,Chapter 01: Professional Nursing Practice
Ignatavicius Medical-Surgical Nursing, 10th
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 states, “How is this different from
what the doctor does?” Which response would be most appropriate for the nurse to make?
a. “The role of the nurse is to administer medications and other treatments prescribed
by your doctor.”
b. “The nurse’s job is to help the doctor by collecting information and
communicating any problems that occur.”
c. “Nurses perform many of the same procedures as the doctor, but nurses are with
the patients for a longer time than the doctor.”
d. “In addition to caring for you while you are sick, the nurses will assist you to
develop an individualized plan to maintain your health.”
ANS: D
This response is consistent with the American Nurses Association (ANA) definition of
nursing, which describes the role of nurses in promoting health. The other responses describe
some of the dependent and collaborative functions of the nursing role but do not accurately
describe the nurse’s role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
2. The nurse describes to a student nurse how to use evidence-based practice guidelines when
caring for patients. Which statement, if made by the nurse, would be the most accurate?
a. “Inferences from clinical research studies are used as a guide.”
b. “Patient care is based on clinical judgment, experience, and traditions.”
c. “Data are evaluated to show that the patient outcomes are consistently met.”
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. 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 interventions should be based on
research from randomized control studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 15
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teaches a student nurse about how to apply the nursing process when providing
patient care. Which statement, if made by the student nurse, indicates that teaching was
successful?
a. “The nursing process is a scientific-based method of diagnosing the patient’s
health care problems.”
b. “The nursing process is a problem-solving tool used to identify and treat patients’
, health care needs.”
c. “The nursing process is used primarily to explain nursing interventions to other
health care professionals.”
d. “The nursing process is based on nursing theory that incorporates the
biopsychosocial nature of humans.”
ANS: B
The nursing process is a problem-solving approach to the identification and treatment of
patients’ problems. Diagnosis is only one phase of the nursing process. 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) REF: 5
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A spatient shas sbeen sadmitted sto sthe shospital sfor ssurgery sand stells sthe snurse, s“I sdo snot
sfeel scomfortable sleaving smy schildren swith smy sparents.” sWhich saction sshould sthe snurse
stake snext?
a. Reassure sthe spatient sthat sthese sfeelings sare scommon sfor sparents.
b. Have sthe spatient scall sthe schildren sto sensure sthat sthey sare sdoing swell.
c. Gather smore sdata sabout sthe spatient’s sfeelings sabout sthe schild-care sarrangements.
d. Call sthe spatient’s sparents sto sdetermine swhether sadequate schild scare sis
sbeingsprovided.
ANS: s C
Because sa scomplete sassessment sis snecessary sin sorder sto sidentify sa sproblem sand schoose
san sappropriate sintervention, sthe snurse’s sfirst saction sshould sbe sto sobtain smore
sinformation. sThe sother sactions smay sbe sappropriate, sbut smore sassessment sis sneeded
sbefore sthe sbest sinterventionscan sbe schosen.
DIF: Cognitive sLevel: sApply s(application) REF: 6
OBJ: s s s Special sQuestions: sPrioritization TOP: s Nursing sProcess:
sAssessmentsMSC: s NCLEX: sPsychosocial sIntegrity
5. A spatient swho sis sparalyzed son sthe sleft sside sof sthe sbody safter sa sstroke sdevelops sa
spressure sulcerson sthe sleft ship. sWhich snursing sdiagnosis sis smost sappropriate?
a. Impaired sphysical smobility srelated sto sleft-sided sparalysis
b. Risk sfor simpaired stissue sintegrity srelated sto sleft-sided sweakness
c. Impaired sskin sintegrity srelated sto saltered scirculation sand spressure
d. Ineffective stissue sperfusion srelated sto sinability sto smove sindependently
ANS: s C
The spatient’s smajor sproblem sis sthe simpaired sskin sintegrity sas sdemonstrated sby sthe
spresence sof sa spressure sulcer. sThe snurse sis sable sto streat sthe scause sof saltered scirculation
sand spressure sby sfrequently srepositioning sthe spatient. sAlthough sleft-sided sweakness sis sa
sproblem sfor sthe spatient,sthe snurse scannot streat sthe sweakness. sThe s“risk sfor” sdiagnosis sis
snot sappropriate sfor sthis spatient,swho salready shas simpaired stissue sintegrity. sThe spatient
sdoes shave sineffective stissue sperfusion, sbut sthe simpaired sskin sintegrity sdiagnosis sindicates
smore sclearly swhat sthe shealth sproblem sis.
