Complete Test Bank For
Lewis's Medical-Surgical Nursing, 12th Edition
By Harding, Hagler
All Chapters Covered Chapter 1-69
,Table Of Contents
Chapter 01: Professional Nursing .................................................................................................................. 5
Chapter 02: Social Determinants Of Health................................................................................................. 14
Chapter 03: Health History And Physical Examination ................................................................................ 21
......................................................................................................................... Error! Bookmark not defined.
Chapter 04: Patient And Caregiver Teaching ............................................................................................... 27
Chapter 05: Chronic Illness And Older Adults.............................................................................................. 35
Chapter 06: Caring For Lesbian, Gay, Bisexual, Transgender, Queer Or Questioning, And Gender Diverse
Patients Harding: ......................................................................................................................................... 45
Chapter 07: Stress Management ................................................................................................................. 51
Chapter 08: Sleep And Sleep Disorders ....................................................................................................... 56
Chapter 09: Pain .......................................................................................................................................... 61
Chapter 10: Palliative And End-Of-Life Care ................................................................................................ 73
Chapter 11: Substance Use Disorders In Acute Care ................................................................................... 81
Chapter 12: Inflammation And Healing ....................................................................................................... 91
Chapter 13: Genetics ................................................................................................................................. 100
Chapter 14: Immune Responses And Transplantation .............................................................................. 104
Chapter 15: Infection................................................................................................................................. 114
Chapter 16: Cancer.................................................................................................................................... 127
Chapter 17: Fluid, Electrolyte, And Acid-Base Imbalances ........................................................................ 146
Chapter 18: Preoperative Care .................................................................................................................. 163
Chapter 19: Intraoperative Care................................................................................................................ 172
Chapter 20: Postoperative Care ................................................................................................................ 180
Chapter 21: Emergency And Disaster Nursing........................................................................................... 190
Chapter 22: Assessment And Management: Visual Problems ................................................................... 201
Chapter 23: Assessment And Management: Auditory Problems .............................................................. 218
Chapter 24: Assessment: Integumentary System ...................................................................................... 227
Chapter 25: Integumentary Problems ....................................................................................................... 233
Chapter 26: Burns...................................................................................................................................... 244
Chapter 27: Assessment: Respiratory System ........................................................................................... 256
Chapter 28: Supporting Ventilation ........................................................................................................... 266
Chapter 29: Upper Respiratory Problems ................................................................................................. 280
Chapter 30: Lower Respiratory Problems.................................................................................................. 288
,Chapter 31: Obstructive Pulmonary Diseases ........................................................................................... 308
Chapter 32: Acute Respiratory Failure And Acute Respiratory Distress Syndrome ................................... 324
Chapter 33: Assessment: Hematologic System ......................................................................................... 336
Chapter 34: Hematologic Problems .......................................................................................................... 342
Chapter 35: Assessment: Cardiovascular System ...................................................................................... 362
Chapter 36: Hypertension ......................................................................................................................... 377
Chapter 37: Coronary Artery Disease And Acute Coronary Syndrome ...................................................... 387
Chapter 38: Heart Failure .......................................................................................................................... 406
Chapter 39: Dysrhythmias ......................................................................................................................... 418
Chapter 40: Inflammatory And Structural Heart Disorders ....................................................................... 430
Chapter 41: Vascular Disorders ................................................................................................................. 445
Chapter 42: Shock, Sepsis, And Multiple Organ Dysfunction Syndrome ................................................... 460
Chapter 43: Assessment: Gastrointestinal System .................................................................................... 475
