Test bank for Lewis-s medical surgical nursing 12th edition by Mariann M. Harding Jeff.

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,Chapter 01: Professional Nursing
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Harding: Lewis’sMedical-Surgical Nursing, 12th Edition
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MULTIPLE CHOICE ss




1. The nurse completes an admission database and explains that the plan of
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care and discharge goals will be developed with the patient‗s input. The patient asks,
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―How is this different from what the physician does?‖ Which response would the nurse
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provide?
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a. ―Therole ofthenurseis to administermedications and othertreatments prescribed cc ss ss ss ss


by your physician.‖
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b. ―Inaddition tocaring for youwhile you aresick,thenurses will help youplanto
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maintain your health.‖
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c. ―Thenurse‗s jobisto collectinformationand communicateanyproblems that s ss ss ss


occur to the physician.‖
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d. ―Nursesperformmanyof thesameprocedures as thephysician, but nurses are
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with the patients for a longer time than the physician.‖
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ANS: s s B
The American Nurses Association (ANA) definition of nursing describes the role of nurses
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in promoting health. The other responses describe dependent and collaborative functions
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of the nursing role but do not accurately describe the nurse‗s unique role in the health
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care system.
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DIF: Cognitive Level: Analyze (Analysis) ss ss ss


TOP: NursingProcess: Implementation s ss MSC: s s NCLEX: Safe and Effective Care Environment ss ss ss ss ss




2. Which statement bythe nurse accurately describes the use of evidence-based practice (EBP)?
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a. ―Patient care is based on clinical judgment, experience, and traditions.‖ cc ss ss ss ss ss cc



b. ―Data areanalyzed later to show that thepatient outcomes areconsistentlymet.‖
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c. ―Research from all published articles areused as a guide forplanningpatient care.‖
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d. ―Recommendations are based on research, clinical expertise, and patient ss s ss ss ss ss ss ss


ss preferences.‖
ANS: s s D
Evidence-based practice (EBP) is the use of the best research-based evidence combined ss ss ss ss ss ss ss ss ss ss ss


with clinician expertise and consideration of patient preferences. Clinical judgment based
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on the nurse‗s clinical experience is part of EBP, but clinical decision making should
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also incorporate current research and research-based guidelines. Evaluation of patient
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outcomes is important, but data analysis is not required to use EBP. All published
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ssarticles do not provide research evidence; interventions should be based on credible
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research, preferably randomized controlled studies with a large number of subjects.
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DIF: Cognitive Level: Understand (Comprehension) ss ss ss TOP: NursingProcess: Planning ss s ss


MSC: NCLEX: Safe and Effective Care Environment
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3. Which statement bythe nurse provides a clear explanation of the nursing process?
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a. ―The nursing process is a research method of diagnosingthepatient‗s health care cc cc ss cc ss cc ss ss ss


ss problems.‖
b. ―The nursing process is usedprimarilyto explain nursing interventions to other cc cc ss ss ss cc ss ss


health care professionals.‖
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c. ―Thenursingprocess is a problem-solvingtool used to identifyand manage the ss ss ss ss ss ss cc ss

, patients‗ health care needs.‖ ss ss ss


d. ―The nursing process isbased onnursingtheorythatincorporates the cc cc s cc s cc



s s biopsychosocial nature of humans.‖ ss ss ss




ANS: s s C
The nursing process is a problem-solving approach to the identification and treatment of
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patients‗ problems. Nursing process does not require research methods for diagnosis. The
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primaryuse of the nursing process is in patient care, not to establish nursing theoryor
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explain nursing interventions to other health care professionals.
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DIF: Cognitive Level: Understand (Comprehension) ss ss ss TOP: NursingProcess: Evaluationss s ss


