,Chapter 01: Professional Nursing Practice
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Lewis: Medical-Surgical Nursing, 10th Edition
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MULTIPLE CHOICE mb
1. The nurse completes an admission database and explains that the plan of care and
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discharge goals will be developed with the patient‘s input. The patient states, ―How is this
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different from what the doctor does?‖ Which response would be most appropriate for the
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nurse to make?
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a. ―The role of the nurse is to administer medications and other treatments
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prescribed by your doctor.‖
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b. ―The nurse‘s job is to help the doctor by collecting information
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and communicating any problems that occur.‖
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c. ―Nurses perform many of the same procedures as the doctor, but nurses are
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with the patients for a longer time thadoctor.‖
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d. ―In addition to caring for you while you are sick, the nurses will assist
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you to develop an individualized plan to maintain your health.‖
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ANS: m b D
This response is consistent with the American Nurses Association (ANA) definition of
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nursing, which describes the role of nurses in promoting health. The other responses describe
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some of the dependent and collaborative functions of the nursing role but do not accurately
mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb
describe the nurse‘s role in the health care system.
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DIF: Cognitive Level: Understand (comprehension) REF: 3 mb mb mb m b m b
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
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2. The nurse describes to a student nurse how to use evidence-based practice guidelines
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when caring for patients. Which statement, if made by the nurse, would be the most
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accurate?
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a. ―Inferences from clinical research studies are used as a guide.‖ mb mb mb mb mb mb mb mb mb
b. ―Patient care is based on clinical judgment, experience, and traditions.‖
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c. ―Data are evaluated to show that the patient outcomes are consistently met.‖
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d. ―Recommendations are based on research, clinical expertise, and mb mb mb mb mb mb mb
patient preferences.‖
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ANS: m b D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with
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clinician expertise. Clinical judgment based on the nurse‘s clinical experience is part of EBP,
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but clinical decision making should also incorporate current research and research-based
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guidelines. Evaluation of patient outcomes is important, but interventions should be based
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on research from randomized control studies with a large number of subjects.
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DIF: Cognitive Level: Remember (knowledge) mb mb mb REF: 15 m b m b
TOP: Nursing Process: Planning
m b MSC: mb mb m b NCLEX: Safe and Effective Care Environment
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3. The nurse teaches a student nurse about how to apply the nursing process when providing
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patient care. Which statement, if made by the student nurse, indicates that teaching was
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successful?
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a. ―The nursing process is a scientific-based method of diagnosing the patient‘s
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, health care problems.‖ mb mb
b. ―The nursing process is a problem-solving tool used to identify and treat
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patients‘ health care needs.‖
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c. ―The nursing process is used primarily to explain nursing interventions to
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other health care professionals.‖
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d. ―The nursing process is based on nursing theory that incorporates
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the biopsychosocial nature of humans.‖
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ANS: m b B
The nursing process is a problem-solving approach to the identification and treatment of
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patients‘ problems. Diagnosis is only one phase of the nursing process. The primary use of
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the nursing process is in patient care, not to establish nursing theory or explain nursing
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interventions to other health care professionals.
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DIF: Cognitive Level: Understand (comprehension) REF: 5 mb mb mb m b m b
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
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4. A patient has been admitted to the hospital for surgery and tells the nurse, ―I do not feel
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comfortable leaving my children with my parents.‖ Which action should the nurse take
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next?
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a. Reassure the patient that these feelings are common for parents.
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b. Have the patient call the children to ensure that they are doing well.
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c. Gather more data about the patient‘s feelings about the child-care arrangements.
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d. Call the patient‘s parents to determine whether adequate child care is
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being provided.
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ANS: m b 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. The
mb mb mb mb mb mb mb mb mb mb mb mb mb
other actions may be appropriate, but more assessment is needed before the best
mb mb mb mb mb mb mb mb mb mb mb mb mb
intervention can be chosen.
mb mb mb mb
DIF: Cognitive Level: Apply (application) REF: 6 mb mb mb
OBJ: Special Questions: Prioritization TOP: Nursing Process:
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Assessment MSC: NCLEX: Psychosocial Integrity
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5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure
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mb ulcer on the left hip. Which nursing diagnosis is most appropriate?
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a. Impaired physical mobility related to left-sided paralysis
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b. Risk for impaired tissue integrity related to left-sided weakness
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c. Impaired skin integrity related to altered circulation and pressure
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d. Ineffective tissue perfusion related to inability to move independently
mb mb mb mb mb mb mb mb
ANS: m b C
The patient‘s major problem is the impaired skin integrity as demonstrated by the presence
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of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure
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by frequently repositioning the patient. Although left-sided weakness is a problem for the
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patient, the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate for
mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb
this patient, who already has impaired tissue integrity. The patient does have ineffective
mb mb mb mb mb mb mb mb mb mb mb mb mb
tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the
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health problem is.