Chapter 44: Nutrition Problems ................................................................................................................ 482
Chapter 45: Obesity................................................................................................................................... 491
Chapter 46: Upper Gastrointestinal Problems .......................................................................................... 500
Chapter 47: Lower Gastrointestinal Problems........................................................................................... 519
Chapter 48: Liver, Biliary Tract, And Pancreas Problems ........................................................................... 543
Chapter 49: Assessment: Urinary System.................................................................................................. 563
Chapter 50: Renal And Urologic Problems ................................................................................................ 573
Chapter 51: Acute Kidney Injury And Chronic Kidney Disease .................................................................. 592
Chapter 52: Assessment: Endocrine System ............................................................................................. 608
Chapter 53: Diabetes ................................................................................................................................. 617
Chapter 54: Endocrine Problems............................................................................................................... 637
Chapter 55: Assessment: Reproductive System ........................................................................................ 657
Chapter 56: Breast Problems..................................................................................................................... 662
Chapter 57: Sexually Transmitted Infections ............................................................................................. 673
Chapter 58: Female Reproductive Problems ............................................................................................. 683
Chapter 59: Male Reproductive Problems ................................................................................................ 700
Chapter 60: Assessment: Nervous System ................................................................................................ 715
Chapter 61: Acute Intracranial Problems .................................................................................................. 723
Chapter 62: Stroke .................................................................................................................................... 741
Chapter 63: Chronic Neurologic Problems ................................................................................................ 753
,Chapter 64: Dementia And Delirium ......................................................................................................... 768
Chapter 65: Spinal Cord And Peripheral Nerve Problems ......................................................................... 778
Chapter 66: Assessment: Musculoskeletal System.................................................................................... 791
Chapter 67: Musculoskeletal Trauma And Orthopedic Surgery ................................................................ 797
Chapter 68: Musculoskeletal Problems ..................................................................................................... 816
Chapter 69: Arthritis And Connective Tissue Diseases .............................................................................. 825
,Chapter 01: Professional Nursing
Multiple Choice
1. The Nurse Completes An Admission Database And Explains That The Plan Of Care And Discharge Goals
Will Be Developed With The Patients 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 By
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 Any Problems That Occur 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.‖
Answer: 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.‖
Answer: 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.‖
Answer: 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 Patients Concerns About The Child Care Arrangements.
D. Call The Patients Parents To Determine Whether Adequate Child Care Is Being Provided.
Answer: C
,Because A Complete Assessment Is Necessary In Order To Identify A Problem And Choose An Appropriate
Intervention, The Nurses 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. Patients Bedding Is Kept Clean And Free Of Moisture.
C. Patient Understands The Need For Increased Fluid Intake.
D. Patients Skin Remains Cool And Dry Throughout Hospitalization.
Answer: 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 Patients Health Problems Have Been Completely Resolved
D. To Establish If The Patient Agrees That The Nursing Care Provided Was Satisfactory
Answer: 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
Answer: 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
Answer: B
When Writing Clinical Problems Or Nursing Diagnoses, The Subjective As Well As Objective Data To
Support The Problems Existence Should Be Included. Goals, Outcomes, And Interventions Are Not
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 Patients Blood Pressure And Pulse Rate After Ambulation.
D. Determine Whether The Patient Is Ready To Increase The Activity Level.
Answer: 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
10. A Nurse Is Caring For A Group Of Patients On The Medical-Surgical Unit With The Help Of One Float
Registered Nurse (Rn), One Assistive Personnel (Ap), And One Licensed Practical/Vocational Nurse
(Lpn/Vn). Which Assignment, If Delegated By The Nurse, Would Be Outside That Individuals Scope Of
Practice?
A. Check For The Presence Of Bowel Sounds By Ap
B. Administration Of Oral Medications By Lpn/Vn
C. Insulin Administration By Float Rn From The Pediatric Unit
D. Measurement Of A Patients Urinary Catheter Output By Ap
Answer: A
Assessment Requires Rn Education And Scope Of Practice So It Cannot Be Delegated To An Lpn/Vn Or Ap.
The Other Assignments Made By The Rn Are Appropriate For The Role Of The Team Member.
Dif: Cognitive Level: Apply (Application)
Top: Nursing Process: Planning
Msc: Nclex: Safe And Effective Care Environment
11. Which Task Is Appropriate For The Nurse To Delegate To A Licensed Practical/Vocational Nurse
(Lpn/Vn)?