MSC: NCLEX: Safe and Effective Care Environment
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4. Apatientadmitted to the hospital forsurgerytells the nurse, ―I do not feel comfortable ss ss cc ss ss ss ss cc ss ss ss


leaving my children with my parents.‖ Which action would the nurse take
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next?
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a. Reassurethe patient that these feelings are common for parents. ss ss ss ss ss ss ss ss


b. Have the patient call the children to ensure that they are doing well.
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c. Gatherinformation on the patient‗s concerns about the child care arrangements. ss ss ss ss ss ss ss ss ss


d. Call the patient‗s parents to determine whether adequate child care is
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being provided.
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ANS: s s C
Because a complete assessment is necessary in order to identify a problem and choose an
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appropriate intervention, the nurse‗s first action should be to obtain more information.
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The other actions maybe appropriate, but more assessment is needed before the best
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intervention can be chosen.
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DIF: Cognitive Level: Analyze (Analysis) ss ss ss


TOP: NursingProcess: Assessment MSC: s ss s s NCLEX: Psychosocial Integrity ss ss




5. A patient with a bacterial infection is hypovolemic dueto a fever and excessive diaphoresis.
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Which expected outcome would the nurse select for this patient?
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a. Patient has abalanced intake and output. ss ss s ss ss ss


b. Patient‗s bedding is kept clean and free of moisture. ss ss ss ss ss ss ss ss


c. Patient understands the need forincreased fluid intake.
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d. Patient‗s skin remains cool and drythroughout hospitalization.
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ANS: s s A
Balanced intake and output gives measurable data showing resolution ofthe problem of
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deficient fluid volume. The other statements would not indicate that the problem of
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hypovolemia was resolved.
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DIF: Cognitive Level: Apply (Application) ss ss ss TOP: NursingProcess: Planning ss s ss


MSC: NCLEX: Physiological Integrity
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6. Which statement describes the purpose of the evaluation phase of the nursing process?
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a. To document the nursing care plan in the progress notes of the health record
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b. Todetermine if interventions have been effective in meeting patient outcomes
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c. To decide whether the patient‗s health problems have been completely resolved
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d. Toestablish if the patient agrees that the nursing care provided was satisfactory
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ANS: s s B

, Evaluation consists of determining whether the desired patient outcomes have been met
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sand whether the nursing interventions were appropriate. The other responses do not
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describe the evaluation phase.
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DIF: Cognitive Level: Understand (Comprehension)
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Evaluation MSC: NCLEX: Safe and Effective Care Environment
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7. Whichstatement describes the purpose of the assessment phase of the nursing process?
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a. To teach interventions that relieve health problems
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b. To use patient data to evaluate patient care outcomes
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c. Toobtain data to diagnose patient strengths and problems
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d. To help the patient identifyrealistic outcomes for health problems
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ANS: s s C
During the assessment phase, the nurse gathers information about the patient to diagnose
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patient strengths and problems. The other responses are examples of the planning,
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intervention, and evaluation phases of the nursing process.
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DIF: Cognitive Level: Understand (Comprehension) ss ss ss


TOP: NursingProcess: Assessment MSC: NCLEX: Safe and Effective Care Environment s ss s s ss s ss ss ss




8. When developing the plan of care, which components would the nurseinclude in the clinical
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ss problem statement? ss


a. Theproblem and the suggested patient goals or outcomes ss ss ss ss ss ss ss


b. The problem, its causes, and the signs and symptoms of the problem
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c. Theproblem with the possible etiologyand the planned interventions
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d. Theproblem, its pathophysiology, and the expected outcome
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ANS: B s s


When writing clinical problems or nursing diagnoses, the subjective as well
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as objective data to support the problem‗s existence should be included. Goals,
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outcomes, and interventions are not included in the problem statement.
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DIF: Cognitive Level: Understand (Comprehension) ss ss ss TOP: NursingProcess: Diagnosis
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MSC: NCLEX: Safe and Effective Care Environment
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9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
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a. Instruct the patient about the need to alternate activityand rest.
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b. Monitor level of shortness of breath or fatigue after ambulation.
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c. Obtainthe patient‗s blood pressure and pulse rate after ambulation.
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d. Determine whether the patient is readyto increase the activitylevel. ss ss ss ss ss ss ss ss




ANS: s s C
AP education includes accurate vital sign measurement. Assessment and patient teaching
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require registered nurse education and scope of practice and cannot be delegated.
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DIF: Cognitive Level: Apply (Application) ss ss ss TOP: NursingProcess: Planning
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MSC: NCLEX: Safe and Effective Care Environment
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