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, DIF: Cognitive Level: Apply (application) REF: 7 mb mb mb
TOP: Nursing Process: Diagnosis
m b MSC: NCLEX: Physiological Integrity
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6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related
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to excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this
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patient?
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a. Patient has a balanced intake and output. mb mb mb mb mb mb
b. Patient‘s bedding is changed when it becomes damp. mb mb mb mb mb mb mb
c. Patient understands the need for increased fluid intake.
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d. Patient‘s skin remains cool and dry throughout hospitalization.
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ANS: m b A
This statement gives measurable data showing resolution of the problem of deficient fluid
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volume that was identified in the nursing diagnosis statement. The other statements would
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not indicate that the problem of deficient fluid volume was resolved.
mb mb mb mb mb mb mb mb mb mb mb
DIF: Cognitive Level: Apply (application) REF: 7 mb mb mb
TOP: Nursing Process: Planning
m b MSC: NCLEX: Physiological Integrity
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7. A nurse asks the patient if pain was relieved after receiving medication. What is the
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purpose of the evaluation phase of the nursing process?
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a. To determine if interventions have been effective in meeting patient outcomes
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b. To document the nursing care plan in the progress notes of the medical record
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c. To decide whether the patient‘s health problems have been completely resolved
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d. To establish if the patient agrees that the nursing care provided was satisfactory
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ANS: m b A
Evaluation consists of determining whether the desired patient outcomes have been met
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and whether the nursing interventions were appropriate. The other responses do not
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describe the evaluation phase.
mb mb mb mb
DIF: Cognitive Level: Understand (comprehension) REF: 5 mb mb mb
TOP: Nursing Process: Evaluation
m b MSC: NCLEX: Safe and Effective Care Environment
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8. The nurse interviews a patient while completing the health history and physical
mb mb mb mb mb mb mb mb mb mb mb
examination. What is the purpose of the assessment phase of the nursing process?
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a. To teach interventions that relieve health problems
mb mb mb mb mb mb
b. To use patient data to evaluate patient care outcomes
mb mb mb mb mb mb mb mb
c. To obtain data with which to diagnose patient problems
mb mb mb mb mb mb mb mb
d. To help the patient identify realistic outcomes for health problems
mb mb mb mb mb mb mb mb mb
ANS: m b C
During the assessment phase, the nurse gathers information about the patient to diagnose
mb mb mb mb mb mb mb mb mb mb mb mb
patient problems. The other responses are examples of the planning, intervention, and
mb mb mb mb mb mb mb mb mb mb mb mb
evaluation phases of the nursing process.
mb mb mb mb mb mb
DIF: Cognitive Level: Understand (comprehension) REF: 5 mb mb mb
TOP: Nursing Process: Assessment
m b MSC: NCLEX: Safe and Effective Care Environment
mb mb m b mb mb mb mb mb
mb mb mb mb
Lewis: Medical-Surgical Nursing, 10th Edition
mb mb mb mb mb
MULTIPLE CHOICE mb
1. The nurse completes an admission database and explains that the plan of care and
mb mb mb mb mb mb mb mb mb mb mb mb mb
discharge goals will be developed with the patient‘s input. The patient states, ―How is this
mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb
different from what the doctor does?‖ Which response would be most appropriate for the
mb mb mb mb mb mb mb mb mb mb mb mb mb mb
nurse to make?
mb mb mb
a. ―The role of the nurse is to administer medications and other treatments
mb mb mb mb mb mb mb mb mb mb mb
prescribed by your doctor.‖
mb mb mb mb
b. ―The nurse‘s job is to help the doctor by collecting information
mb mb mb mb mb mb mb mb mb mb
and communicating any problems that occur.‖
mb mb mb mb mb mb
c. ―Nurses perform many of the same procedures as the doctor, but nurses are
mb mb mb mb mb mb mb mb mb mb mb mb
with the patients for a longer time thadoctor.‖
mb mb mb mb mb mb mb mb
d. ―In addition to caring for you while you are sick, the nurses will assist
mb mb mb mb mb mb mb mb mb mb mb mb mb
you to develop an individualized plan to maintain your health.‖
mb mb mb mb mb mb mb mb mb mb
ANS: m b D
This response is consistent with the American Nurses Association (ANA) definition of
mb mb mb mb mb mb mb mb mb mb mb
nursing, which describes the role of nurses in promoting health. The other responses describe
mb mb mb mb mb mb mb mb mb mb mb mb mb mb
some of the dependent and collaborative functions of the nursing role but do not accurately
mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb
describe the nurse‘s role in the health care system.
