Test Bank For Le
bv bv bv
wis\'s Medical-
bv
Surgical Nursing,
v
b bv v
b
12th Edition by M
bv bv bv
ariann M. Harding bv bv
, Jeffrey Kwong, D
bv bv bv
ebra Hagler bv
Chapter 1-69 bv
,Chapter 01: Professional Nursing
bv bv bv
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
bv bv bv bv bv
MULTIPLE CHOICE bv
1. The nurse completes an admission database and explains that the plan of care and dischar
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
gegoals will be developed with the patient‘s input. The patient asks, “How is this different f
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
romwhat the physician does?” Which response would the nurse provide?
bv bv bv bv bv bv bv bv bv bv
a. “The role of the nurse is to administer medications and other treatments prescribe
bv bv bv bv bv bv bv bv bv bv bv bv
dby your physician.”
bv bv bv
b. “In addition to caring for you while you are sick, the nurses will help you plan
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
tomaintain your health.”bv bv bv
c. “The nurse‘s job is to collect information and communicate any problems tha
bv bv bv bv bv bv bv bv bv bv bv
toccur to the physician.”
bv bv bv bv
d. “Nurses perform many of the same procedures as the physician, but nurses ar
bv bv bv bv bv bv bv bv bv bv bv bv
e with the patients for a longer time than the physician.”
bv bv bv bv bv bv bv bv bv bv
ANS: B bv
The American Nurses Association (ANA) definition of nursing describes the role of nurses
bv bv bv bv bv bv bv bv bv bv bv bv bv
inpromoting health. The other responses describe dependent and collaborative functions of
bv bv bv bv bv bv bv bv bv bv bv b
vthe nursing role but do not accurately describe the nurse‘s unique role in the health care sy
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
stem.
DIF: Cognitive Level: Analyze (Analysis) bv bv bv
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
b v bv bv b v bv bv bv bv bv
2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
bv bv bv bv bv bv bv bv bv bv bv bv
a. “Patient care is based on clinical judgment, experience, and traditions.”
bv bv bv bv bv bv bv bv bv
b. “Data are analyzed later to show that the patient outcomes are consistently met.”
bv bv bv bv bv bv bv bv bv bv bv bv
c. “Research from all published articles are used as a guide for planning patient care.”
bv bv bv bv bv bv bv bv bv bv bv bv bv
d. “Recommendations are based on research, clinical expertise, and patien bv bv bv bv bv bv bv bv
t preferences.”
bv
ANS: D bv
Evidence-based practice (EBP) is the use of the best research- bv bv bv bv bv bv bv bv bv
based evidence combined withclinician expertise and consideration of patient preferences.
bv bv bv bv bv bv bv bv bv bv bv
Clinical judgment based on the nurse‘s clinical experience is part of EBP, but clinical deci
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
sion making should also incorporate current research and research-
bv bv bv bv bv bv bv bv
based guidelines. Evaluation of patient outcomes isimportant, but data analysis is not requi
bv bv bv bv bv bv bv bv bv bv bv bv bv
red to use EBP. All published articles do not provide research evidence; interventions shou
bv bv bv bv bv bv bv bv bv bv bv bv bv
ld be based on credible research, preferably randomizedcontrolled studies with a large nu
bv bv bv bv bv bv bv bv bv bv bv bv bv
mber of subjects. bv bv
DIF: Cognitive Level: Understand (Comprehension) bv bv bv
TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment
bv bv bv bv b v bv bv bv bv bv
3. Which statement by the nurse provides a clear explanation of the nursing process?
bv bv bv bv bv bv bv bv bv bv bv bv
a. “The nursing process is a research method of diagnosing the patient‘s health car
bv bv bv bv bv bv bv bv bv bv bv bv
eproblems.” v
b
b. “The nursing process is used primarily to explain nursing interventions to othe
bv bv bv bv bv bv bv bv bv bv bv
rhealth care professionals.”
bv bv bv
c. “The nursing process is a problem-solving tool used to identify and manage the
bv bv bv bv bv bv bv bv bv bv bv bv
, patients‘ health care needs.” bv bv bv
d. “The nursing process is based on nursing theory that incorporates th
bv bv bv bv bv bv bv bv bv bv
ebiopsychosocial nature of humans.”
v
b bv bv bv
ANS: C bv
The nursing process is a problem-
bv bv bv bv bv
solving approach to the identification and treatment of patients‘ problems. Nursing process
bv bv bv bv bv bv bv bv bv bv bv
does not require research methods for diagnosis. The primary use of the nursing process is
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
in patient care, not to establish nursing theory or explainnursing interventions to other heal
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
th care professionals.
