Lewis’s Medical Surgical Nursing 12th Edition Harding
v
yy v
yy v
yy yy v v
yy v
yy
TestBank Chapter 1 - 69 Updated 2023
v
yy v
y v
yy v
yy v
yy v
yy v
yy v
yy
TEST BANK FOR LEWIS MEDICAL SURGICAL NURSING 12TH
yy yy yy yy yy yy yy
yy EDITION BY BY MARIANN M. HARDING, JEFFREY KWONG,
yy yy yy yy yy yy yy
yy DEBRA HAGLER, AND COURTNEY REINISCH/UPDATED
yy yy yy yy
yy VERSION 2023/2024/ ALL CHAPTERS COVERED(CHAPTER 1
yy yy yy yy yy
yy TO CHAPTER 69)/100% CORRECT ANSWERS WITH
yy yy yy yy yy
yy RATIONALE/GRADED A+/P yy
,Lewis’s Medical Surgical Nursing 12th Edition Harding Test Bank
v
yy yy v yy v v
yy yy v v
yy yy v v
yy yy v
Chapter 01: Professional Nursing
v
yy v
yy yy v
Harding: Lewis’s Medical-Surgical
y y v y y v y y v Nursing, 12th y y v y y v Edition
MULTIPLE
vCHOICE
yy
1. The vnurse vcompletes van vadmission vdatabase vand vexplains vthat vthe vplan vof vcare vand
yy yy yy yy yy yy yy yy yy yy yy yy yy
yydischarge vgoals vwill vbe vdeveloped vwith vthe vpatient‗s vinput. vThe vpatient vasks, v―How vis
v y yy yy yy yy yy yy yy yy yy yy yy yy
yythis vdifferent vfrom vwhat vthe vphysician vdoes?‖ vWhich vresponse vwould vthe vnurse
v yy yy yy yy yy yy yy yy yy yy yy
vprovide?
yy
a. ―The vrole vof vthe vnurse vis vto vadminister vmedications vand vother vtreatments
yy yy yy yy yy yy yy yy yy yy yy
vprescribed vby vyour vphysician.‖
yy yy yy yy
b. ―In vaddition vto vcaring vfor vyou vwhile vyou vare vsick, vthe vnurses vwill vhelp vyou
yy yy yy yy yy yy yy yy yy yy yy yy yy yy
vplan vto vmaintain vyour vhealth.‖
yy yy yy yy yy
c. ―The vnurse‗s vjob vis vto vcollect vinformation vand vcommunicate vany vproblems
yy yy yy yy yy yy yy yy yy yy
vthat voccur vto vthe vphysician.‖
yy yy yy yy yy
d. ―Nurses vperform vmany vof vthe vsame vprocedures vas vthe vphysician, vbut
yy yy yy yy yy yy yy yy yy yy
vnurses vare vwith vthe vpatients vfor va vlonger vtime vthan vthe vphysician.‖
yy yy yy yy yy yy yy yy yy yy yy yy
ANS: v B yy
The vAmerican vNurses vAssociation v(ANA) vdefinition vof vnursing vdescribes vthe vrole vof
yy yy yy yy yy yy yy yy yy yy yy
vnurses vin v
yy promoting vhealth. vThe vother vresponses vdescribe vdependent vand vcollaborative
yy y yy yy yy yy yy yy yy yy
vfunctions vof vthe vnursing vrole vbut vdo vnot vaccurately vdescribe vthe vnurse‗s vunique vrole
yy yy yy yy yy yy yy yy yy yy yy yy yy yy
vin vthe vhealth vcare vsystem.
yy yy yy yy yy
DIF: v Cognitive vLevel: vAnalyze v(Analysis)
y y yy yy yy
TOP: v Nursing vProcess: yvImplementation
y v yy yy yy yy v yy v yy v y y v MSC: y y v NCLEX: vSafe vand vEffective vCare yy yy yy yy