A. Complete The Initial Admission Assessment And Plan Of Care.
, B. Measure Bedside Blood Glucose Before Administering Insulin.
C. Document Teaching Completed Before A Diagnostic Procedure.
D. Instruct A Patient About Low-Fat, Reduced Sodium Dietary Restrictions.
Answer: B
The Education And Scope Of Practice Of The Lpn/Lvn Include Activities Such As Obtaining Glucose Testing
Using A Finger Stick And Administering Insulin. Patient Teaching And The Initial Assessment And
Development Of The Plan Of Care Are Nursing Actions That Require Registered Nurse Education And
Scope Of Practice.
Dif: Cognitive Level: Apply (Application)
Top: Nursing Process: Planning
Msc: Nclex: Safe And Effective Care Environment
12. A Nurse Is Assigned As A Case Manager For A Hospitalized Patient Who Has A Spinal Cord Injury.
Which Activity Can The Patient Expect The Nurse In This Role To Perform?
A. Care For The Patient During Hospitalization For The Injuries.
B. Assist The Patient With Home Care Activities During Recovery.
C. Coordinate The Services The Patient Receives In The Hospital And At Home.
D. Determine What Medical Care The Patient Needs For Optimal Rehabilitation.
Answer: C
The Role Of The Case Manager Is To Coordinate The Patients Care Through Multiple Settings And Levels
Of Care To Allow The Maximal Patient Benefit At The Least Cost. The Case Manager Does Not Provide
Direct Care In The Acute Or Home Setting. The Case Manager Coordinates And Advocates For Care. The
Hcp Determines What Medical Care Is Needed.
Dif: Cognitive Level: Apply (Application)
Top: Nursing Process: Implementation
Msc: Nclex: Safe And Effective Care Environment
13. The Nurse Is Caring For An Older Adult Patient Who Needs Continued Nursing Care And Physical
Therapy To Improve Mobility After Surgery To Repair A Fractured Hip. The Nurse Would Help To Arrange
For Transfer Of The Patient To Which Type Of Facility?
A. A Skilled Care Facility
Lewis's Medical-Surgical Nursing, 12th Edition
By Harding, Hagler
All Chapters Covered Chapter 1-69
,Table Of Contents
Chapter 01: Professional Nursing .................................................................................................................. 5
Chapter 02: Social Determinants Of Health................................................................................................. 14
Chapter 03: Health History And Physical Examination ................................................................................ 21
......................................................................................................................... Error! Bookmark not defined.
Chapter 04: Patient And Caregiver Teaching ............................................................................................... 27
Chapter 05: Chronic Illness And Older Adults.............................................................................................. 35
Chapter 06: Caring For Lesbian, Gay, Bisexual, Transgender, Queer Or Questioning, And Gender Diverse
Patients Harding: ......................................................................................................................................... 45
Chapter 07: Stress Management ................................................................................................................. 51
Chapter 08: Sleep And Sleep Disorders ....................................................................................................... 56
Chapter 09: Pain .......................................................................................................................................... 61
Chapter 10: Palliative And End-Of-Life Care ................................................................................................ 73
Chapter 11: Substance Use Disorders In Acute Care ................................................................................... 81
Chapter 12: Inflammation And Healing ....................................................................................................... 91
Chapter 13: Genetics ................................................................................................................................. 100
Chapter 14: Immune Responses And Transplantation .............................................................................. 104
Chapter 15: Infection................................................................................................................................. 114
Chapter 16: Cancer.................................................................................................................................... 127
Chapter 17: Fluid, Electrolyte, And Acid-Base Imbalances ........................................................................ 146
Chapter 18: Preoperative Care .................................................................................................................. 163
Chapter 19: Intraoperative Care................................................................................................................ 172
Chapter 20: Postoperative Care ................................................................................................................ 180
Chapter 21: Emergency And Disaster Nursing........................................................................................... 190
Chapter 22: Assessment And Management: Visual Problems ................................................................... 201
Chapter 23: Assessment And Management: Auditory Problems .............................................................. 218
Chapter 24: Assessment: Integumentary System ...................................................................................... 227
Chapter 25: Integumentary Problems ....................................................................................................... 233
Chapter 26: Burns...................................................................................................................................... 244
Chapter 27: Assessment: Respiratory System ........................................................................................... 256
Chapter 28: Supporting Ventilation ........................................................................................................... 266
Chapter 29: Upper Respiratory Problems ................................................................................................. 280