bv bv
DIF: Cognitive Level: Understand (Comprehension) bv bv bv
TOP: Nursing Process: EvaluationMSC: NCLEX: Safe and Effective Care Environment
bv bv bv bv b v bv bv bv bv bv
4. A patient admitted to the hospital for surgery tells the nurse, “I do not feel comfortab
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
leleaving my children with my parents.” Which action would the nurse take next?
bv bv bv bv bv bv bv bv bv bv bv bv bv
a. Reassure the patient that these feelings are common for parents.
bv bv bv bv bv bv bv bv bv
b. Have the patient call the children to ensure that they are doing well.
bv bv bv bv bv bv bv bv bv bv bv bv
c. Gather information on the patient‘s concerns about the child care arrangements.
bv bv bv bv bv bv bv bv bv bv
d. Call the patient‘s parents to determine whether adequate child care is bein
bv bv bv bv bv bv bv bv bv bv bv
gprovided. bv
ANS: C bv
Because a complete assessment is necessary in order to identify a problem and choose an
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
appropriate intervention, the nurse‘s first action should be to obtain more information. The
bv bv bv bv bv bv bv bv bv bv bv bv
other actions may be appropriate, but more assessment is needed before the best interventi
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
oncan be chosen.
bv bv bv
DIF: Cognitive Level: Analyze (Analysis) bv bv bv
TOP: Nursing Process: Assessment
b v MSC: NCLEX: Psychosocial Integrity
bv bv bv bv bv
5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresi
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
s.Which expected outcome would the nurse select for this patient?
bv bv bv bv bv bv bv bv bv bv
a. Patient has a balanced intake and output. bv bv bv bv bv bv
b. Patient‘s bedding is kept clean and free of moisture. bv bv bv bv bv bv bv bv
c. Patient understands the need for increased fluid intake.
bv bv bv bv bv bv bv
d. Patient‘s skin remains cool and dry throughout hospitalization.
bv bv bv bv bv bv bv
ANS: A bv
Balanced intake and output gives measurable data showing resolution of the problem ofdefi
bv bv bv bv bv bv bv bv bv bv bv bv bv
cient fluid volume. The other statements would not indicate that the problem of hypovole
bv bv bv bv bv bv bv bv bv bv bv bv bv
mia was resolved.bv bv
DIF: Cognitive Level: Apply (Application) bv bv bv
TOP: Nursing Process: PlanningMSC: NCLEX: Physiological Integrity
bv bv bv bv b v bv bv
6. Which statement describes the purpose of the evaluation phase of the nursing process?
bv bv bv bv bv bv bv bv bv bv bv bv
a. To document the nursing care plan in the progress notes of the health record
bv bv bv bv bv bv bv bv bv bv bv bv bv
b. To determine if interventions have been effective in meeting patient outcomes
bv bv bv bv bv bv bv bv bv bv
c. To decide whether the patient‘s health problems have been completely resolved
bv bv bv bv bv bv bv bv bv bv
d. To establish if the patient agrees that the nursing care provided was satisfactory
bv bv bv bv bv bv bv bv bv bv bv bv
ANS: B bv
, Evaluation consists of determining whether the desired patient outcomes have been met a
bv bv bv bv bv bv bv bv bv bv bv bv
ndwhether the nursing interventions were appropriate. The other responses do not describ
bv bv bv bv bv bv bv bv bv bv bv bv
e theevaluation phase.
bv bv bv
DIF: Cognitive Level: Understand (Comprehension) bv bv bv
TOP: Nursing Process: EvaluationMSC: NCLEX: Safe and Effective Care Environment
bv bv bv bv b v bv bv bv bv bv
7. Which statement describes the purpose of the assessment phase of the nursing process?
bv bv bv bv bv bv bv bv bv bv bv bv
a. To teach interventions that relieve health problems
bv bv bv bv bv bv
b. To use patient data to evaluate patient care outcomes
bv bv bv bv bv bv bv bv
c. To obtain data to diagnose patient strengths and problems
bv bv bv bv bv bv bv bv
d. To help the patient identify realistic outcomes for health problems
bv bv bv bv bv bv bv bv bv
ANS: C bv
During the assessment phase, the nurse gathers information about the patient to diagnosepat
bv bv bv bv bv bv bv bv bv bv bv bv bv
ient strengths and problems. The other responses are examples of the planning, interventio
bv bv bv bv bv bv bv bv bv bv bv bv
n, and evaluation phases of the nursing process.