vEnvironment
yy
2. Which vstatement vby vthe vnurse vaccurately vdescribes vthe vuse vof vevidence-based vpractice v(EBP)?
yy yy yy yy yy yy yy yy yy yy yy yy
a. ―Patient vcare vis vbased von vclinical vjudgment, vexperience, vand vtraditions.‖
yy yy yy yy yy yy yy yy yy
b. ―Data vare vanalyzed vlater vto vshow vthat vthe vpatient voutcomes vare vconsistently vmet.‖
yy yy yy yy yy yy yy yy yy yy yy yy
c. ―Research vfrom vall vpublished varticles vare vused vas va vguide vfor vplanning vpatient vcare.‖
yy yy yy yy yy yy yy yy yy yy yy yy yy
d. ―Recommendations vare vbased von vresearch, vclinical vexpertise, vand yy yy yy yy yy yy yy
v
yy patient vpreferences.‖ yy
ANS: v D yy
Evidence-based vpractice v(EBP) vis vthe vuse vof vthe vbest vresearch-based vevidence yy yy yy yy yy yy yy yy yy yy
vcombined vwithv
yy clinician vexpertise vand vconsideration vof vpatient vpreferences. vClinical
yy y yy yy yy yy yy yy yy
vjudgment vbased von vthe vnurse‗s vclinical vexperience vis vpart vof vEBP, vbut vclinical
yy yy yy yy yy yy yy yy yy yy yy yy yy
vdecision vmaking vshould valso vincorporate vcurrent vresearch vand vresearch-based
yy yy yy yy yy yy yy yy yy
vguidelines. vEvaluation vof vpatient voutcomes visvimportant, vbut vdata vanalysis vis vnot
yy yy yy yy yy yy y yy yy yy yy yy
vrequired vto vuse vEBP. vAll vpublished varticles vdo vnot vprovide vresearch vevidence;
yy yy yy yy yy yy yy yy yy yy yy yy
vinterventions vshould vbe vbased von vcredible vresearch, vpreferably vrandomizedvcontrolled
yy yy yy yy yy yy yy yy yy y
vstudies vwith va vlarge vnumber vof vsubjects.
yy yy yy yy yy yy yy
DIF: Cognitive vLevel: vUnderstand v(Comprehension) TOP: v Nursing vProcess: yy yy yy yy yy
vPlanningv
yy MSC: v NCLEX: vSafe vand vEffective vCare vEnvironment
y y y yy yy yy yy yy
3. Which vstatement vby vthe vnurse vprovides va vclear vexplanation vof vthe vnursing vprocess?
yy yy yy yy yy yy yy yy yy yy yy yy
a. ―The vnursing vprocess vis va vresearch vmethod vof vdiagnosing vthe vpatient‗s vhealth
yy yy yy yy yy yy yy yy yy yy yy
care vproblems.‖
v
yy yy
b. ―The vnursing vprocess vis vused vprimarily vto vexplain vnursing vinterventions vto
yy yy yy yy yy yy yy yy yy yy
vother vhealth vcare vprofessionals.‖
yy yy yy yy
c. ―The vnursing vprocess vis va vproblem-solving vtool vused vto videntify vand vmanage vthe
yy yy yy yy yy yy yy yy yy yy yy yy
, patients‗ vhealth vcare vneeds.‖ yy yy yy
d. ―The vnursing vprocess vis vbased von vnursing vtheory vthat vincorporates
yy yy yy yy yy yy yy yy yy
v
yy the vbiopsychosocial vnature vof vhumans.‖
yy yy yy yy
ANS: v C yy
The vnursing vprocess vis va vproblem-solving vapproach vto vthe videntification vand vtreatment
yy yy yy yy yy yy yy yy yy yy yy
vof vpatients‗ vproblems. vNursing vprocess vdoes vnot vrequire vresearch vmethods vfor
yy yy yy yy yy yy yy yy yy yy yy
vdiagnosis. vThe vprimary vuse vof vthe vnursing vprocess vis vin vpatient vcare, vnot vto vestablish
yy yy yy yy yy yy yy yy yy yy yy yy yy yy yy
vnursing vtheory vor vexplainv
yy nursing vinterventions vto vother vhealth vcare vprofessionals.
yy yy yy y yy yy yy yy yy yy
DIF: Cognitive vLevel: vUnderstand v(Comprehension) TOP: v Nursing vProcess: yy yy yy y y yy
vEvaluationv
yy MSC: v NCLEX: vSafe vand vEffective vCare vEnvironment
y y y yy yy yy yy yy
4. A vpatient v admitted v to v the vhospital v for vsurgery vtells v the v nurse, v ―I vdo v not v feel
yy yy yy yy yy yy yy yy yy yy yy yy yy yy
yycomfortablevleaving vmy vchildren vwith vmy vparents.‖ vWhich vaction vwould vthe
v y yy yy yy yy yy yy yy yy yy
vnurse vtake vnext?
yy yy yy
a. Reassure vthe vpatient vthat vthese vfeelings vare vcommon vfor vparents.
