,Chapter01: Professional Nursing
f4 f4 f4
Harding:Lewis’sMedical-SurgicalNursing,12thEdition
f4 f4 f4 f4 f4
MULTIPLECHOICE f4
1. The nurse completes an admission database and explains that the plan of care and discharge goals
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
will be developed with the patient‘s input. The patient asks, “How is this different from what the
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
physician does?” Which response would the nurse provide?
f4 f4 f4 f4 f4 f4 f4 f4
a. “Theroleofthenurseistoadministermedicationsandothertreatmentsprescribed by f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
your physician.”
f4 f4
b. “Inadditiontocaringforyouwhile youaresick,thenurseswillhelp youplanto
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
maintain your health.”
f4 f4 f4
c. “Thenurse‘sjobistocollectinformationandcommunicateanyproblemsthat f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
occur to the physician.”
f4 f4 f4 f4
d. “Nursesperformmanyofthesameproceduresasthephysician,butnursesare with f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
the patients for a longer time than the physician.”
f4 f4 f4 f4 f4 f4 f4 f4 f4
ANS: B f 4
The American Nurses Association (ANA) definition of nursing describes the role of nurses in
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
promoting health. The other responses describe dependent and collaborative functions of the
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
nursing role but do not accurately describe the nurse‘s unique role in the health care system.
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
DIF: f 4 f 4 CognitiveLevel:Analyze(Analysis) f4 f4 f4
TOP: f 4 NursingProcess: Implementation f4 f4 f 4 f 4 f 4 MSC: NCLEX:SafeandEffectiveCareEnvironment f 4 f4 f4 f4 f4 f4
2. Whichstatement bythe nurseaccuratelydescribes the useof evidence-based practice (EBP)?
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
a. “Patientcareisbasedonclinicaljudgment,experience,andtraditions.” f4 f4 f4 f4 f4 f4 f4 f4 f4
b. “Dataareanalyzedlatertoshowthatthepatientoutcomesareconsistentlymet.” f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
c. “Researchfromallpublishedarticlesareusedasaguideforplanningpatientcare.” f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
d. “Recommendations arebased on research, clinical expertise, and patient f4 f4 f4 f4 f4 f4 f4 f4
preferences.”
f4
ANS: D f 4
Evidence-based practice (EBP) is the use of the best research-based evidence combined with f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
clinician expertise and consideration of patient preferences. Clinical judgment based on the
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
nurse‘s clinical experience is part of EBP, but clinical decision making should also incorporate
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
current researchandresearch-basedguidelines.Evaluation ofpatient outcomesis important, but
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
data analysis is not required to use EBP. All published articles do not provide researchevidence;
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
interventionsshouldbebasedoncredibleresearch,preferablyrandomized controlled studies with a
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
large number of subjects.
f4 f4 f4 f4
DIF: Cognitive Level: Understand (Comprehension) f4 f4 f4 TOP: NursingProcess:Planning f4 f4 f4
MSC: NCLEX: Safe and Effective Care Environment
f4 f 4 f4 f4 f4 f4 f4
3. Whichstatement bythe nurseprovides a clear explanation of the nursingprocess?
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
a. “Thenursingprocessisaresearchmethodofdiagnosingthepatient‘shealthcare f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
problems.”
f4
b. “Thenursingprocessisusedprimarilytoexplainnursinginterventionstoother f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
health care professionals.”
f4 f4 f4
c. “Thenursingprocessisa problem-solvingtoolusedtoidentifyandmanagethe f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
, patients‘health careneeds.” f4 f4 f4
d. “Thenursingprocessisbasedonnursingtheorythatincorporatesthe f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
f4 biopsychosocial nature of humans.” f4 f4 f4
ANS: C f 4
The nursing process is a problem-solving approach to the identification and treatment of patients‘
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
problems. Nursing process does not require research methods for diagnosis. The primaryuseof the
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
nursingprocess is inpatient care, not toestablish nursingtheoryorexplain nursing interventions to
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
other health care professionals.
f4 f4 f4 f4
DIF: Cognitive Level: Understand (Comprehension) f4 f4 f4 TOP: NursingProcess:Evaluation f4 f4 f4
MSC: NCLEX: Safe and Effective Care Environment
f4 f 4 f4 f4 f4 f4 f4
4. Apatientadmittedtothehospitalforsurgerytellsthenurse,“Idonotfeelcomfortable leaving
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
my children with my parents.” Which action would the nurse take next?