Chapter 30: Lower Respiratory Problems.................................................................................................. 288
,Chapter 31: Obstructive Pulmonary Diseases ........................................................................................... 308
Chapter 32: Acute Respiratory Failure And Acute Respiratory Distress Syndrome ................................... 324
Chapter 33: Assessment: Hematologic System ......................................................................................... 336
Chapter 34: Hematologic Problems .......................................................................................................... 342
Chapter 35: Assessment: Cardiovascular System ...................................................................................... 362
Chapter 36: Hypertension ......................................................................................................................... 377
Chapter 37: Coronary Artery Disease And Acute Coronary Syndrome ...................................................... 387
Chapter 38: Heart Failure .......................................................................................................................... 406
Chapter 39: Dysrhythmias ......................................................................................................................... 418
Chapter 40: Inflammatory And Structural Heart Disorders ....................................................................... 430
Chapter 41: Vascular Disorders ................................................................................................................. 445
Chapter 42: Shock, Sepsis, And Multiple Organ Dysfunction Syndrome ................................................... 460
Chapter 43: Assessment: Gastrointestinal System .................................................................................... 475
Chapter 44: Nutrition Problems ................................................................................................................ 482
Chapter 45: Obesity................................................................................................................................... 491
Chapter 46: Upper Gastrointestinal Problems .......................................................................................... 500
Chapter 47: Lower Gastrointestinal Problems........................................................................................... 519
Chapter 48: Liver, Biliary Tract, And Pancreas Problems ........................................................................... 543
Chapter 49: Assessment: Urinary System.................................................................................................. 563
Chapter 50: Renal And Urologic Problems ................................................................................................ 573
Chapter 51: Acute Kidney Injury And Chronic Kidney Disease .................................................................. 592
Chapter 52: Assessment: Endocrine System ............................................................................................. 608
Chapter 53: Diabetes ................................................................................................................................. 617
Chapter 54: Endocrine Problems............................................................................................................... 637
Chapter 55: Assessment: Reproductive System ........................................................................................ 657
Chapter 56: Breast Problems..................................................................................................................... 662
Chapter 57: Sexually Transmitted Infections ............................................................................................. 673
Chapter 58: Female Reproductive Problems ............................................................................................. 683
Chapter 59: Male Reproductive Problems ................................................................................................ 700
Chapter 60: Assessment: Nervous System ................................................................................................ 715
Chapter 61: Acute Intracranial Problems .................................................................................................. 723
Chapter 62: Stroke .................................................................................................................................... 741
Chapter 63: Chronic Neurologic Problems ................................................................................................ 753
,Chapter 64: Dementia And Delirium ......................................................................................................... 768
Chapter 65: Spinal Cord And Peripheral Nerve Problems ......................................................................... 778
Chapter 66: Assessment: Musculoskeletal System.................................................................................... 791
Chapter 67: Musculoskeletal Trauma And Orthopedic Surgery ................................................................ 797
Chapter 68: Musculoskeletal Problems ..................................................................................................... 816
Chapter 69: Arthritis And Connective Tissue Diseases .............................................................................. 825
,Chapter 01: Professional Nursing
Multiple Choice
1. The Nurse Completes An Admission Database And Explains That The Plan Of Care And Discharge Goals
Will Be Developed With The Patients 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 By
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 Any Problems That Occur 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.‖
Answer: 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.‖
Answer: 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.‖
Answer: 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 Patients Concerns About The Child Care Arrangements.
D. Call The Patients Parents To Determine Whether Adequate Child Care Is Being Provided.
Answer: C
,Because A Complete Assessment Is Necessary In Order To Identify A Problem And Choose An Appropriate
Intervention, The Nurses 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. Patients Bedding Is Kept Clean And Free Of Moisture.