yy yy yy yy yy yy yy yy yy
b. Have vthe vpatient vcall vthe vchildren vto vensure vthat vthey vare vdoing vwell.
yy yy yy yy yy yy yy yy yy yy yy yy
c. Gather vinformation von vthe vpatient‗s vconcerns vabout vthe vchild vcare varrangements.
yy yy yy yy yy yy yy yy yy yy
d. Call vthe vpatient‗s vparents vto vdetermine vwhether vadequate vchild vcare vis
yy yy yy yy yy yy yy yy yy yy
vbeingv
provided.
yy y
ANS: v C yy
Because va vcomplete vassessment vis vnecessary vin vorder vto videntify va vproblem vand
yy yy yy yy yy yy yy yy yy yy yy yy
vchoose van vappropriate vintervention, vthe vnurse‗s vfirst vaction vshould vbe vto vobtain vmore
yy yy yy yy yy yy yy yy yy yy yy yy yy
vinformation. vThe vother vactions vmay vbe vappropriate, vbut vmore vassessment vis vneeded
yy yy yy yy yy yy yy yy yy yy yy yy
vbefore vthe vbest vinterventionv
yy can vbe vchosen.
yy yy yy y yy yy
DIF: Cognitive vLevel: vAnalyze v(Analysis) yy yy yy
TOP: v Nursing vProcess: vAssessment MSC:
y y yy yy y y v NCLEX: vPsychosocial vIntegrity yy yy
5. A vpatient vwith va vbacterial vinfection vis vhypovolemic vdue vto va vfever vand vexcessive
yy yy yy yy yy yy yy yy yy yy yy yy yy
diaphoresis.vWhich vexpected voutcome vwould vthe vnurse vselect vfor vthis vpatient?
v
yy y yy yy yy yy yy yy yy yy yy
a. Patient vhas va vbalanced vintake vand voutput. yy yy yy yy yy yy
b. Patient‗s vbedding vis vkept vclean vand vfree vof vmoisture. yy yy yy yy yy yy yy yy
c. Patient vunderstands vthe vneed vfor vincreased vfluid vintake.
yy yy yy yy yy yy yy
d. Patient‗s v skin v remains v cool v and v dry vthroughout v hospitalization.
y y y y y y y y y y yy y y
ANS: v A yy
Balanced vintake vand voutput vgives vmeasurable vdata vshowing vresolution vof vthe vproblem
yy yy yy yy yy yy yy yy yy yy yy
vofvdeficient vfluid vvolume. vThe vother vstatements vwould vnot vindicate vthat vthe vproblem
yy y yy yy yy yy yy yy yy yy yy yy yy
vof vhypovolemia vwas vresolved.
yy yy yy yy
DIF: Cognitive vLevel: vApply v(Application) yy yy yy TOP: y y v Nursing vProcess: yy
vPlanningv
yy MSC: v NCLEX: vPhysiological vIntegrity
y y y yy yy
6. Which vstatement vdescribes vthe vpurpose vof vthe vevaluation vphase vof vthe vnursing vprocess?
yy yy yy yy yy yy yy yy yy yy yy yy
a. To vdocument vthe vnursing vcare vplan vin vthe vprogress vnotes vof vthe vhealth vrecord
yy yy yy yy yy yy yy yy yy yy yy yy yy
b. To vdetermine vif vinterventions vhave vbeen veffective vin vmeeting vpatient voutcomes
yy yy yy yy yy yy yy yy yy yy
c. To vdecide vwhether vthe vpatient‗s vhealth vproblems vhave vbeen vcompletely vresolved
yy yy yy yy yy yy yy yy yy yy
d. To vestablish vif vthe vpatient vagrees vthat vthe vnursing vcare vprovided vwas vsatisfactory
yy yy yy yy yy yy yy yy yy yy yy yy
ANS: v B yy
, Evaluation vconsists vof vdetermining vwhether vthe vdesired vpatient voutcomes vhave vbeen
yy yy yy yy yy yy yy yy yy yy
vmet vand v
yy whether vthe vnursing vinterventions vwere vappropriate. vThe vother vresponses vdo
yy y yy yy yy yy yy yy yy yy yy
vnot vdescribe vthevevaluation vphase.