DIF: Cognitive sLevel: sApply s(application) REF: 7
TOP: s Nursing sProcess: sDiagnosis MSC: s NCLEX: sPhysiological sIntegrity
, 6. A spatient swith sa sbacterial sinfection shas sa snursing sdiagnosis sof sdeficient sfluid svolume
srelated stosexcessive sdiaphoresis. sWhich soutcome swould sthe snurse srecognize sas
sappropriate sfor sthis spatient?
a. Patient shas sa sbalanced sintake sand soutput.
b. Patient’s sbedding sis schanged swhen sit sbecomes sdamp.
c. Patient sunderstands sthe sneed sfor sincreased sfluid sintake.
d. Patient’s sskin sremains scool sand sdry sthroughout shospitalization.
ANS: s A
This sstatement sgives smeasurable sdata sshowing sresolution sof sthe sproblem sof sdeficient
sfluid svolume sthat swas sidentified sin sthe snursing sdiagnosis sstatement. sThe sother
sstatements swould snotsindicate sthat sthe sproblem sof sdeficient sfluid svolume swas sresolved.
DIF: Cognitive sLevel: sApply s(application) REF: 7
TOP: s Nursing sProcess: sPlanning MSC: s NCLEX: sPhysiological sIntegrity
7. A snurse sasks sthe spatient sif spain swas srelieved safter sreceiving smedication. sWhat sis sthe
spurposesof sthe sevaluation sphase sof sthe snursing sprocess?
a. To sdetermine sif sinterventions shave sbeen seffective sin smeeting spatient soutcomes
b. To sdocument sthe snursing scare splan sin sthe sprogress snotes sof sthe smedical srecord
c. To sdecide swhether sthe spatient’s shealth sproblems shave sbeen scompletely sresolved
d. To sestablish sif sthe spatient sagrees sthat sthe snursing scare sprovided swas ssatisfactory
ANS: s A
Evaluation sconsists sof sdetermining swhether sthe sdesired spatient soutcomes shave sbeen
smet sand swhether sthe snursing sinterventions swere sappropriate. sThe sother sresponses sdo
snot sdescribe sthesevaluation sphase.
DIF: s s s Cognitive sLevel: sUnderstand s(comprehension) REF: s 5
TOP: s Nursing sProcess: sEvaluation MSC: s NCLEX: sSafe sand sEffective sCare sEnvironment
8. The snurse sinterviews sa spatient swhile scompleting sthe shealth shistory sand sphysical
sexamination.sWhat sis sthe spurpose sof sthe sassessment sphase sof sthe snursing sprocess?
a. To steach sinterventions sthat srelieve shealth sproblems
b. To suse spatient sdata sto sevaluate spatient scare soutcomes
c. To sobtain sdata swith swhich sto sdiagnose spatient sproblems
d. To shelp sthe spatient sidentify srealistic soutcomes sfor shealth sproblems
ANS: s C
During sthe sassessment sphase, sthe snurse sgathers sinformation sabout sthe spatient sto
sdiagnosespatient sproblems. sThe sother sresponses sare sexamples sof sthe splanning,
sintervention, sand sevaluation sphases sof sthe snursing sprocess.