mb mb mb mb mb mb mb mb mb
DIF: Cognitive Level: Understand (comprehension) REF: 3 mb mb mb m b m b
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
m b mb mb m b mb mb mb mb mb
2. The nurse describes to a student nurse how to use evidence-based practice guidelines
mb mb mb mb mb mb mb mb mb mb mb mb
when caring for patients. Which statement, if made by the nurse, would be the most
mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb
accurate?
mb
a. ―Inferences from clinical research studies are used as a guide.‖ mb mb mb mb mb mb mb mb mb
b. ―Patient care is based on clinical judgment, experience, and traditions.‖
mb mb mb mb mb mb mb mb mb
c. ―Data are evaluated to show that the patient outcomes are consistently met.‖
mb mb mb mb mb mb mb mb mb mb mb
d. ―Recommendations are based on research, clinical expertise, and mb mb mb mb mb mb mb
patient preferences.‖
mb mb
ANS: m b D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with
mb mb mb mb mb mb mb mb mb mb mb mb
clinician expertise. Clinical judgment based on the nurse‘s clinical experience is part of EBP,
mb mb mb mb mb mb mb mb mb mb mb mb mb mb
but clinical decision making should also incorporate current research and research-based
mb mb mb mb mb mb mb mb mb mb mb
guidelines. Evaluation of patient outcomes is important, but interventions should be based
mb mb mb mb mb mb mb mb mb mb mb mb
on research from randomized control studies with a large number of subjects.
mb mb mb mb mb mb mb mb mb mb mb mb
DIF: Cognitive Level: Remember (knowledge) mb mb mb REF: 15 m b m b
TOP: Nursing Process: Planning
m b MSC: mb mb m b NCLEX: Safe and Effective Care Environment
mb mb mb mb mb
3. The nurse teaches a student nurse about how to apply the nursing process when providing
mb mb mb mb mb mb mb mb mb mb mb mb mb mb
patient care. Which statement, if made by the student nurse, indicates that teaching was
mb mb mb mb mb mb mb mb mb mb mb mb mb mb
successful?
mb
a. ―The nursing process is a scientific-based method of diagnosing the patient‘s
mb mb mb mb mb mb mb mb mb mb
, health care problems.‖ mb mb
b. ―The nursing process is a problem-solving tool used to identify and treat
mb mb mb mb mb mb mb mb mb mb mb
patients‘ health care needs.‖
mb mb mb mb
c. ―The nursing process is used primarily to explain nursing interventions to
mb mb mb mb mb mb mb mb mb mb
other health care professionals.‖
mb mb mb mb
d. ―The nursing process is based on nursing theory that incorporates
mb mb mb mb mb mb mb mb mb
the biopsychosocial nature of humans.‖
mb mb mb mb mb
ANS: m b B
The nursing process is a problem-solving approach to the identification and treatment of
mb mb mb mb mb mb mb mb mb mb mb mb
patients‘ problems. Diagnosis is only one phase of the nursing process. The primary use of
mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb
the nursing process is in patient care, not to establish nursing theory or explain nursing
mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb
interventions to other health care professionals.
mb mb mb mb mb mb
DIF: Cognitive Level: Understand (comprehension) REF: 5 mb mb mb m b m b
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
m b mb mb m b mb mb mb mb mb
4. A patient has been admitted to the hospital for surgery and tells the nurse, ―I do not feel
mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb
comfortable leaving my children with my parents.‖ Which action should the nurse take
mb mb mb mb mb mb mb mb mb mb mb mb mb
next?
mb
a. Reassure the patient that these feelings are common for parents.
mb mb mb mb mb mb mb mb mb
b. Have the patient call the children to ensure that they are doing well.
mb mb mb mb mb mb mb mb mb mb mb mb
c. Gather more data about the patient‘s feelings about the child-care arrangements.
mb mb mb mb mb mb mb mb mb mb
d. Call the patient‘s parents to determine whether adequate child care is
mb mb mb mb mb mb mb mb mb mb
being provided.
mb mb
ANS: m b C
Because a complete assessment is necessary in order to identify a problem and choose an
mb mb mb mb mb mb mb mb mb mb mb mb mb mb
appropriate intervention, the nurse‘s first action should be to obtain more information. The
mb mb mb mb mb mb mb mb mb mb mb mb mb
other actions may be appropriate, but more assessment is needed before the best
mb mb mb mb mb mb mb mb mb mb mb mb mb
intervention can be chosen.
mb mb mb mb
DIF: Cognitive Level: Apply (application) REF: 6 mb mb mb
OBJ: Special Questions: Prioritization TOP: Nursing Process:
m b mb mb m b mb
Assessment MSC: NCLEX: Psychosocial Integrity
mb mb m b mb mb
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure
mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb
mb ulcer on the left hip. Which nursing diagnosis is most appropriate?
