,Chapter 01: Professional Nursing
ss ss ss
Harding: Lewis’s Medical-Surgical Nursing,
s s s s 12th Edition
MULTIPLE s s CHOICE
1. The ssnurse sscompletes ssan ssadmission ssdatabase ssand ssexplains ssthat ssthe ssplan ssof sscare ssand
ssdischarge goals sswill ssbe ssdeveloped sswith ssthe sspatient‗s ssinput. ssThe sspatient ssasks, ss―How
yy
ssis ssthis ssdifferent s s from what s s the s s physician s s does?‖ s s Which s s response s s would s s the
yy
s s nurse s s provide?
a. ―The ssrole ssof ssthe ssnurse ssis ssto ssadminister ssmedications ssand ssother
sstreatments ssprescribed by ss your s s physician.‖
yy
b. ―In ssaddition ssto sscaring ssfor ssyou sswhile s s you ssare sssick, ssthe ssnurses sswill
sshelp s s you ssplan ssto maintain s s your s s health.‖
yy
c. ―The ssnurse‗s ssjob ssis ssto sscollect ssinformation ssand sscommunicate ssany
ssproblems ssthatoccur s s to s s the s s physician.‖
d. ―Nurses ssperform ssmanyssof ssthe sssame ssprocedures ssas ssthe ssphysician, ssbut
ssnurses ssare s s with s s the s s patients s s for s s a s s longer s s time s s than s s the
s s physician.‖
ANS: s s B
The s s American s s Nurses s s Association s s (ANA) s s definition s s of s s nursing s s describes s s the
s s role s s of ssnurses ssinpromoting sshealth. ssThe ssother ssresponses ssdescribe ssdependent ssand
sscollaborative ssfunctions s s of s s the s s nursing s s role s s but s s do s s not s s accurately s s describe
s s the s s nurse‗s s s unique s s role s s in ssthe sshealth s s care sssystem.
DIF: s s s s s s Cognitive ssLevel: ssAnalyze ss(Analysis)
TOP: Nursing s s Process: s s Implementation MSC: NCLEX: s s Safe s s and
s s Effective s s Care ssEnvironment
2. Which s s statement s s by ssthe s s nurse s s accurately s s describes s s the s s use s s of s s evidence-based s s practice
ss(EBP)?
a. ―Patient ss care ssis ssbased sson ssclinical ssjudgment, ssexperience, s s and sstraditions.‖
b. ―Data ssare ssanalyzed sslater ssto ssshow ssthat ssthe sspatient ssoutcomes ssare ssconsistently ssmet.‖
c. ―Research ssfrom s s all s s published ssarticles s s are ssused s s as s s a s s guide s s for ssplanning sspatient ss care.‖
d. ―Recommendations ssare ssbased sson ssresearch, ssclinical ssexpertise,
ssand sspatient s s preferences.‖
ANS: s s D
Evidence-based s s practice s s (EBP) s s is s s the s s use s s of s s the s s best s s research-based
s s evidence s s combined sswith clinician s s expertise s s and s s consideration s s of s s patient
yy
s s preferences. s s Clinical s s judgment s s based sson s s the s s nurse‗s s s clinical s s experience s s is
s s part s s of s s EBP, s s but s s clinical s s decision s s making s s should ssalso s s incorporate sscurrent
s s research ssand ssresearch-based ssguidelines. ssEvaluation ssof sspatient ssoutcomes s s isimportant,
s s but s s data s s analysis s s is s s not s s required s s to s s use s s EBP. s s All s s published ssarticles s s do
s s not s s provide s s research ssevidence; ssinterventions ssshould ssbe ssbased sson sscredible ssresearch,
s s preferably ssrandomizedcontrolled s s studies s s with s s a s s large s s number s s of s s subjects.