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
a. Reassurethe patient that thesefeelings arecommon forparents. f4 f4 f4 f4 f4 f4 f4 f4 f4
b. Havethe patient call the children to ensurethat theyaredoing well. f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
c. Gatherinformation onthepatient‘s concerns about thechildcarearrangements. f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
d. Callthepatient‘s parents todeterminewhetheradequatechildcareisbeing
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
provided. f4
ANS: C f 4
Because a complete assessment is necessary in order to identify a problem and choose an
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
appropriate intervention, the nurse‘s first action should be to obtain more information. The other
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
actions maybeappropriate,but moreassessment isneeded beforethebest intervention can be
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
chosen.
f4
DIF: Cognitive Level: Analyze (Analysis) f4 f4 f4
TOP: NursingProcess: Assessment f MSC: NCLEX:PsychosocialIntegrity
4 f4 f4 f 4 f4 f4
5. Apatient withabacterial infectionishypovolemic duetoafeverand excessivediaphoresis. Which
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
expected outcome would the nurse select for this patient?
f4 f4 f4 f4 f4 f4 f4 f4 f4
a. Patienthasabalanced intakeand output. f4 f4 f4 f4 f4 f4
b. Patient‘s beddingis keptclean and freeof moisture. f4 f4 f4 f4 f4 f4 f4 f4
c. Patientunderstandstheneed forincreased fluidintake. f4 f4 f4 f4 f4 f4 f4
d. Patient‘sskinremainscooland drythroughout hospitalization. f4 f4 f4 f4 f4 f4 f4
ANS: A f 4
Balancedintake andoutputgivesmeasurabledata showingresolution oftheproblemof deficient f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
fluid volume. The other statements would not indicate that the problem of hypovolemia was
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
resolved.
f4
DIF: Cognitive Level: Apply (Application) f4 f4 f4 TOP: NursingProcess:Planning f4 f4 f4
MSC: NCLEX: Physiological Integrity
f4 f 4 f4 f4
6. Whichstatement describes the purposeoftheevaluation phase ofthe nursingprocess?
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
a. Todocument the nursing careplan in theprogress notes of thehealth record
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
b. Todetermineifinterventions havebeen effective in meetingpatient outcomes
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
c. To decide whetherthepatient‘s health problems havebeen completelyresolved
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
d. Toestablish if thepatient agrees thatthenursingcareprovided was satisfactory
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
ANS: B f 4
, Evaluation consists of determining whether the desired patient outcomes have been met and f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
whether the nursing interventions were appropriate. The other responses do not describe the
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
evaluation phase.
f4 f4
DIF: Cognitive Level: Understand (Comprehension)
f 4 f4 f4 f4 TOP: Nursing Process: Evaluation f4 f4 f4
MSC: NCLEX: Safe and Effective Care Environment
f4 f 4 f4 f4 f4 f4 f4
7. Whichstatement describes the purposeoftheassessment phase ofthenursingprocess?
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
a. Toteachinterventionsthatrelievehealthproblems
f4 f4 f4 f4 f4 f4
b. To usepatient datato evaluatepatient careoutcomes
f4 f4 f4 f4 f4 f4 f4 f4
c. Toobtaindatatodiagnosepatient strengths and problems
f4 f4 f4 f4 f4 f4 f4 f4
d. Tohelp thepatient identifyrealisticoutcomes for healthproblems
f4 f4 f4 f4 f4 f4 f4 f4 f4
ANS: C f 4
Duringtheassessment phase,thenursegathersinformation about thepatient todiagnose patient
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
strengths and problems. The other responses are examples of the planning, intervention, and
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
evaluation phases of the nursing process.
f4 f4 f4 f4 f4 f4
DIF: CognitiveLevel: Understand (Comprehension) f4 f4 f4
TOP: NursingProcess: Assessment
f MSC: NCLEX:SafeandEffectiveCareEnvironment
4 f4 f4 f 4 f4 f4 f4 f4 f4
8. Whendevelopingtheplanofcare,which components wouldthenurseincludein theclinical
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
problem statement?
