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