DIF: s s s Cognitive sLevel: sUnderstand s(comprehension) REF: s 5
TOP: s Nursing sProcess: sAssessment MSC: s NCLEX: sSafe sand sEffective sCare sEnvironment
9. Which snursing sdiagnosis sstatement sis swritten scorrectly?
a. Altered stissue sperfusion srelated sto sheart sfailure
b. Risk sfor simpaired stissue sintegrity srelated sto ssacral sredness
c. Ineffective scoping srelated sto sresponse sto sbiopsy stest sresults
d. Altered surinary selimination srelated sto surinary stract sinfection
Ignatavicius Medical-Surgical Nursing, 10th
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 states, “How is this different from
what the doctor does?” Which response would be most appropriate for the nurse to make?
a. “The role of the nurse is to administer medications and other treatments prescribed
by your doctor.”
b. “The nurse’s job is to help the doctor by collecting information and
communicating any problems that occur.”
c. “Nurses perform many of the same procedures as the doctor, but nurses are with
the patients for a longer time than the doctor.”
d. “In addition to caring for you while you are sick, the nurses will assist you to
develop an individualized plan to maintain your health.”
ANS: D
This response is consistent with the American Nurses Association (ANA) definition of
nursing, which describes the role of nurses in promoting health. The other responses describe
some of the dependent and collaborative functions of the nursing role but do not accurately
describe the nurse’s role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
2. The nurse describes to a student nurse how to use evidence-based practice guidelines when
caring for patients. Which statement, if made by the nurse, would be the most accurate?
a. “Inferences from clinical research studies are used as a guide.”
b. “Patient care is based on clinical judgment, experience, and traditions.”
c. “Data are evaluated to show that the patient outcomes are consistently met.”
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. 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 interventions should be based on
research from randomized control studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 15
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teaches a student nurse about how to apply the nursing process when providing
patient care. Which statement, if made by the student nurse, indicates that teaching was
successful?
a. “The nursing process is a scientific-based method of diagnosing the patient’s
health care problems.”
b. “The nursing process is a problem-solving tool used to identify and treat patients’
, health care needs.”
c. “The nursing process is used primarily to explain nursing interventions to other
health care professionals.”
d. “The nursing process is based on nursing theory that incorporates the
biopsychosocial nature of humans.”
ANS: B
The nursing process is a problem-solving approach to the identification and treatment of
patients’ problems. Diagnosis is only one phase of the nursing process. 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) REF: 5
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A spatient shas sbeen sadmitted sto sthe shospital sfor ssurgery sand stells sthe snurse, s“I sdo snot
sfeel scomfortable sleaving smy schildren swith smy sparents.” sWhich saction sshould sthe snurse
stake snext?
a. Reassure sthe spatient sthat sthese sfeelings sare scommon sfor sparents.
b. Have sthe spatient scall sthe schildren sto sensure sthat sthey sare sdoing swell.
c. Gather smore sdata sabout sthe spatient’s sfeelings sabout sthe schild-care sarrangements.
d. Call sthe spatient’s sparents sto sdetermine swhether sadequate schild scare sis
sbeingsprovided.
ANS: s C
Because sa scomplete sassessment sis snecessary sin sorder sto sidentify sa sproblem sand schoose
san sappropriate sintervention, sthe snurse’s sfirst saction sshould sbe sto sobtain smore
sinformation. sThe sother sactions smay sbe sappropriate, sbut smore sassessment sis sneeded
sbefore sthe sbest sinterventionscan sbe schosen.
DIF: Cognitive sLevel: sApply s(application) REF: 6
OBJ: s s s Special sQuestions: sPrioritization TOP: s Nursing sProcess:
sAssessmentsMSC: s NCLEX: sPsychosocial sIntegrity
5. A spatient swho sis sparalyzed son sthe sleft sside sof sthe sbody safter sa sstroke sdevelops sa
spressure sulcerson sthe sleft ship. sWhich snursing sdiagnosis sis smost sappropriate?
a. Impaired sphysical smobility srelated sto sleft-sided sparalysis
b. Risk sfor simpaired stissue sintegrity srelated sto sleft-sided sweakness
c. Impaired sskin sintegrity srelated sto saltered scirculation sand spressure
d. Ineffective stissue sperfusion srelated sto sinability sto smove sindependently
ANS: s C
The spatient’s smajor sproblem sis sthe simpaired sskin sintegrity sas sdemonstrated sby sthe
spresence sof sa spressure sulcer. sThe snurse sis sable sto streat sthe scause sof saltered scirculation
sand spressure sby sfrequently srepositioning sthe spatient. sAlthough sleft-sided sweakness sis sa
sproblem sfor sthe spatient,sthe snurse scannot streat sthe sweakness. sThe s“risk sfor” sdiagnosis sis
snot sappropriate sfor sthis spatient,swho salready shas simpaired stissue sintegrity. sThe spatient
sdoes shave sineffective stissue sperfusion, sbut sthe simpaired sskin sintegrity sdiagnosis sindicates
smore sclearly swhat sthe shealth sproblem sis.