yy yy yy y yy
DIF: v v v Cognitive vLevel: vUnderstand v(Comprehension)
yy yy y y TOP: yy yy yy y y v Nursing yy vProcess:
vEvaluationv
yy MSC: v NCLEX: vSafe vand vEffective vCare vEnvironment
y y y yy yy yy yy yy
7. Which vstatement vdescribes vthe vpurpose vof vthe vassessment vphase vof vthe vnursing vprocess?
yy yy yy yy yy yy yy yy yy yy yy yy
a. To vteach vinterventions vthat vrelieve vhealth vproblems
yy yy yy yy yy yy
b. To vuse vpatient vdata vto vevaluate vpatient vcare voutcomes
yy yy yy yy yy yy yy yy
c. To vobtain vdata vto vdiagnose vpatient vstrengths vand vproblems
yy yy yy yy yy yy yy yy
d. To vhelp vthe vpatient videntify vrealistic voutcomes vfor vhealth vproblems
yy yy yy yy yy yy yy yy yy
ANS: v C yy
During vthe vassessment vphase, vthe vnurse vgathers vinformation vabout vthe vpatient vto
yy yy yy yy yy yy yy yy yy yy yy
vdiagnosev
yy patient vstrengths vand vproblems. vThe vother vresponses vare vexamples vof vthe
y yy yy yy yy yy yy yy yy yy yy
vplanning, vintervention, vand vevaluation vphases vof vthe vnursing vprocess.
yy yy yy yy yy yy yy yy yy
DIF: Cognitive vLevel: vUnderstand v(Comprehension) yy yy yy
TOP: v Nursing vProcess: vAssessment MSC: v NCLEX: vSafe vand vEffective vCare vEnvironment
y y yy yy y y yy yy yy yy yy
8. When vdeveloping vthe vplan vof vcare, vwhich vcomponents vwould vthe vnurse vinclude vin vthe
yy yy yy yy yy yy yy yy yy yy yy yy yy
v
yy clinicalvproblem vstatement? y yy
a. The vproblem vand vthe vsuggested vpatient vgoals vor voutcomes
yy yy yy yy yy yy yy yy
b. The vproblem, vits vcauses, vand vthe vsigns vand vsymptoms vof vthe vproblem
yy yy yy yy yy yy yy yy yy yy yy
c. The vproblem vwith vthe vpossible vetiology vand vthe vplanned vinterventions
yy yy yy yy yy yy yy yy yy
d. The vproblem, vits vpathophysiology, vand vthe vexpected voutcome
yy yy yy yy yy yy yy
ANS: v B yy
When vwriting vclinical vproblems vor vnursing vdiagnoses, vthe vsubjective vas vwell vas
yy yy yy yy yy yy yy yy yy yy yy
vobjective vdata vto vsupport vthe vproblem‗s vexistence vshould vbe vincluded. vGoals, voutcomes,
yy yy yy yy yy yy yy yy yy yy yy yy
vand vinterventions varev
yy yy not vincluded vin vthe vproblem vstatement. yy y yy yy yy yy yy
DIF: Cognitive vLevel: vUnderstand v(Comprehension) TOP: yy yy yy y y v Nursing vProcess: yy
vDiagnosisv
yy MSC: v NCLEX: vSafe vand vEffective vCare vEnvironment
y y y yy yy yy yy yy
9. Which vpatient vcare vtask vwould vthe vnurse vdelegate vto vexperienced vassistive vpersonnel v(AP)?
yy yy yy yy yy yy yy yy yy yy yy yy
a. Instruct vthe vpatient vabout vthe vneed vto valternate vactivity vand vrest.
yy yy yy yy yy yy yy yy yy yy
b. Monitor vlevel vof vshortness vof vbreath vor vfatigue vafter vambulation.
yy yy yy yy yy yy yy yy yy
c. Obtain vthe vpatient‗s vblood vpressure vand vpulse vrate vafter vambulation.
yy yy yy yy yy yy yy yy yy
d. Determine vwhether vthe vpatient vis vready vto vincrease vthe vactivity vlevel.
yy yy yy yy yy yy yy yy yy yy
ANS: v C yy
AP veducation vincludes vaccurate vvital vsign vmeasurement. vAssessment vand vpatient
yy yy yy yy yy yy yy yy yy
vteachingvrequire vregistered vnurse veducation vand vscope vof vpractice vand vcannot vbe
yy y yy yy yy yy yy yy yy yy yy yy
vdelegated.