C. Patient Understands The Need For Increased Fluid Intake.
D. Patients Skin Remains Cool And Dry Throughout Hospitalization.
Answer: 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 Patients Health Problems Have Been Completely Resolved
D. To Establish If The Patient Agrees That The Nursing Care Provided Was Satisfactory
Answer: 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
Answer: 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
Answer: B
When Writing Clinical Problems Or Nursing Diagnoses, The Subjective As Well As Objective Data To
Support The Problems Existence Should Be Included. Goals, Outcomes, And Interventions Are Not
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 Patients Blood Pressure And Pulse Rate After Ambulation.
D. Determine Whether The Patient Is Ready To Increase The Activity Level.
Answer: 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
10. A Nurse Is Caring For A Group Of Patients On The Medical-Surgical Unit With The Help Of One Float
Registered Nurse (Rn), One Assistive Personnel (Ap), And One Licensed Practical/Vocational Nurse
(Lpn/Vn). Which Assignment, If Delegated By The Nurse, Would Be Outside That Individuals Scope Of
Practice?
A. Check For The Presence Of Bowel Sounds By Ap
B. Administration Of Oral Medications By Lpn/Vn
C. Insulin Administration By Float Rn From The Pediatric Unit
D. Measurement Of A Patients Urinary Catheter Output By Ap
Answer: A
Assessment Requires Rn Education And Scope Of Practice So It Cannot Be Delegated To An Lpn/Vn Or Ap.
The Other Assignments Made By The Rn Are Appropriate For The Role Of The Team Member.
Dif: Cognitive Level: Apply (Application)
Top: Nursing Process: Planning
Msc: Nclex: Safe And Effective Care Environment
11. Which Task Is Appropriate For The Nurse To Delegate To A Licensed Practical/Vocational Nurse
(Lpn/Vn)?
A. Complete The Initial Admission Assessment And Plan Of Care.
, B. Measure Bedside Blood Glucose Before Administering Insulin.
C. Document Teaching Completed Before A Diagnostic Procedure.
D. Instruct A Patient About Low-Fat, Reduced Sodium Dietary Restrictions.
Answer: B
The Education And Scope Of Practice Of The Lpn/Lvn Include Activities Such As Obtaining Glucose Testing
Using A Finger Stick And Administering Insulin. Patient Teaching And The Initial Assessment And
Development Of The Plan Of Care Are Nursing Actions That Require Registered Nurse Education And
Scope Of Practice.
Dif: Cognitive Level: Apply (Application)
Top: Nursing Process: Planning
Msc: Nclex: Safe And Effective Care Environment
12. A Nurse Is Assigned As A Case Manager For A Hospitalized Patient Who Has A Spinal Cord Injury.
Which Activity Can The Patient Expect The Nurse In This Role To Perform?
A. Care For The Patient During Hospitalization For The Injuries.
B. Assist The Patient With Home Care Activities During Recovery.
C. Coordinate The Services The Patient Receives In The Hospital And At Home.
D. Determine What Medical Care The Patient Needs For Optimal Rehabilitation.
Answer: C
The Role Of The Case Manager Is To Coordinate The Patients Care Through Multiple Settings And Levels
Of Care To Allow The Maximal Patient Benefit At The Least Cost. The Case Manager Does Not Provide
Direct Care In The Acute Or Home Setting. The Case Manager Coordinates And Advocates For Care. The
Hcp Determines What Medical Care Is Needed.
Dif: Cognitive Level: Apply (Application)
Top: Nursing Process: Implementation
Msc: Nclex: Safe And Effective Care Environment
13. The Nurse Is Caring For An Older Adult Patient Who Needs Continued Nursing Care And Physical
Therapy To Improve Mobility After Surgery To Repair A Fractured Hip. The Nurse Would Help To Arrange
For Transfer Of The Patient To Which Type Of Facility?
A. A Skilled Care Facility