f4 f4
a. Theproblem andthesuggested patient goalsoroutcomesf4 f4 f4 f4 f4 f4 f4 f4
b. Theproblem, its causes, andthesigns andsymptoms ofthe problem
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
c. Theproblem with thepossible etiologyand theplanned interventions
f4 f4 f4 f4 f4 f4 f4 f4 f4
d. Theproblem, itspathophysiology, andtheexpected outcome
f4 f4 f4 f4 f4 f4 f4
ANS: B f 4
When writing clinical problems or nursing diagnoses, the subjective as well as objective data to
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
support the problem‘s existence should be included. Goals, outcomes, and interventions are not
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
included in the problem statement.
f4 f4 f4 f4 f4
DIF: Cognitive Level: Understand (Comprehension) f4 f4 f4 TOP: NursingProcess:Diagnosis f4 f4 f4
MSC: NCLEX: Safe and Effective Care Environment
f4 f 4 f4 f4 f4 f4 f4
9. Whichpatient caretask wouldthe nursedelegate toexperienced assistive personnel (AP)?
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
a. Instructthepatient about the need to alternate activityand rest. f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
b. Monitorlevel ofshortness ofbreath orfatigueafterambulation. f4 f4 f4 f4 f4 f4 f4 f4 f4
c. Obtainthepatient‘sbloodpressureand pulserate after ambulation. f4 f4 f4 f4 f4 f4 f4 f4 f4
d. Determinewhetherthe patient isreadytoincrease theactivitylevel. f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
ANS: C f 4
APeducationincludesaccuratevitalsignmeasurement.Assessmentandpatientteaching require
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
registered nurse education and scope of practice and cannot be delegated.
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
DIF: Cognitive Level: Apply (Application) f4 f4 f4 TOP: NursingProcess:Planning f4 f4 f4
MSC: NCLEX: Safe and Effective Care Environment
f4 f 4 f4 f4 f4 f4 f4
f4 f4 f4
Harding:Lewis’sMedical-SurgicalNursing,12thEdition
f4 f4 f4 f4 f4
MULTIPLECHOICE f4
1. The nurse completes an admission database and explains that the plan of care and discharge goals
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
will be developed with the patient‘s input. The patient asks, “How is this different from what the
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
physician does?” Which response would the nurse provide?
f4 f4 f4 f4 f4 f4 f4 f4
a. “Theroleofthenurseistoadministermedicationsandothertreatmentsprescribed by f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
your physician.”
f4 f4
b. “Inadditiontocaringforyouwhile youaresick,thenurseswillhelp youplanto
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
maintain your health.”
f4 f4 f4
c. “Thenurse‘sjobistocollectinformationandcommunicateanyproblemsthat f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
occur to the physician.”
f4 f4 f4 f4
d. “Nursesperformmanyofthesameproceduresasthephysician,butnursesare with f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
the patients for a longer time than the physician.”
f4 f4 f4 f4 f4 f4 f4 f4 f4
ANS: B f 4
The American Nurses Association (ANA) definition of nursing describes the role of nurses in
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
promoting health. The other responses describe dependent and collaborative functions of the
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
nursing role but do not accurately describe the nurse‘s unique role in the health care system.
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
DIF: f 4 f 4 CognitiveLevel:Analyze(Analysis) f4 f4 f4
TOP: f 4 NursingProcess: Implementation f4 f4 f 4 f 4 f 4 MSC: NCLEX:SafeandEffectiveCareEnvironment f 4 f4 f4 f4 f4 f4
2. Whichstatement bythe nurseaccuratelydescribes the useof evidence-based practice (EBP)?
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
a. “Patientcareisbasedonclinicaljudgment,experience,andtraditions.” f4 f4 f4 f4 f4 f4 f4 f4 f4
b. “Dataareanalyzedlatertoshowthatthepatientoutcomesareconsistentlymet.” f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
c. “Researchfromallpublishedarticlesareusedasaguideforplanningpatientcare.” f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
d. “Recommendations arebased on research, clinical expertise, and patient f4 f4 f4 f4 f4 f4 f4 f4
preferences.”