yy
DIF: Cognitive vLevel: vApply v(Application) TOP: yy yy yy y y v Nursing vProcess: yy
vPlanningv
yy MSC: v NCLEX: vSafe vand vEffective vCare vEnvironment
y y y yy yy yy yy yy
v
yy v
yy v
yy yy v v
yy v
yy
TestBank Chapter 1 - 69 Updated 2023
v
yy v
y v
yy v
yy v
yy v
yy v
yy v
yy
TEST BANK FOR LEWIS MEDICAL SURGICAL NURSING 12TH
yy yy yy yy yy yy yy
yy EDITION BY BY MARIANN M. HARDING, JEFFREY KWONG,
yy yy yy yy yy yy yy
yy DEBRA HAGLER, AND COURTNEY REINISCH/UPDATED
yy yy yy yy
yy VERSION 2023/2024/ ALL CHAPTERS COVERED(CHAPTER 1
yy yy yy yy yy
yy TO CHAPTER 69)/100% CORRECT ANSWERS WITH
yy yy yy yy yy
yy RATIONALE/GRADED A+/P yy
,Lewis’s Medical Surgical Nursing 12th Edition Harding Test Bank
v
yy yy v yy v v
yy yy v v
yy yy v v
yy yy v
Chapter 01: Professional Nursing
v
yy v
yy yy v
Harding: Lewis’s Medical-Surgical
y y v y y v y y v Nursing, 12th y y v y y v Edition
MULTIPLE
vCHOICE
yy
1. The vnurse vcompletes van vadmission vdatabase vand vexplains vthat vthe vplan vof vcare vand
yy yy yy yy yy yy yy yy yy yy yy yy yy
yydischarge vgoals vwill vbe vdeveloped vwith vthe vpatient‗s vinput. vThe vpatient vasks, v―How vis
v y yy yy yy yy yy yy yy yy yy yy yy yy
yythis vdifferent vfrom vwhat vthe vphysician vdoes?‖ vWhich vresponse vwould vthe vnurse
v yy yy yy yy yy yy yy yy yy yy yy
vprovide?
yy
a. ―The vrole vof vthe vnurse vis vto vadminister vmedications vand vother vtreatments
yy yy yy yy yy yy yy yy yy yy yy
vprescribed vby vyour vphysician.‖
yy yy yy yy
b. ―In vaddition vto vcaring vfor vyou vwhile vyou vare vsick, vthe vnurses vwill vhelp vyou
yy yy yy yy yy yy yy yy yy yy yy yy yy yy
vplan vto vmaintain vyour vhealth.‖
yy yy yy yy yy
c. ―The vnurse‗s vjob vis vto vcollect vinformation vand vcommunicate vany vproblems
yy yy yy yy yy yy yy yy yy yy
vthat voccur vto vthe vphysician.‖
yy yy yy yy yy
d. ―Nurses vperform vmany vof vthe vsame vprocedures vas vthe vphysician, vbut
yy yy yy yy yy yy yy yy yy yy
vnurses vare vwith vthe vpatients vfor va vlonger vtime vthan vthe vphysician.‖
yy yy yy yy yy yy yy yy yy yy yy yy
ANS: v B yy
The vAmerican vNurses vAssociation v(ANA) vdefinition vof vnursing vdescribes vthe vrole vof
yy yy yy yy yy yy yy yy yy yy yy
vnurses vin v
yy promoting vhealth. vThe vother vresponses vdescribe vdependent vand vcollaborative
yy y yy yy yy yy yy yy yy yy
vfunctions vof vthe vnursing vrole vbut vdo vnot vaccurately vdescribe vthe vnurse‗s vunique vrole
yy yy yy yy yy yy yy yy yy yy yy yy yy yy
vin vthe vhealth vcare vsystem.
yy yy yy yy yy
DIF: v Cognitive vLevel: vAnalyze v(Analysis)
y y yy yy yy
TOP: v Nursing vProcess: yvImplementation
y v yy yy yy yy v yy v yy v y y v MSC: y y v NCLEX: vSafe vand vEffective vCare yy yy yy yy