DIF: Cognitive ssLevel: s s Understand ss(Comprehension) TOP: s s Nursing
ssProcess: ssPlanning MSC: yy NCLEX: s s Safe s s and
s s Effective s s Care s s Environment
3. Which s s statement s s by ssthe s s nurse ss provides s s a s s clear s s explanation s s of s s the s s nursing s s process?
a. ―The ssnursing ssprocess ssis ssa ssresearch ssmethod ssof ssdiagnosing ssthe sspatient‗s
health sscareproblems.‖
ss
b. ―The ssnursing ssprocess ssis ssused ssprimarilyssto ssexplain ssnursing ssinterventions
ss to ssotherhealth s s care s s professionals.‖
c. ―The ssnursing ssprocess ssis ssa s s problem-solving sstool ssused ssto ssidentify ssand ssmanage ssthe
, patients‗ sshealth sscare ssneeds.‖
d. ―The ssnursing ssprocess ssis ssbased sson ssnursing sstheoryssthat
incorporates ssthe biopsychosocial s s nature ssof s s humans.‖
ss yy
ANS: s s C
The s s nursing s s process s s is s s a s s problem-solving s s approach s s to s s the s s identification s s and
s s treatment s s of sspatients‗ s s problems. s s Nursing s s process s s does s s not s s require s s research
s s methods s s for s s diagnosis.
The s s primary ssuse s s of s s the ssnursing ssprocess s s is s s in s s patient s s care, s s not s s to s s establish
s s nursing s s theory ssor ssexplain nursing ssinterventions s s to s s other sshealth s s care s s professionals.
yy
DIF: Cognitive ssLevel: s s Understand ss(Comprehension) TOP: s s Nursing
ssProcess: ssEvaluationMSC: NCLEX: s s Safe s s and
s s Effective s s Care s s Environment
4. A sspatient ssadmitted ssto ssthe sshospital ssfor sssurgery sstells ssthe ssnurse, ss―I ssdo ssnot
feel sscomfortableleaving ssmy sschildren s s with s s my ssparents.‖ s s Which s s action
ss
sswould s s the ssnurse s s take s s next?
a. Reassure ssthe s s patient s s that s s these s s feelings s s are s s common s s for ss parents.
b. Have s s the s s patient s s call s s the s s children s s to s s ensure s s that s s they ss are s s doing s s well.
c. Gather ssinformation s s on s s the s s patient‗s s s concerns s s about s s the ss child s s care s s arrangements.
d. Call ssthe sspatient‗s ssparents s s to ssdetermine sswhether ssadequate sschild
sscare ssis ssbeing provided.
yy
ANS: s s C
Because s s a s s complete s s assessment s s is s s necessary s s in s s order s s to s s identify s s a s s problem
s s and s s choose ssan s s appropriate s s intervention, s s the s s nurse‗s s s first s s action s s should s s be
s s to s s obtain s s more ssinformation. s s The s s other ssactions s s may ssbe ssappropriate, ssbut s s more
s s assessment s s is ssneeded s s before ssthe ssbest ssintervention can s s be s s chosen.
yy
DIF: Cognitive ssLevel: ssAnalyze ss(Analysis)
TOP: Nursing ssProcess: s s Assessment MSC: s s ss NCLEX: s s Psychosocial s s Integrity
5. A sspatient s s with s s a ssbacterial ssinfection ssis sshypovolemic s s due ssto ssa ssfever s s and
s s excessive ssdiaphoresis.Which s s expected s s outcome s s would s s the s s nurse
s s select s s for s s this s s patient?
a. Patient s s has s s a ssbalanced s s intake s s and s s output.
b. Patient‗s s s bedding ssis s s kept s s clean s s and s s free s s of s s moisture.
c. Patient s s understands s s the s s need s s for ssincreased s s fluid s s intake.
d. Patient‗s s s skin s s remains s s cool s s and s s dry ssthroughout s s hospitalization.
ANS: s s A
Balanced ssintake s s and ssoutput ssgives ssmeasurable ssdata s s showing ssresolution s s of ssthe ssproblem
ssofdeficient s s fluid s s volume. s s The s s other s s statements s s would s s not s s indicate s s that s s the
s s problem s s of sshypovolemia s s was s s resolved.
