
diagnose patient strengths and problems. The other responses are examples of
gg yy g g gg gg gg gg gg gg gg gg
the planning, intervention, and evaluation phases of the nursing process.
gg gg g g g g g g g g g g g g g g g g
DIF: Cognitive Level: Understand (Comprehension) gg gg gg
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
gg g g gg gg gg gg gg
8. When developing the plan of care, which components would the nurse include
gg gg gg gg gg gg g g gg gg gg gg
in the clinical problem statement?
gg gg gg yy g g
a. The problem and the suggested patient goals or outcomes
gg g g gg gg gg g g gg gg
b. The problem, its causes, and the signs and symptoms of the problem
gg gg gg g g gg gg g g gg gg gg gg
c. The problem with the possible etiology and the planned interventions
gg gg gg gg gg gg g g gg gg
d. The problem, its pathophysiology, and the expected outcome
gg g g gg g g gg gg gg
ANS: g g B
When writing clinical problems or nursing diagnoses, the subjective as well
g g g g g g g g g g g g g g g g g g g g
as objective data to support the problem‗s existence should be included. Goals,
g g g g gg gg gg gg gg gg gg gg gg gg
outcomes, and interventions are not included in the problem statement.
gg gg gg g g yy g g g g g g g g g g
DIF: Cognitive Level: Understand (Comprehension) gg g g gg TOP: Nursing g g
Process: DiagnosisMSC:
gg gg NCLEX: Safe and g g g g
Effective Care Environment
g g g g g g
9. Which patient care task would the nurse delegate
gg to experienced assistive personnel
g g gg g g gg gg gg g g gg g g gg
gg(AP)?
a. Instruct the patient about the need to alternate activity and rest.
gg gg g g g g gg gg g g g g gg g g
b. Monitor level of shortness of breath or fatigue after ambulation.
gg g g gg gg gg g g gg gg gg
c. Obtain the patient‗s blood pressure and pulse rate after ambulation.
gg gg gg gg gg gg gg g g gg
d. Determine whether the patient is ready to increase the activity level.
gg gg gg gg gg gg gg g g gg gg
ANS: g g C
AP education includes accurate vital sign measurement. Assessment and patient
gg gg gg gg gg gg gg gg gg
teaching require registered nurse education and scope of practice and
gg yy gg gg gg gg g g gg gg gg
cannot be delegated.
gg g g gg
DIF: Cognitive Level: Apply (Application) gg g g gg TOP: Nursing g g
Process: Planning MSC:
gg gg yy NCLEX: Safe and g g g g
Effective Care Environment
g g g g g g
,01: Professional Nursing
gg gg
Harding: Lewis’s Medical-Surgical Nursing, g g g g 12th Edition
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 asks, ―How
gg yy gg gg gg gg gg gg gg gg gg gg gg
is this different from what the physician does?‖ Which response would the
gg gg gg g g yy g g g g g g g g g g g g g g
nurse provide?
g g g g
a. ―The role of the nurse is to administer medications and other
gg gg gg gg gg gg gg gg gg gg
treatments prescribed by your physician.‖
gg gg yy gg g g
b. ―In addition to caring for you while you are sick, the nurses will help
gg gg gg gg gg gg gg gg gg gg gg gg gg
you plan to maintain your health.‖
gg gg gg yy g g g g
c. ―The nurse‗s job is to collect information and communicate any
gg gg gg gg gg gg gg gg gg
problems thatoccur to the physician.‖
gg gg g g g g g g
d. ―Nurses perform many of the same procedures as the physician, but
gg gg gg gg gg gg gg gg gg gg
nurses are with the patients for a longer time than the
gg gg g g g g g g g g g g g g g g g g g g
physician.‖
g g
ANS: g g B
The American Nurses Association (ANA) definition of nursing describes the
g g g g g g g g g g g g g g g g g g
role of nurses inpromoting health. The other responses describe dependent and
g g g g gg gg gg gg gg gg gg gg gg
collaborative functions of the nursing role but do not accurately describe
gg gg g g g g g g g g g g g g g g g g g g
the nurse‗s unique role in the health care system.
g g g g g g g g g g gg gg g g gg
DIF: Cognitive Level: Analyze (Analysis)
g g g g g g gg gg gg
TOP: Nursing Process: Implementation g g g g MSC: NCLEX: g g Safe g g and
g Effective
g Care Environment g g gg
2. Which statement by the nurse accurately describes
gg g g gg g g gg gg g g the use of evidence-based practice
gg gg g g g g
gg (EBP)?