f4
ANS: D f 4
Evidence-based practice (EBP) is the use of the best research-based evidence combined with f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
clinician expertise and consideration of patient preferences. Clinical judgment based on the
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
nurse‘s clinical experience is part of EBP, but clinical decision making should also incorporate
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
current researchandresearch-basedguidelines.Evaluation ofpatient outcomesis important, but
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
data analysis is not required to use EBP. All published articles do not provide researchevidence;
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
interventionsshouldbebasedoncredibleresearch,preferablyrandomized controlled studies with a
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
large number of subjects.
f4 f4 f4 f4
DIF: Cognitive Level: Understand (Comprehension) f4 f4 f4 TOP: NursingProcess:Planning f4 f4 f4
MSC: NCLEX: Safe and Effective Care Environment
f4 f 4 f4 f4 f4 f4 f4
3. Whichstatement bythe nurseprovides a clear explanation of the nursingprocess?
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
a. “Thenursingprocessisaresearchmethodofdiagnosingthepatient‘shealthcare f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
problems.”
f4
b. “Thenursingprocessisusedprimarilytoexplainnursinginterventionstoother f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
health care professionals.”
f4 f4 f4
c. “Thenursingprocessisa problem-solvingtoolusedtoidentifyandmanagethe f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
, patients‘health careneeds.” f4 f4 f4
d. “Thenursingprocessisbasedonnursingtheorythatincorporatesthe f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
f4 biopsychosocial nature of humans.” f4 f4 f4
ANS: C f 4
The nursing process is a problem-solving approach to the identification and treatment of patients‘
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
problems. Nursing process does not require research methods for diagnosis. The primaryuseof the
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
nursingprocess is inpatient care, not toestablish nursingtheoryorexplain nursing interventions to
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
other health care professionals.
f4 f4 f4 f4
DIF: Cognitive Level: Understand (Comprehension) f4 f4 f4 TOP: NursingProcess:Evaluation f4 f4 f4
MSC: NCLEX: Safe and Effective Care Environment
f4 f 4 f4 f4 f4 f4 f4
4. Apatientadmittedtothehospitalforsurgerytellsthenurse,“Idonotfeelcomfortable leaving
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
my children with my parents.” Which action would the nurse take next?
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
a. Reassurethe patient that thesefeelings arecommon forparents. f4 f4 f4 f4 f4 f4 f4 f4 f4
b. Havethe patient call the children to ensurethat theyaredoing well. f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
c. Gatherinformation onthepatient‘s concerns about thechildcarearrangements. f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
d. Callthepatient‘s parents todeterminewhetheradequatechildcareisbeing
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
provided. f4
ANS: C f 4
Because a complete assessment is necessary in order to identify a problem and choose an
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
appropriate intervention, the nurse‘s first action should be to obtain more information. The other
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
actions maybeappropriate,but moreassessment isneeded beforethebest intervention can be
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
chosen.
f4
DIF: Cognitive Level: Analyze (Analysis) f4 f4 f4
TOP: NursingProcess: Assessment f MSC: NCLEX:PsychosocialIntegrity
4 f4 f4 f 4 f4 f4
5. Apatient withabacterial infectionishypovolemic duetoafeverand excessivediaphoresis. Which
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
expected outcome would the nurse select for this patient?
f4 f4 f4 f4 f4 f4 f4 f4 f4
a. Patienthasabalanced intakeand output. f4 f4 f4 f4 f4 f4
b. Patient‘s beddingis keptclean and freeof moisture. f4 f4 f4 f4 f4 f4 f4 f4
c. Patientunderstandstheneed forincreased fluidintake. f4 f4 f4 f4 f4 f4 f4
d. Patient‘sskinremainscooland drythroughout hospitalization. f4 f4 f4 f4 f4 f4 f4
ANS: A f 4
Balancedintake andoutputgivesmeasurabledata showingresolution oftheproblemof deficient f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
fluid volume. The other statements would not indicate that the problem of hypovolemia was
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
resolved.