bv bv bv bv bv bv bv
DIF: Cognitive Level: Understand (Comprehension) bv bv bv
TOP: Nursing Process: Assessment
b v MSC: NCLEX: Safe and Effective Care Environment
bv bv b v bv bv bv bv bv
8. When developing the plan of care, which components would the nurse include in the clinic
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
alproblem statement?
bv bv
a. The problem and the suggested patient goals or outcomes
bv bv bv bv bv bv bv bv
b. The problem, its causes, and the signs and symptoms of the problem
bv bv bv bv bv bv bv bv bv bv bv
c. The problem with the possible etiology and the planned interventions
bv bv bv bv bv bv bv bv bv
d. The problem, its pathophysiology, and the expected outcome
bv bv bv bv bv bv bv
ANS: B bv
When writing clinical problems or nursing diagnoses, the subjective as well as objective da
bv bv bv bv bv bv bv bv bv bv bv bv bv
ta to support the problem‘s existence should be included. Goals, outcomes, and interventions
bv bv bv bv bv bv bv bv bv bv bv bv
arenot included in the problem statement.
bv bv bv bv bv bv bv
DIF: Cognitive Level: Understand (Comprehension) bv bv bv
TOP: Nursing Process: DiagnosisMSC: NCLEX: Safe and Effective Care Environment
bv bv bv bv b v bv bv bv bv bv
9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
bv bv bv bv bv bv bv bv bv bv bv bv
a. Instruct the patient about the need to alternate activity and rest.
bv bv bv bv bv bv bv bv bv bv
b. Monitor level of shortness of breath or fatigue after ambulation.
bv bv bv bv bv bv bv bv bv
c. Obtain the patient‘s blood pressure and pulse rate after ambulation.
bv bv bv bv bv bv bv bv bv
d. Determine whether the patient is ready to increase the activity level.
bv bv bv bv bv bv bv bv bv bv
ANS: C bv
AP education includes accurate vital sign measurement. Assessment and patient teachingreq
bv bv bv bv bv bv bv bv bv bv bv
uire registered nurse education and scope of practice and cannot be delegated.
bv bv bv bv bv bv bv bv bv bv bv
DIF: Cognitive Level: Apply (Application) bv bv bv
TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment
bv bv bv bv b v bv bv bv bv bv
bv bv bv
wis\'s Medical-
bv
Surgical Nursing,
v
b bv v
b
12th Edition by M
bv bv bv
ariann M. Harding bv bv
, Jeffrey Kwong, D
bv bv bv
ebra Hagler bv
Chapter 1-69 bv
,Chapter 01: Professional Nursing
bv bv bv
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
bv bv bv bv bv
MULTIPLE CHOICE bv
1. The nurse completes an admission database and explains that the plan of care and dischar
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
gegoals will be developed with the patient‘s input. The patient asks, “How is this different f
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
romwhat the physician does?” Which response would the nurse provide?
bv bv bv bv bv bv bv bv bv bv
a. “The role of the nurse is to administer medications and other treatments prescribe
bv bv bv bv bv bv bv bv bv bv bv bv
dby your physician.”
bv bv bv
b. “In addition to caring for you while you are sick, the nurses will help you plan
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
tomaintain your health.”bv bv bv
c. “The nurse‘s job is to collect information and communicate any problems tha
bv bv bv bv bv bv bv bv bv bv bv
toccur to the physician.”
bv bv bv bv
d. “Nurses perform many of the same procedures as the physician, but nurses ar
bv bv bv bv bv bv bv bv bv bv bv bv
e with the patients for a longer time than the physician.”
bv bv bv bv bv bv bv bv bv bv
ANS: B bv
The American Nurses Association (ANA) definition of nursing describes the role of nurses
bv bv bv bv bv bv bv bv bv bv bv bv bv
inpromoting health. The other responses describe dependent and collaborative functions of
bv bv bv bv bv bv bv bv bv bv bv b
vthe nursing role but do not accurately describe the nurse‘s unique role in the health care sy
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
stem.