DIF: Cognitive sLevel: sApply s(application) REF: 7
TOP: s Nursing sProcess: sDiagnosis MSC: s NCLEX: sPhysiological sIntegrity
, 6. A spatient swith sa sbacterial sinfection shas sa snursing sdiagnosis sof sdeficient sfluid svolume
srelated stosexcessive sdiaphoresis. sWhich soutcome swould sthe snurse srecognize sas
sappropriate sfor sthis spatient?
a. Patient shas sa sbalanced sintake sand soutput.
b. Patient’s sbedding sis schanged swhen sit sbecomes sdamp.
c. Patient sunderstands sthe sneed sfor sincreased sfluid sintake.
d. Patient’s sskin sremains scool sand sdry sthroughout shospitalization.
ANS: s A
This sstatement sgives smeasurable sdata sshowing sresolution sof sthe sproblem sof sdeficient
sfluid svolume sthat swas sidentified sin sthe snursing sdiagnosis sstatement. sThe sother
sstatements swould snotsindicate sthat sthe sproblem sof sdeficient sfluid svolume swas sresolved.
DIF: Cognitive sLevel: sApply s(application) REF: 7
TOP: s Nursing sProcess: sPlanning MSC: s NCLEX: sPhysiological sIntegrity
7. A snurse sasks sthe spatient sif spain swas srelieved safter sreceiving smedication. sWhat sis sthe
spurposesof sthe sevaluation sphase sof sthe snursing sprocess?
a. To sdetermine sif sinterventions shave sbeen seffective sin smeeting spatient soutcomes
b. To sdocument sthe snursing scare splan sin sthe sprogress snotes sof sthe smedical srecord
c. To sdecide swhether sthe spatient’s shealth sproblems shave sbeen scompletely sresolved
d. To sestablish sif sthe spatient sagrees sthat sthe snursing scare sprovided swas ssatisfactory
ANS: s A
Evaluation sconsists sof sdetermining swhether sthe sdesired spatient soutcomes shave sbeen
smet sand swhether sthe snursing sinterventions swere sappropriate. sThe sother sresponses sdo
snot sdescribe sthesevaluation sphase.
DIF: s s s Cognitive sLevel: sUnderstand s(comprehension) REF: s 5
TOP: s Nursing sProcess: sEvaluation MSC: s NCLEX: sSafe sand sEffective sCare sEnvironment
8. The snurse sinterviews sa spatient swhile scompleting sthe shealth shistory sand sphysical
sexamination.sWhat sis sthe spurpose sof sthe sassessment sphase sof sthe snursing sprocess?
a. To steach sinterventions sthat srelieve shealth sproblems
b. To suse spatient sdata sto sevaluate spatient scare soutcomes
c. To sobtain sdata swith swhich sto sdiagnose spatient sproblems
d. To shelp sthe spatient sidentify srealistic soutcomes sfor shealth sproblems
ANS: s C
During sthe sassessment sphase, sthe snurse sgathers sinformation sabout sthe spatient sto
sdiagnosespatient sproblems. sThe sother sresponses sare sexamples sof sthe splanning,
sintervention, sand sevaluation sphases sof sthe snursing sprocess.
DIF: s s s Cognitive sLevel: sUnderstand s(comprehension) REF: s 5
TOP: s Nursing sProcess: sAssessment MSC: s NCLEX: sSafe sand sEffective sCare sEnvironment
9. Which snursing sdiagnosis sstatement sis swritten scorrectly?
a. Altered stissue sperfusion srelated sto sheart sfailure
b. Risk sfor simpaired stissue sintegrity srelated sto ssacral sredness
c. Ineffective scoping srelated sto sresponse sto sbiopsy stest sresults
d. Altered surinary selimination srelated sto surinary stract sinfection