mb mb mb mb mb mb mb mb mb mb
a. Impaired physical mobility related to left-sided paralysis
mb mb mb mb mb mb
b. Risk for impaired tissue integrity related to left-sided weakness
mb mb mb mb mb mb mb mb
c. Impaired skin integrity related to altered circulation and pressure
mb mb mb mb mb mb mb mb
d. Ineffective tissue perfusion related to inability to move independently
mb mb mb mb mb mb mb mb
ANS: m b C
The patient‘s major problem is the impaired skin integrity as demonstrated by the presence
mb mb mb mb mb mb mb mb mb mb mb mb mb
of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure
mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb
by frequently repositioning the patient. Although left-sided weakness is a problem for the
mb mb mb mb mb mb mb mb mb mb mb mb mb
patient, the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate for
mb mb mb mb mb mb mb mb mb mb mb mb mb mb mb
this patient, who already has impaired tissue integrity. The patient does have ineffective
mb mb mb mb mb mb mb mb mb mb mb mb mb
tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the
mb mb mb mb mb mb mb mb mb mb mb mb mb
health problem is.
mb mb mb
, DIF: Cognitive Level: Apply (application) REF: 7 mb mb mb
TOP: Nursing Process: Diagnosis
m b MSC: NCLEX: Physiological Integrity
mb mb m b mb mb
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related
mb mb mb mb mb mb mb mb mb mb mb mb mb mb
to excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this
mb mb mb mb mb mb mb mb mb mb mb mb mb
patient?
mb
a. Patient has a balanced intake and output. mb mb mb mb mb mb
b. Patient‘s bedding is changed when it becomes damp. mb mb mb mb mb mb mb
c. Patient understands the need for increased fluid intake.
mb mb mb mb mb mb mb
d. Patient‘s skin remains cool and dry throughout hospitalization.
mb mb mb mb mb mb mb
ANS: m b A
This statement gives measurable data showing resolution of the problem of deficient fluid
mb mb mb mb mb mb mb mb mb mb mb mb
volume that was identified in the nursing diagnosis statement. The other statements would
mb mb mb mb mb mb mb mb mb mb mb mb mb
not indicate that the problem of deficient fluid volume was resolved.
mb mb mb mb mb mb mb mb mb mb mb
DIF: Cognitive Level: Apply (application) REF: 7 mb mb mb
TOP: Nursing Process: Planning
m b MSC: NCLEX: Physiological Integrity
mb mb m b mb mb
7. A nurse asks the patient if pain was relieved after receiving medication. What is the
mb mb mb mb mb mb mb mb mb mb mb mb mb mb
purpose of the evaluation phase of the nursing process?
mb mb mb mb mb mb mb mb mb
a. To determine if interventions have been effective in meeting patient outcomes
mb mb mb mb mb mb mb mb mb mb
b. To document the nursing care plan in the progress notes of the medical record
mb mb mb mb mb mb mb mb mb mb mb mb mb
c. To decide whether the patient‘s health problems have been completely resolved
mb mb mb mb mb mb mb mb mb mb
d. To establish if the patient agrees that the nursing care provided was satisfactory
mb mb mb mb mb mb mb mb mb mb mb mb
ANS: m b A
Evaluation consists of determining whether the desired patient outcomes have been met
mb mb mb mb mb mb mb mb mb mb mb
and whether the nursing interventions were appropriate. The other responses do not
mb mb mb mb mb mb mb mb mb mb mb mb
describe the evaluation phase.
mb mb mb mb
DIF: Cognitive Level: Understand (comprehension) REF: 5 mb mb mb
TOP: Nursing Process: Evaluation
m b MSC: NCLEX: Safe and Effective Care Environment
mb mb m b mb mb mb mb mb
8. The nurse interviews a patient while completing the health history and physical
mb mb mb mb mb mb mb mb mb mb mb
examination. What is the purpose of the assessment phase of the nursing process?
mb mb mb mb mb mb mb mb mb mb mb mb mb
a. To teach interventions that relieve health problems
mb mb mb mb mb mb
b. To use patient data to evaluate patient care outcomes
mb mb mb mb mb mb mb mb
c. To obtain data with which to diagnose patient problems
mb mb mb mb mb mb mb mb
d. To help the patient identify realistic outcomes for health problems
mb mb mb mb mb mb mb mb mb
ANS: m b C
During the assessment phase, the nurse gathers information about the patient to diagnose
mb mb mb mb mb mb mb mb mb mb mb mb
patient problems. The other responses are examples of the planning, intervention, and
mb mb mb mb mb mb mb mb mb mb mb mb
evaluation phases of the nursing process.
mb mb mb mb mb mb
DIF: Cognitive Level: Understand (comprehension) REF: 5 mb mb mb
TOP: Nursing Process: Assessment
m b MSC: NCLEX: Safe and Effective Care Environment
mb mb m b mb mb mb mb mb