a. ―Patient care is based on clinical judgment, experience, and traditions.‖
gg gg gg gg gg gg gg gg gg
b. ―Data are analyzed later to show that the patient outcomes are consistently met.‖
gg gg gg gg gg gg gg gg gg gg gg gg
c. ―Research from all published articles are used as a guide for planning patient care.‖
gg gg gg gg gg gg gg gg gg gg gg gg gg
d. ―Recommendations are based on research, clinical expertise, gg gg gg gg gg gg
and patient preferences.‖
gg gg g g
ANS: g g D
Evidence-based practice (EBP) is the use of the best research-based g g g g g g g g g g g g g g g g g g
evidence combined with clinician expertise and consideration of patient
g g g g gg yy g g gg gg g g gg
preferences. Clinical judgment based on the nurse‗s clinical experience is
gg g g gg gg gg g g g g g g g g g g
part of EBP, but clinical decision making should also incorporate current
g g g g g g g g g g g g g g g g gg g g gg
research and research-based guidelines. Evaluation of patient outcomes isimportant,
g g gg gg gg gg gg gg gg g g
but data analysis is not required to use EBP. All published articles do
g g g g g g g g g g g g g g g g g g g g g g gg g g
not provide research evidence; interventions should be based on credible research,
g g g g g g gg gg gg gg gg gg gg gg
preferably randomizedcontrolled studies with a large number of subjects.
g g gg g g g g g g g g g g g g g g
DIF: Cognitive Level: Understand (Comprehension) gg g g gg TOP: Nursing g g
Process: Planning MSC:
gg gg yy NCLEX: Safe and g g g g
Effective Care Environment
g g g g g g
3. Which statement by the nurse provides a clear explanation of the nursing process?
gg g g gg g g gg g g g g g g gg gg g g gg
a. ―The nursing process is a research method of diagnosing the patient‗s
gg gg gg gg gg gg gg gg gg gg
health careproblems.‖
gg gg
b. ―The nursing process is used primarily to explain nursing interventions
gg gg gg gg gg gg gg gg gg
to otherhealth care professionals.‖
gg gg g g g g
c. ―The nursing process is a problem-solving tool used to identify and manage the
gg gg gg gg gg gg gg gg gg gg gg gg
, patients‗ health care needs.‖ gg gg gg
d. ―The nursing process is based on nursing theory that
gg gg gg gg gg gg gg gg
incorporates the biopsychosocial nature of humans.‖
gg gg yy g g gg g g
ANS: g g C
The nursing process is a problem-solving approach to the identification and
g g g g g g g g g g g g g g g g g g g g
treatment of patients‗ problems. Nursing process does not require research
g g g g gg g g g g g g g g g g g g g g
methods for diagnosis.
g g g g g g
The primary use of the nursing process is in patient care, not to establish
g g gg gg g g gg gg g g g g gg g g g g gg gg
nursing theory or explain nursing interventions to other health care professionals.
gg gg gg gg yy gg g g g g gg g g g g
DIF: Cognitive Level: Understand (Comprehension) gg g g gg TOP: Nursing g g
Process: EvaluationMSC:
gg gg NCLEX: Safe and g g g g
Effective Care Environment
g g g g g g
4. A patient admitted to the hospital for surgery tells the nurse, ―I do not
gg gg gg gg gg gg gg gg gg gg gg gg gg
feel comfortableleaving my children with my parents.‖ Which action
gg gg gg gg g g g g gg g g g g
would the nurse take next?
g g g g gg g g g g
a. Reassure the patient that these feelings are common for parents.
gg gg gg g g gg gg gg gg gg
b. Have the patient call the children to ensure that they are doing well.
gg gg g g g g g g g g gg gg g g gg gg gg
c. Gather information on the patient‗s concerns 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
gg gg gg gg gg gg gg gg
care is being provided.
gg gg gg yy
ANS: g g C
Because a complete assessment is necessary in order to identify a problem
g g g g g g g g g g g g g g g g g g g g g g
and choose an appropriate intervention, the nurse‗s first action should be
g g g g gg g g g g g g g g g g g g g g g g
to obtain more information. The other actions may be appropriate, but more
g g g g g g gg g g g g gg gg gg gg gg g g
assessment is needed before the best intervention can be chosen.
gg gg gg g g gg gg gg yy g g g g
DIF: Cognitive Level: Analyze (Analysis) gg gg gg
TOP: Nursing Process: Assessment MSC: gg g g g g g g NCLEX: Psychosocial Integrity gg gg
5. A patient with a bacterial infection is hypovolemic due to a fever and
gg gg gg gg g g gg gg g g gg gg gg gg
excessive diaphoresis.Which expected outcome would the nurse select
g g gg g g g g g g g g g g g g
for this patient?
g g g g g g
a. Patient has a balanced intake and output.
gg gg gg gg gg g g
b. Patient‗s bedding is kept clean and free of moisture.