DIF: Cognitive Level: Analyze (Analysis) bv bv bv
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
b v bv bv b v bv bv bv bv bv
2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
bv bv bv bv bv bv bv bv bv bv bv bv
a. “Patient care is based on clinical judgment, experience, and traditions.”
bv bv bv bv bv bv bv bv bv
b. “Data are analyzed later to show that the patient outcomes are consistently met.”
bv bv bv bv bv bv bv bv bv bv bv bv
c. “Research from all published articles are used as a guide for planning patient care.”
bv bv bv bv bv bv bv bv bv bv bv bv bv
d. “Recommendations are based on research, clinical expertise, and patien bv bv bv bv bv bv bv bv
t preferences.”
bv
ANS: D bv
Evidence-based practice (EBP) is the use of the best research- bv bv bv bv bv bv bv bv bv
based evidence combined withclinician expertise and consideration of patient preferences.
bv bv bv bv bv bv bv bv bv bv bv
Clinical judgment based on the nurse‘s clinical experience is part of EBP, but clinical deci
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
sion making should also incorporate current research and research-
bv bv bv bv bv bv bv bv
based guidelines. Evaluation of patient outcomes isimportant, but data analysis is not requi
bv bv bv bv bv bv bv bv bv bv bv bv bv
red to use EBP. All published articles do not provide research evidence; interventions shou
bv bv bv bv bv bv bv bv bv bv bv bv bv
ld be based on credible research, preferably randomizedcontrolled studies with a large nu
bv bv bv bv bv bv bv bv bv bv bv bv bv
mber of subjects. bv bv
DIF: Cognitive Level: Understand (Comprehension) bv bv bv
TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment
bv bv bv bv b v bv bv bv bv bv
3. Which statement by the nurse provides a clear explanation of the nursing process?
bv bv bv bv bv bv bv bv bv bv bv bv
a. “The nursing process is a research method of diagnosing the patient‘s health car
bv bv bv bv bv bv bv bv bv bv bv bv
eproblems.” v
b
b. “The nursing process is used primarily to explain nursing interventions to othe
bv bv bv bv bv bv bv bv bv bv bv
rhealth care professionals.”
bv bv bv
c. “The nursing process is a problem-solving tool used to identify and manage the
bv bv bv bv bv bv bv bv bv bv bv bv
, patients‘ health care needs.” bv bv bv
d. “The nursing process is based on nursing theory that incorporates th
bv bv bv bv bv bv bv bv bv bv
ebiopsychosocial nature of humans.”
v
b bv bv bv
ANS: C bv
The nursing process is a problem-
bv bv bv bv bv
solving approach to the identification and treatment of patients‘ problems. Nursing process
bv bv bv bv bv bv bv bv bv bv bv
does not require research methods for diagnosis. The primary use of the nursing process is
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
in patient care, not to establish nursing theory or explainnursing interventions to other heal
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
th care professionals.
bv bv
DIF: Cognitive Level: Understand (Comprehension) bv bv bv
TOP: Nursing Process: EvaluationMSC: NCLEX: Safe and Effective Care Environment
bv bv bv bv b v bv bv bv bv bv
4. A patient admitted to the hospital for surgery tells the nurse, “I do not feel comfortab
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
leleaving my children with my parents.” Which action would the nurse take next?
bv bv bv bv bv bv bv bv bv bv bv bv bv
a. Reassure the patient that these feelings are common for parents.
bv bv bv bv bv bv bv bv bv
b. Have the patient call the children to ensure that they are doing well.
bv bv bv bv bv bv bv bv bv bv bv bv
c. Gather information on the patient‘s concerns about the child care arrangements.
bv bv bv bv bv bv bv bv bv bv
d. Call the patient‘s parents to determine whether adequate child care is bein
bv bv bv bv bv bv bv bv bv bv bv
gprovided. bv
ANS: C bv
Because a complete assessment is necessary in order to identify a problem and choose an
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
appropriate intervention, the nurse‘s first action should be to obtain more information. The
bv bv bv bv bv bv bv bv bv bv bv bv
other actions may be appropriate, but more assessment is needed before the best interventi
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
oncan be chosen.
bv bv bv
DIF: Cognitive Level: Analyze (Analysis) bv bv bv
TOP: Nursing Process: Assessment
b v MSC: NCLEX: Psychosocial Integrity
bv bv bv bv bv
5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresi
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
s.Which expected outcome would the nurse select for this patient?
bv bv bv bv bv bv bv bv bv bv
a. Patient has a balanced intake and output. bv bv bv bv bv bv
b. Patient‘s bedding is kept clean and free of moisture. bv bv bv bv bv bv bv bv
c. Patient understands the need for increased fluid intake.
bv bv bv bv bv bv bv
d. Patient‘s skin remains cool and dry throughout hospitalization.