f4
DIF: Cognitive Level: Apply (Application) f4 f4 f4 TOP: NursingProcess:Planning f4 f4 f4
MSC: NCLEX: Physiological Integrity
f4 f 4 f4 f4
6. Whichstatement describes the purposeoftheevaluation phase ofthe nursingprocess?
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
a. Todocument the nursing careplan in theprogress notes of thehealth record
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
b. Todetermineifinterventions havebeen effective in meetingpatient outcomes
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
c. To decide whetherthepatient‘s health problems havebeen completelyresolved
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
d. Toestablish if thepatient agrees thatthenursingcareprovided was satisfactory
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
ANS: B f 4
, Evaluation consists of determining whether the desired patient outcomes have been met and f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
whether the nursing interventions were appropriate. The other responses do not describe the
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
evaluation phase.
f4 f4
DIF: Cognitive Level: Understand (Comprehension)
f 4 f4 f4 f4 TOP: Nursing Process: Evaluation f4 f4 f4
MSC: NCLEX: Safe and Effective Care Environment
f4 f 4 f4 f4 f4 f4 f4
7. Whichstatement describes the purposeoftheassessment phase ofthenursingprocess?
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
a. Toteachinterventionsthatrelievehealthproblems
f4 f4 f4 f4 f4 f4
b. To usepatient datato evaluatepatient careoutcomes
f4 f4 f4 f4 f4 f4 f4 f4
c. Toobtaindatatodiagnosepatient strengths and problems
f4 f4 f4 f4 f4 f4 f4 f4
d. Tohelp thepatient identifyrealisticoutcomes for healthproblems
f4 f4 f4 f4 f4 f4 f4 f4 f4
ANS: C f 4
Duringtheassessment phase,thenursegathersinformation about thepatient todiagnose patient
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
strengths and problems. The other responses are examples of the planning, intervention, and
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
evaluation phases of the nursing process.
f4 f4 f4 f4 f4 f4
DIF: CognitiveLevel: Understand (Comprehension) f4 f4 f4
TOP: NursingProcess: Assessment
f MSC: NCLEX:SafeandEffectiveCareEnvironment
4 f4 f4 f 4 f4 f4 f4 f4 f4
8. Whendevelopingtheplanofcare,which components wouldthenurseincludein theclinical
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
problem statement?
f4 f4
a. Theproblem andthesuggested patient goalsoroutcomesf4 f4 f4 f4 f4 f4 f4 f4
b. Theproblem, its causes, andthesigns andsymptoms ofthe problem
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
c. Theproblem with thepossible etiologyand theplanned interventions
f4 f4 f4 f4 f4 f4 f4 f4 f4
d. Theproblem, itspathophysiology, andtheexpected outcome
f4 f4 f4 f4 f4 f4 f4
ANS: B f 4
When writing clinical problems or nursing diagnoses, the subjective as well as objective data to
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
support the problem‘s existence should be included. Goals, outcomes, and interventions are not
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
included in the problem statement.
f4 f4 f4 f4 f4
DIF: Cognitive Level: Understand (Comprehension) f4 f4 f4 TOP: NursingProcess:Diagnosis f4 f4 f4
MSC: NCLEX: Safe and Effective Care Environment
f4 f 4 f4 f4 f4 f4 f4
9. Whichpatient caretask wouldthe nursedelegate toexperienced assistive personnel (AP)?
f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
a. Instructthepatient about the need to alternate activityand rest. f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
b. Monitorlevel ofshortness ofbreath orfatigueafterambulation. f4 f4 f4 f4 f4 f4 f4 f4 f4
c. Obtainthepatient‘sbloodpressureand pulserate after ambulation. f4 f4 f4 f4 f4 f4 f4 f4 f4
d. Determinewhetherthe patient isreadytoincrease theactivitylevel. f4 f4 f4 f4 f4 f4 f4 f4 f4 f4
ANS: C f 4
APeducationincludesaccuratevitalsignmeasurement.Assessmentandpatientteaching require
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registered nurse education and scope of practice and cannot be delegated.
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DIF: Cognitive Level: Apply (Application) f4 f4 f4 TOP: NursingProcess:Planning f4 f4 f4
MSC: NCLEX: Safe and Effective Care Environment
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