vEnvironment
yy
2. Which vstatement vby vthe vnurse vaccurately vdescribes vthe vuse vof vevidence-based vpractice v(EBP)?
yy yy yy yy yy yy yy yy yy yy yy yy
a. ―Patient vcare vis vbased von vclinical vjudgment, vexperience, vand vtraditions.‖
yy yy yy yy yy yy yy yy yy
b. ―Data vare vanalyzed vlater vto vshow vthat vthe vpatient voutcomes vare vconsistently vmet.‖
yy yy yy yy yy yy yy yy yy yy yy yy
c. ―Research vfrom vall vpublished varticles vare vused vas va vguide vfor vplanning vpatient vcare.‖
yy yy yy yy yy yy yy yy yy yy yy yy yy
d. ―Recommendations vare vbased von vresearch, vclinical vexpertise, vand yy yy yy yy yy yy yy
v
yy patient vpreferences.‖ yy
ANS: v D yy
Evidence-based vpractice v(EBP) vis vthe vuse vof vthe vbest vresearch-based vevidence yy yy yy yy yy yy yy yy yy yy
vcombined vwithv
yy clinician vexpertise vand vconsideration vof vpatient vpreferences. vClinical
yy y yy yy yy yy yy yy yy
vjudgment vbased von vthe vnurse‗s vclinical vexperience vis vpart vof vEBP, vbut vclinical
yy yy yy yy yy yy yy yy yy yy yy yy yy
vdecision vmaking vshould valso vincorporate vcurrent vresearch vand vresearch-based
yy yy yy yy yy yy yy yy yy
vguidelines. vEvaluation vof vpatient voutcomes visvimportant, vbut vdata vanalysis vis vnot
yy yy yy yy yy yy y yy yy yy yy yy
vrequired vto vuse vEBP. vAll vpublished varticles vdo vnot vprovide vresearch vevidence;
yy yy yy yy yy yy yy yy yy yy yy yy
vinterventions vshould vbe vbased von vcredible vresearch, vpreferably vrandomizedvcontrolled
yy yy yy yy yy yy yy yy yy y
vstudies vwith va vlarge vnumber vof vsubjects.
yy yy yy yy yy yy yy
DIF: Cognitive vLevel: vUnderstand v(Comprehension) TOP: v Nursing vProcess: yy yy yy yy yy
vPlanningv
yy MSC: v NCLEX: vSafe vand vEffective vCare vEnvironment
y y y yy yy yy yy yy
3. Which vstatement vby vthe vnurse vprovides va vclear vexplanation vof vthe vnursing vprocess?
yy yy yy yy yy yy yy yy yy yy yy yy
a. ―The vnursing vprocess vis va vresearch vmethod vof vdiagnosing vthe vpatient‗s vhealth
yy yy yy yy yy yy yy yy yy yy yy
care vproblems.‖
v
yy yy
b. ―The vnursing vprocess vis vused vprimarily vto vexplain vnursing vinterventions vto
yy yy yy yy yy yy yy yy yy yy
vother vhealth vcare vprofessionals.‖
yy yy yy yy
c. ―The vnursing vprocess vis va vproblem-solving vtool vused vto videntify vand vmanage vthe
yy yy yy yy yy yy yy yy yy yy yy yy
, patients‗ vhealth vcare vneeds.‖ yy yy yy
d. ―The vnursing vprocess vis vbased von vnursing vtheory vthat vincorporates
yy yy yy yy yy yy yy yy yy
v
yy the vbiopsychosocial vnature vof vhumans.‖
yy yy yy yy
ANS: v C yy
The vnursing vprocess vis va vproblem-solving vapproach vto vthe videntification vand vtreatment
yy yy yy yy yy yy yy yy yy yy yy
vof vpatients‗ vproblems. vNursing vprocess vdoes vnot vrequire vresearch vmethods vfor
yy yy yy yy yy yy yy yy yy yy yy
vdiagnosis. vThe vprimary vuse vof vthe vnursing vprocess vis vin vpatient vcare, vnot vto vestablish
yy yy yy yy yy yy yy yy yy yy yy yy yy yy yy
vnursing vtheory vor vexplainv
yy nursing vinterventions vto vother vhealth vcare vprofessionals.
yy yy yy y yy yy yy yy yy yy
DIF: Cognitive vLevel: vUnderstand v(Comprehension) TOP: v Nursing vProcess: yy yy yy y y yy
vEvaluationv
yy MSC: v NCLEX: vSafe vand vEffective vCare vEnvironment
y y y yy yy yy yy yy
4. A vpatient v admitted v to v the vhospital v for vsurgery vtells v the v nurse, v ―I vdo v not v feel
yy yy yy yy yy yy yy yy yy yy yy yy yy yy
yycomfortablevleaving vmy vchildren vwith vmy vparents.‖ vWhich vaction vwould vthe
v y yy yy yy yy yy yy yy yy yy
vnurse vtake vnext?
yy yy yy
a. Reassure vthe vpatient vthat vthese vfeelings vare vcommon vfor vparents.