bv bv bv bv bv bv bv
ANS: A bv
Balanced intake and output gives measurable data showing resolution of the problem ofdefi
bv bv bv bv bv bv bv bv bv bv bv bv bv
cient fluid volume. The other statements would not indicate that the problem of hypovole
bv bv bv bv bv bv bv bv bv bv bv bv bv
mia was resolved.bv bv
DIF: Cognitive Level: Apply (Application) bv bv bv
TOP: Nursing Process: PlanningMSC: NCLEX: Physiological Integrity
bv bv bv bv b v bv bv
6. Which statement describes the purpose of the evaluation phase of the nursing process?
bv bv bv bv bv bv bv bv bv bv bv bv
a. To document the nursing care plan in the progress notes of the health record
bv bv bv bv bv bv bv bv bv bv bv bv bv
b. To determine if interventions have been effective in meeting patient outcomes
bv bv bv bv bv bv bv bv bv bv
c. To decide whether the patient‘s health problems have been completely resolved
bv bv bv bv bv bv bv bv bv bv
d. To establish if the patient agrees that the nursing care provided was satisfactory
bv bv bv bv bv bv bv bv bv bv bv bv
ANS: B bv
, Evaluation consists of determining whether the desired patient outcomes have been met a
bv bv bv bv bv bv bv bv bv bv bv bv
ndwhether the nursing interventions were appropriate. The other responses do not describ
bv bv bv bv bv bv bv bv bv bv bv bv
e theevaluation phase.
bv bv bv
DIF: Cognitive Level: Understand (Comprehension) bv bv bv
TOP: Nursing Process: EvaluationMSC: NCLEX: Safe and Effective Care Environment
bv bv bv bv b v bv bv bv bv bv
7. Which statement describes the purpose of the assessment phase of the nursing process?
bv bv bv bv bv bv bv bv bv bv bv bv
a. To teach interventions that relieve health problems
bv bv bv bv bv bv
b. To use patient data to evaluate patient care outcomes
bv bv bv bv bv bv bv bv
c. To obtain data to diagnose patient strengths and problems
bv bv bv bv bv bv bv bv
d. To help the patient identify realistic outcomes for health problems
bv bv bv bv bv bv bv bv bv
ANS: C bv
During the assessment phase, the nurse gathers information about the patient to diagnosepat
bv bv bv bv bv bv bv bv bv bv bv bv bv
ient strengths and problems. The other responses are examples of the planning, interventio
bv bv bv bv bv bv bv bv bv bv bv bv
n, and evaluation phases of the nursing process.
bv bv bv bv bv bv bv
DIF: Cognitive Level: Understand (Comprehension) bv bv bv
TOP: Nursing Process: Assessment
b v MSC: NCLEX: Safe and Effective Care Environment
bv bv b v bv bv bv bv bv
8. When developing the plan of care, which components would the nurse include in the clinic
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
alproblem statement?
bv bv
a. The problem and the suggested patient goals or outcomes
bv bv bv bv bv bv bv bv
b. The problem, its causes, and the signs and symptoms of the problem
bv bv bv bv bv bv bv bv bv bv bv
c. The problem with the possible etiology and the planned interventions
bv bv bv bv bv bv bv bv bv
d. The problem, its pathophysiology, and the expected outcome
bv bv bv bv bv bv bv
ANS: B bv
When writing clinical problems or nursing diagnoses, the subjective as well as objective da
bv bv bv bv bv bv bv bv bv bv bv bv bv
ta to support the problem‘s existence should be included. Goals, outcomes, and interventions
bv bv bv bv bv bv bv bv bv bv bv bv
arenot included in the problem statement.
bv bv bv bv bv bv bv
DIF: Cognitive Level: Understand (Comprehension) bv bv bv
TOP: Nursing Process: DiagnosisMSC: NCLEX: Safe and Effective Care Environment
bv bv bv bv b v bv bv bv bv bv
9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
bv bv bv bv bv bv bv bv bv bv bv bv
a. Instruct the patient about the need to alternate activity and rest.
bv bv bv bv bv bv bv bv bv bv
b. Monitor level of shortness of breath or fatigue after ambulation.
bv bv bv bv bv bv bv bv bv
c. Obtain the patient‘s blood pressure and pulse rate after ambulation.
bv bv bv bv bv bv bv bv bv
d. Determine whether the patient is ready to increase the activity level.
bv bv bv bv bv bv bv bv bv bv
ANS: C bv
AP education includes accurate vital sign measurement. Assessment and patient teachingreq
bv bv bv bv bv bv bv bv bv bv bv
uire registered nurse education and scope of practice and cannot be delegated.
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DIF: Cognitive Level: Apply (Application) bv bv bv
TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment
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