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