DIF: Cognitive ssLevel: s s Apply ss(Application) TOP: s s Nursing
ssProcess: ssPlanning MSC:
yy NCLEX:
s s Physiological s s Integrity
6. Which s s statement s s describes s s the s s purpose s s of s s the s s evaluation s s phase s s of s s the s s nursing
process?
ss
a. To s s document s s the s s nursing s s care s s plan s s in s s the s s progress s s notes s s of s s the s s health s s record
b. To s s determine s s if s s interventions s s have ss been s s effective s s in s s meeting ss patient s s outcomes
c. To s s decide s s whether s s the s s patient‗s s s health s s problems s s have s s been s s completely s s resolved
d. To ss establish s s if s s the s s patient s s agrees s s that s s the s s nursing s s care s s provided s s was s s satisfactory
ANS: s s B
, Evaluation s s consists s s of s s determining s s whether s s the s s desired s s patient s s outcomes
s s have s s been s s met s s andwhether s s the s s nursing s s interventions s s were s s appropriate.
s s The s s other s s responses s s do s s not s s describe s s theevaluation s s phase.
DIF: s s s s Cognitive ssLevel: s s Understand s s (Comprehension) TOP: Nursing ss Process:
ssEvaluation MSC: s s NCLEX: s s Safe s s and s s Effective s s Care s s Environment
yy
7. Which ssstatement s s describes s s the s s purpose s s of s s the s s assessment s s phase s s of s s the s s nursing
ss process?
a. To ssteach s s interventions s s that s s relieve s s health s s problems
b. To s s use s s patient s s data s s to s s evaluate s s patient s s care ssoutcomes
c. To s s obtain s s data s s to s s diagnose s s patient s s strengths s s and s s problems
d. To s s help s s the s s patient s s identify ssrealistic s s outcomes s s for s s health s s problems
ANS: s s C
During ssthe ssassessment ssphase, ssthe ssnurse ssgathers ssinformation s s about s s the sspatient s s to
ssdiagnose patient s s strengths s s and s s problems. s s The s s other s s responses s s are s s examples s s of
yy
s s the ssplanning, s s intervention, s s and s s evaluation s s phases s s of s s the s s nursing s s process.
DIF: Cognitive ssLevel: ssUnderstand ss(Comprehension)
TOP: Nursing ssProcess: s s Assessment MSC: NCLEX: s s Safe s s and s s Effective s s Care s s Environment
8. When ssdeveloping ssthe ssplan s s of sscare, s s which s s components s s would ssthe ssnurse ssinclude
ss in s s the ssclinical problem s s statement?
yy
a. The ssproblem s s and s s the s s suggested s s patient s s goals s s or s s outcomes
b. The ssproblem, s s its s s causes, s s and s s the s s signs s s and s s symptoms s s of s s the s s problem
c. The ssproblem s s with s s the s s possible s s etiology ssand s s the s s planned s s interventions
d. The ssproblem, s s its s s pathophysiology, s s and s s the s s expected s s outcome
ANS: s s B
When s s writing s s clinical s s problems s s or s s nursing s s diagnoses, s s the s s subjective s s as s s well
s s as s s objective ssdata ssto sssupport ssthe ssproblem‗s ssexistence ssshould ssbe ssincluded. ssGoals,
ssoutcomes, ssand ssinterventions s s are not s s included s s in s s the s s problem s s statement.
yy
DIF: Cognitive ssLevel: s s Understand ss(Comprehension) TOP: s s Nursing
ssProcess: ssDiagnosisMSC: NCLEX: s s Safe s s and
s s Effective s s Care s s Environment
9. Which s s patient s s care s s task s s would s s the s s nurse ss delegate s s to s s experienced s s assistive s s personnel
(AP)?
ss
a. Instruct s s the s s patient s s about s s the s s need s s to s s alternate s s activity ssand s s rest.
b. Monitor s s level s s of s s shortness s s of s s breath s s or s s fatigue s s after s s ambulation.
c. Obtain ssthe sspatient‗s s s blood s s pressure s s and s s pulse s s rate s s after s s ambulation.
d. Determine s s whether s s the s s patient s s is s s ready ssto s s increase s s the s s activity sslevel.
ANS: s s C
AP sseducation ssincludes ssaccurate ssvital sssign ssmeasurement. ssAssessment ssand
sspatient ssteaching require ssregistered s s nurse s s education s s and s s scope ssof s s practice
yy
s s and s s cannot s s be ssdelegated.