gg 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
Balanced intake and output gives measurable data showing resolution of the problem
gg g g gg gg gg gg g g gg g g gg gg
ofdeficient fluid volume. The other statements would not indicate that the
gg g g g g g g g g g g g g g g g g g g g g
problem of hypovolemia was resolved.
g g g g gg g g g g
DIF: Cognitive Level: Apply (Application) gg g g gg TOP: Nursing g g
Process: Planning MSC:
gg gg yy NCLEX:
Physiological Integrity
g g g g
6. Which statement describes the purpose of the evaluation phase of the nursing
gg g g gg gg gg gg gg g g gg gg gg
process?
gg
a. To document the nursing care plan in the progress notes of the health record
gg g g gg g g gg g g g g gg g g gg gg gg g g
b. To determine if interventions have been effective in meeting patient outcomes
gg gg gg gg gg gg gg gg gg g g
c. To decide whether the patient‗s health problems have been completely resolved
gg gg gg gg gg gg g g gg g g gg
d. To establish if the patient agrees that the nursing care provided was satisfactory
gg gg gg gg g g gg gg gg gg gg g g g g
ANS: g g B
, Evaluation consists of determining whether the desired patient outcomes
g g g g g g g g g g g g g g g g
have been
g g met andwhether the nursing interventions were appropriate.
g g g g g g g g g g g g g g g g
The other responses do not describe theevaluation phase.
g g g g g g g g g g g g g g g g
DIF: Cognitive Level: Understand (Comprehension) TOP:
g g g g Nursing gg g g g g Process:
gg
Evaluation MSC:
gg NCLEX: Safe and Effective Care Environment
yy g g g g g g g g g g g g
7. Which statement describes the purpose of the assessment phase of the nursing
gg g g gg g g gg gg gg g g gg gg gg
process?
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 g g gg gg gg g g gg
c. To obtain data to diagnose patient strengths and problems
gg gg gg gg gg gg g g gg
d. To help the patient identify realistic outcomes for health problems
gg g g gg g g gg gg g g gg gg
ANS: g g C
During the assessment phase, the nurse gathers information about the patient to
gg gg gg gg gg gg gg g g g g gg g g
diagnose patient strengths and problems. The other responses are examples of
gg yy g g gg gg gg gg gg gg gg gg
the planning, intervention, and evaluation phases of the nursing process.
gg gg g g g g g g g g g g g g g g g g
DIF: Cognitive Level: Understand (Comprehension) gg gg gg
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
gg g g gg gg gg gg gg
8. When developing the plan of care, which components would the nurse include
gg gg gg gg gg gg g g gg gg gg gg
in the clinical problem statement?
gg gg gg yy g g
a. The problem and the suggested patient goals or outcomes
gg g g gg gg gg g g gg gg
b. The problem, its causes, and the signs and symptoms of the problem
gg gg gg g g gg gg g g gg gg gg gg
c. The problem with the possible etiology and the planned interventions
gg gg gg gg gg gg g g gg gg
d. The problem, its pathophysiology, and the expected outcome
gg g g gg g g gg gg gg
ANS: g g B
When writing clinical problems or nursing diagnoses, the subjective as well
g g g g g g g g g g g g g g g g g g g g
as objective data to support the problem‗s existence should be included. Goals,
g g g g gg gg gg gg gg gg gg gg gg gg
outcomes, and interventions are not included in the problem statement.
gg gg gg g g yy g g g g g g g g g g
DIF: Cognitive Level: Understand (Comprehension) gg g g gg TOP: Nursing g g
Process: DiagnosisMSC:
gg gg NCLEX: Safe and g g g g
Effective Care Environment
g g g g g g
9. Which patient care task would the nurse delegate
gg to experienced assistive personnel
g g gg g g gg gg gg g g gg g g gg
gg(AP)?
a. Instruct the patient about the need to alternate activity and rest.
gg gg g g g g gg gg g g g g gg g g
b. Monitor level of shortness of breath or fatigue after ambulation.
gg g g gg gg gg g g gg gg gg
c. Obtain the patient‗s blood pressure and pulse rate after ambulation.
gg gg gg gg gg gg gg g g gg
d. Determine whether the patient is ready to increase the activity level.
gg gg gg gg gg gg gg g g gg gg
ANS: g g C
AP education includes accurate vital sign measurement. Assessment and patient
gg gg gg gg gg gg gg gg gg
teaching require registered nurse education and scope of practice and
gg yy gg gg gg gg g g gg gg gg
cannot be delegated.
gg g g gg
DIF: Cognitive Level: Apply (Application) gg g g gg TOP: Nursing g g
Process: Planning MSC:
gg gg yy NCLEX: Safe and g g g g
Effective Care Environment
g g g g g g