yy yy yy yy yy yy yy yy yy
b. Have vthe vpatient vcall vthe vchildren vto vensure vthat vthey vare vdoing vwell.
yy yy yy yy yy yy yy yy yy yy yy yy
c. Gather vinformation von vthe vpatient‗s vconcerns vabout vthe vchild vcare varrangements.
yy yy yy yy yy yy yy yy yy yy
d. Call vthe vpatient‗s vparents vto vdetermine vwhether vadequate vchild vcare vis
yy yy yy yy yy yy yy yy yy yy
vbeingv
provided.
yy y
ANS: v C yy
Because va vcomplete vassessment vis vnecessary vin vorder vto videntify va vproblem vand
yy yy yy yy yy yy yy yy yy yy yy yy
vchoose van vappropriate vintervention, vthe vnurse‗s vfirst vaction vshould vbe vto vobtain vmore
yy yy yy yy yy yy yy yy yy yy yy yy yy
vinformation. vThe vother vactions vmay vbe vappropriate, vbut vmore vassessment vis vneeded
yy yy yy yy yy yy yy yy yy yy yy yy
vbefore vthe vbest vinterventionv
yy can vbe vchosen.
yy yy yy y yy yy
DIF: Cognitive vLevel: vAnalyze v(Analysis) yy yy yy
TOP: v Nursing vProcess: vAssessment MSC:
y y yy yy y y v NCLEX: vPsychosocial vIntegrity yy yy
5. A vpatient vwith va vbacterial vinfection vis vhypovolemic vdue vto va vfever vand vexcessive
yy yy yy yy yy yy yy yy yy yy yy yy yy
diaphoresis.vWhich vexpected voutcome vwould vthe vnurse vselect vfor vthis vpatient?
v
yy y yy yy yy yy yy yy yy yy yy
a. Patient vhas va vbalanced vintake vand voutput. yy yy yy yy yy yy
b. Patient‗s vbedding vis vkept vclean vand vfree vof vmoisture. yy yy yy yy yy yy yy yy
c. Patient vunderstands vthe vneed vfor vincreased vfluid vintake.
yy yy yy yy yy yy yy
d. Patient‗s v skin v remains v cool v and v dry vthroughout v hospitalization.
y y y y y y y y y y yy y y
ANS: v A yy
Balanced vintake vand voutput vgives vmeasurable vdata vshowing vresolution vof vthe vproblem
yy yy yy yy yy yy yy yy yy yy yy
vofvdeficient vfluid vvolume. vThe vother vstatements vwould vnot vindicate vthat vthe vproblem
yy y yy yy yy yy yy yy yy yy yy yy yy
vof vhypovolemia vwas vresolved.
yy yy yy yy
DIF: Cognitive vLevel: vApply v(Application) yy yy yy TOP: y y v Nursing vProcess: yy
vPlanningv
yy MSC: v NCLEX: vPhysiological vIntegrity
y y y yy yy
6. Which vstatement vdescribes vthe vpurpose vof vthe vevaluation vphase vof vthe vnursing vprocess?
yy yy yy yy yy yy yy yy yy yy yy yy
a. To vdocument vthe vnursing vcare vplan vin vthe vprogress vnotes vof vthe vhealth vrecord
yy yy yy yy yy yy yy yy yy yy yy yy yy
b. To vdetermine vif vinterventions vhave vbeen veffective vin vmeeting vpatient voutcomes
yy yy yy yy yy yy yy yy yy yy
c. To vdecide vwhether vthe vpatient‗s vhealth vproblems vhave vbeen vcompletely vresolved
yy yy yy yy yy yy yy yy yy yy
d. To vestablish vif vthe vpatient vagrees vthat vthe vnursing vcare vprovided vwas vsatisfactory
yy yy yy yy yy yy yy yy yy yy yy yy
ANS: v B yy
, Evaluation vconsists vof vdetermining vwhether vthe vdesired vpatient voutcomes vhave vbeen
yy yy yy yy yy yy yy yy yy yy
vmet vand v
yy whether vthe vnursing vinterventions vwere vappropriate. vThe vother vresponses vdo
yy y yy yy yy yy yy yy yy yy yy
vnot vdescribe vthevevaluation vphase.