DIF: Cognitive ssLevel: s s Apply ss(Application) TOP: s s Nursing
ssProcess: ssPlanning MSC: yy NCLEX: s s Safe s s and
s s Effective s s Care s s Environment
ss ss ss
Harding: Lewis’s Medical-Surgical Nursing,
s s s s 12th Edition
MULTIPLE s s CHOICE
1. The ssnurse sscompletes ssan ssadmission ssdatabase ssand ssexplains ssthat ssthe ssplan ssof sscare ssand
ssdischarge goals sswill ssbe ssdeveloped sswith ssthe sspatient‗s ssinput. ssThe sspatient ssasks, ss―How
yy
ssis ssthis ssdifferent s s from what s s the s s physician s s does?‖ s s Which s s response s s would s s the
yy
s s nurse s s provide?
a. ―The ssrole ssof ssthe ssnurse ssis ssto ssadminister ssmedications ssand ssother
sstreatments ssprescribed by ss your s s physician.‖
yy
b. ―In ssaddition ssto sscaring ssfor ssyou sswhile s s you ssare sssick, ssthe ssnurses sswill
sshelp s s you ssplan ssto maintain s s your s s health.‖
yy
c. ―The ssnurse‗s ssjob ssis ssto sscollect ssinformation ssand sscommunicate ssany
ssproblems ssthatoccur s s to s s the s s physician.‖
d. ―Nurses ssperform ssmanyssof ssthe sssame ssprocedures ssas ssthe ssphysician, ssbut
ssnurses ssare s s with s s the s s patients s s for s s a s s longer s s time s s than s s the
s s physician.‖
ANS: s s B
The s s American s s Nurses s s Association s s (ANA) s s definition s s of s s nursing s s describes s s the
s s role s s of ssnurses ssinpromoting sshealth. ssThe ssother ssresponses ssdescribe ssdependent ssand
sscollaborative ssfunctions s s of s s the s s nursing s s role s s but s s do s s not s s accurately s s describe
s s the s s nurse‗s s s unique s s role s s in ssthe sshealth s s care sssystem.
DIF: s s s s s s Cognitive ssLevel: ssAnalyze ss(Analysis)
TOP: Nursing s s Process: s s Implementation MSC: NCLEX: s s Safe s s and
s s Effective s s Care ssEnvironment
2. Which s s statement s s by ssthe s s nurse s s accurately s s describes s s the s s use s s of s s evidence-based s s practice
ss(EBP)?
a. ―Patient ss care ssis ssbased sson ssclinical ssjudgment, ssexperience, s s and sstraditions.‖
b. ―Data ssare ssanalyzed sslater ssto ssshow ssthat ssthe sspatient ssoutcomes ssare ssconsistently ssmet.‖
c. ―Research ssfrom s s all s s published ssarticles s s are ssused s s as s s a s s guide s s for ssplanning sspatient ss care.‖
d. ―Recommendations ssare ssbased sson ssresearch, ssclinical ssexpertise,
ssand sspatient s s preferences.‖
ANS: s s D
Evidence-based s s practice s s (EBP) s s is s s the s s use s s of s s the s s best s s research-based
s s evidence s s combined sswith clinician s s expertise s s and s s consideration s s of s s patient
yy
s s preferences. s s Clinical s s judgment s s based sson s s the s s nurse‗s s s clinical s s experience s s is
s s part s s of s s EBP, s s but s s clinical s s decision s s making s s should ssalso s s incorporate sscurrent
s s research ssand ssresearch-based ssguidelines. ssEvaluation ssof sspatient ssoutcomes s s isimportant,
s s but s s data s s analysis s s is s s not s s required s s to s s use s s EBP. s s All s s published ssarticles s s do
s s not s s provide s s research ssevidence; ssinterventions ssshould ssbe ssbased sson sscredible ssresearch,
s s preferably ssrandomizedcontrolled s s studies s s with s s a s s large s s number s s of s s subjects.
DIF: Cognitive ssLevel: s s Understand ss(Comprehension) TOP: s s Nursing
ssProcess: ssPlanning MSC: yy NCLEX: s s Safe s s and
s s Effective s s Care s s Environment
3. Which s s statement s s by ssthe s s nurse ss provides s s a s s clear s s explanation s s of s s the s s nursing s s process?
a. ―The ssnursing ssprocess ssis ssa ssresearch ssmethod ssof ssdiagnosing ssthe sspatient‗s
health sscareproblems.‖
ss
b. ―The ssnursing ssprocess ssis ssused ssprimarilyssto ssexplain ssnursing ssinterventions
ss to ssotherhealth s s care s s professionals.‖
c. ―The ssnursing ssprocess ssis ssa s s problem-solving sstool ssused ssto ssidentify ssand ssmanage ssthe
, patients‗ sshealth sscare ssneeds.‖
d. ―The ssnursing ssprocess ssis ssbased sson ssnursing sstheoryssthat
incorporates ssthe biopsychosocial s s nature ssof s s humans.‖
ss yy
ANS: s s C
The s s nursing s s process s s is s s a s s problem-solving s s approach s s to s s the s s identification s s and
s s treatment s s of sspatients‗ s s problems. s s Nursing s s process s s does s s not s s require s s research
s s methods s s for s s diagnosis.
The s s primary ssuse s s of s s the ssnursing ssprocess s s is s s in s s patient s s care, s s not s s to s s establish
s s nursing s s theory ssor ssexplain nursing ssinterventions s s to s s other sshealth s s care s s professionals.
yy
DIF: Cognitive ssLevel: s s Understand ss(Comprehension) TOP: s s Nursing
ssProcess: ssEvaluationMSC: NCLEX: s s Safe s s and
s s Effective s s Care s s Environment
4. A sspatient ssadmitted ssto ssthe sshospital ssfor sssurgery sstells ssthe ssnurse, ss―I ssdo ssnot
feel sscomfortableleaving ssmy sschildren s s with s s my ssparents.‖ s s Which s s action
ss
sswould s s the ssnurse s s take s s next?
a. Reassure ssthe s s patient s s that s s these s s feelings s s are s s common s s for ss parents.
b. Have s s the s s patient s s call s s the s s children s s to s s ensure s s that s s they ss are s s doing s s well.
c. Gather ssinformation s s on s s the s s patient‗s s s concerns s s about s s the ss child s s care s s arrangements.
d. Call ssthe sspatient‗s ssparents s s to ssdetermine sswhether ssadequate sschild
sscare ssis ssbeing provided.
yy
ANS: s s C
Because s s a s s complete s s assessment s s is s s necessary s s in s s order s s to s s identify s s a s s problem
s s and s s choose ssan s s appropriate s s intervention, s s the s s nurse‗s s s first s s action s s should s s be
s s to s s obtain s s more ssinformation. s s The s s other ssactions s s may ssbe ssappropriate, ssbut s s more
s s assessment s s is ssneeded s s before ssthe ssbest ssintervention can s s be s s chosen.
yy
DIF: Cognitive ssLevel: ssAnalyze ss(Analysis)
TOP: Nursing ssProcess: s s Assessment MSC: s s ss NCLEX: s s Psychosocial s s Integrity
5. A sspatient s s with s s a ssbacterial ssinfection ssis sshypovolemic s s due ssto ssa ssfever s s and
s s excessive ssdiaphoresis.Which s s expected s s outcome s s would s s the s s nurse
s s select s s for s s this s s patient?
a. Patient s s has s s a ssbalanced s s intake s s and s s output.
b. Patient‗s s s bedding ssis s s kept s s clean s s and s s free s s of s s moisture.
c. Patient s s understands s s the s s need s s for ssincreased s s fluid s s intake.
d. Patient‗s s s skin s s remains s s cool s s and s s dry ssthroughout s s hospitalization.
ANS: s s A
Balanced ssintake s s and ssoutput ssgives ssmeasurable ssdata s s showing ssresolution s s of ssthe ssproblem
ssofdeficient s s fluid s s volume. s s The s s other s s statements s s would s s not s s indicate s s that s s the
s s problem s s of sshypovolemia s s was s s resolved.