yy yy yy y yy
DIF: v v v Cognitive vLevel: vUnderstand v(Comprehension)
yy yy y y TOP: yy yy yy y y v Nursing yy vProcess:
vEvaluationv
yy MSC: v NCLEX: vSafe vand vEffective vCare vEnvironment
y y y yy yy yy yy yy
7. Which vstatement vdescribes vthe vpurpose vof vthe vassessment vphase vof vthe vnursing vprocess?
yy yy yy yy yy yy yy yy yy yy yy yy
a. To vteach vinterventions vthat vrelieve vhealth vproblems
yy yy yy yy yy yy
b. To vuse vpatient vdata vto vevaluate vpatient vcare voutcomes
yy yy yy yy yy yy yy yy
c. To vobtain vdata vto vdiagnose vpatient vstrengths vand vproblems
yy yy yy yy yy yy yy yy
d. To vhelp vthe vpatient videntify vrealistic voutcomes vfor vhealth vproblems
yy yy yy yy yy yy yy yy yy
ANS: v C yy
During vthe vassessment vphase, vthe vnurse vgathers vinformation vabout vthe vpatient vto
yy yy yy yy yy yy yy yy yy yy yy
vdiagnosev
yy patient vstrengths vand vproblems. vThe vother vresponses vare vexamples vof vthe
y yy yy yy yy yy yy yy yy yy yy
vplanning, vintervention, vand vevaluation vphases vof vthe vnursing vprocess.
yy yy yy yy yy yy yy yy yy
DIF: Cognitive vLevel: vUnderstand v(Comprehension) yy yy yy
TOP: v Nursing vProcess: vAssessment MSC: v NCLEX: vSafe vand vEffective vCare vEnvironment
y y yy yy y y yy yy yy yy yy
8. When vdeveloping vthe vplan vof vcare, vwhich vcomponents vwould vthe vnurse vinclude vin vthe
yy yy yy yy yy yy yy yy yy yy yy yy yy
v
yy clinicalvproblem vstatement? y yy
a. The vproblem vand vthe vsuggested vpatient vgoals vor voutcomes
yy yy yy yy yy yy yy yy
b. The vproblem, vits vcauses, vand vthe vsigns vand vsymptoms vof vthe vproblem
yy yy yy yy yy yy yy yy yy yy yy
c. The vproblem vwith vthe vpossible vetiology vand vthe vplanned vinterventions
yy yy yy yy yy yy yy yy yy
d. The vproblem, vits vpathophysiology, vand vthe vexpected voutcome
yy yy yy yy yy yy yy
ANS: v B yy
When vwriting vclinical vproblems vor vnursing vdiagnoses, vthe vsubjective vas vwell vas
yy yy yy yy yy yy yy yy yy yy yy
vobjective vdata vto vsupport vthe vproblem‗s vexistence vshould vbe vincluded. vGoals, voutcomes,
yy yy yy yy yy yy yy yy yy yy yy yy
vand vinterventions varev
yy yy not vincluded vin vthe vproblem vstatement. yy y yy yy yy yy yy
DIF: Cognitive vLevel: vUnderstand v(Comprehension) TOP: yy yy yy y y v Nursing vProcess: yy
vDiagnosisv
yy MSC: v NCLEX: vSafe vand vEffective vCare vEnvironment
y y y yy yy yy yy yy
9. Which vpatient vcare vtask vwould vthe vnurse vdelegate vto vexperienced vassistive vpersonnel v(AP)?
yy yy yy yy yy yy yy yy yy yy yy yy
a. Instruct vthe vpatient vabout vthe vneed vto valternate vactivity vand vrest.
yy yy yy yy yy yy yy yy yy yy
b. Monitor vlevel vof vshortness vof vbreath vor vfatigue vafter vambulation.
yy yy yy yy yy yy yy yy yy
c. Obtain vthe vpatient‗s vblood vpressure vand vpulse vrate vafter vambulation.
yy yy yy yy yy yy yy yy yy
d. Determine vwhether vthe vpatient vis vready vto vincrease vthe vactivity vlevel.
yy yy yy yy yy yy yy yy yy yy
ANS: v C yy
AP veducation vincludes vaccurate vvital vsign vmeasurement. vAssessment vand vpatient
yy yy yy yy yy yy yy yy yy
vteachingvrequire vregistered vnurse veducation vand vscope vof vpractice vand vcannot vbe
yy y yy yy yy yy yy yy yy yy yy yy
vdelegated.
yy
DIF: Cognitive vLevel: vApply v(Application) TOP: yy yy yy y y v Nursing vProcess: yy
vPlanningv
yy MSC: v NCLEX: vSafe vand vEffective vCare vEnvironment
y y y yy yy yy yy yy