DIF: Cognitive ssLevel: s s Apply ss(Application) TOP: s s Nursing
ssProcess: ssPlanning MSC:
yy NCLEX:
s s Physiological s s Integrity
6. Which s s statement s s describes s s the s s purpose s s of s s the s s evaluation s s phase s s of s s the s s nursing
process?
ss
a. To s s document s s the s s nursing s s care s s plan s s in s s the s s progress s s notes s s of s s the s s health s s record
b. To s s determine s s if s s interventions s s have ss been s s effective s s in s s meeting ss patient s s outcomes
c. To s s decide s s whether s s the s s patient‗s s s health s s problems s s have s s been s s completely s s resolved
d. To ss establish s s if s s the s s patient s s agrees s s that s s the s s nursing s s care s s provided s s was s s satisfactory
ANS: s s B
, Evaluation s s consists s s of s s determining s s whether s s the s s desired s s patient s s outcomes
s s have s s been s s met s s andwhether s s the s s nursing s s interventions s s were s s appropriate.
s s The s s other s s responses s s do s s not s s describe s s theevaluation s s phase.
DIF: s s s s Cognitive ssLevel: s s Understand s s (Comprehension) TOP: Nursing ss Process:
ssEvaluation MSC: s s NCLEX: s s Safe s s and s s Effective s s Care s s Environment
yy
7. Which ssstatement s s describes s s the s s purpose s s of s s the s s assessment s s phase s s of s s the s s nursing
ss process?
a. To ssteach s s interventions s s that s s relieve s s health s s problems
b. To s s use s s patient s s data s s to s s evaluate s s patient s s care ssoutcomes
c. To s s obtain s s data s s to s s diagnose s s patient s s strengths s s and s s problems
d. To s s help s s the s s patient s s identify ssrealistic s s outcomes s s for s s health s s problems
ANS: s s C
During ssthe ssassessment ssphase, ssthe ssnurse ssgathers ssinformation s s about s s the sspatient s s to
ssdiagnose patient s s strengths s s and s s problems. s s The s s other s s responses s s are s s examples s s of
yy
s s the ssplanning, s s intervention, s s and s s evaluation s s phases s s of s s the s s nursing s s process.
DIF: Cognitive ssLevel: ssUnderstand ss(Comprehension)
TOP: Nursing ssProcess: s s Assessment MSC: NCLEX: s s Safe s s and s s Effective s s Care s s Environment
8. When ssdeveloping ssthe ssplan s s of sscare, s s which s s components s s would ssthe ssnurse ssinclude
ss in s s the ssclinical problem s s statement?
yy
a. The ssproblem s s and s s the s s suggested s s patient s s goals s s or s s outcomes
b. The ssproblem, s s its s s causes, s s and s s the s s signs s s and s s symptoms s s of s s the s s problem
c. The ssproblem s s with s s the s s possible s s etiology ssand s s the s s planned s s interventions
d. The ssproblem, s s its s s pathophysiology, s s and s s the s s expected s s outcome
ANS: s s B
When s s writing s s clinical s s problems s s or s s nursing s s diagnoses, s s the s s subjective s s as s s well
s s as s s objective ssdata ssto sssupport ssthe ssproblem‗s ssexistence ssshould ssbe ssincluded. ssGoals,
ssoutcomes, ssand ssinterventions s s are not s s included s s in s s the s s problem s s statement.
yy
DIF: Cognitive ssLevel: s s Understand ss(Comprehension) TOP: s s Nursing
ssProcess: ssDiagnosisMSC: NCLEX: s s Safe s s and
s s Effective s s Care s s Environment
9. Which s s patient s s care s s task s s would s s the s s nurse ss delegate s s to s s experienced s s assistive s s personnel
(AP)?
ss
a. Instruct s s the s s patient s s about s s the s s need s s to s s alternate s s activity ssand s s rest.
b. Monitor s s level s s of s s shortness s s of s s breath s s or s s fatigue s s after s s ambulation.
c. Obtain ssthe sspatient‗s s s blood s s pressure s s and s s pulse s s rate s s after s s ambulation.
d. Determine s s whether s s the s s patient s s is s s ready ssto s s increase s s the s s activity sslevel.
ANS: s s C
AP sseducation ssincludes ssaccurate ssvital sssign ssmeasurement. ssAssessment ssand
sspatient ssteaching require ssregistered s s nurse s s education s s and s s scope ssof s s practice
yy
s s and s s cannot s s be ssdelegated.
DIF: Cognitive ssLevel: s s Apply ss(Application) TOP: s s Nursing
ssProcess: ssPlanning MSC: yy NCLEX: s s Safe s s and
s s Effective s s Care s s Environment
