,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 dpatient dhas dbeen dadmitted dto dthe dhospital dfor dsurgery dand dtells dthe dnurse, d“I ddo dnot
dfeel dcomfortable dleaving dmy dchildren dwith dmy dparents.” dWhich daction dshould dthe
dnurse dtake dnext?
a. Reassure dthe dpatient dthat dthese dfeelings dare dcommon dfor dparents.
b. Have dthe dpatient dcall dthe dchildren dto densure dthat dthey dare ddoing dwell.
c. Gather dmore ddata dabout dthe dpatient’s dfeelings dabout dthe dchild-care darrangements.
d. Call dthe dpatient’s dparents dto ddetermine dwhether dadequate dchild dcare
dis dbeingdprovided.
ANS: d C
Because da dcomplete dassessment dis dnecessary din dorder dto didentify da dproblem dand
dchoose dan dappropriate dintervention, dthe dnurse’s dfirst daction dshould dbe dto dobtain dmore
dinformation. dThe dother dactions dmay dbe dappropriate, dbut dmore dassessment dis dneeded
dbefore dthe dbest dinterventiondcan dbe dchosen.
DIF: Cognitive dLevel: dApply d(application) REF: 6
OBJ: d d d Special dQuestions: dPrioritization TOP: d Nursing dProcess:
dAssessmentdMSC: d NCLEX: dPsychosocial dIntegrity
5. A dpatient dwho dis dparalyzed don dthe dleft dside dof dthe dbody dafter da dstroke ddevelops da
dpressure dulcerdon dthe dleft dhip. dWhich dnursing ddiagnosis dis d most dappropriate?
a. Impaired dphysical dmobility drelated dto dleft-sided dparalysis
b. Risk dfor dimpaired dtissue dintegrity drelated dto dleft-sided dweakness
c. Impaired dskin dintegrity drelated dto daltered dcirculation dand dpressure
d. Ineffective dtissue dperfusion drelated dto dinability dto dmove dindependently
ANS: d C
The dpatient’s dmajor dproblem dis dthe dimpaired dskin dintegrity das ddemonstrated dby dthe
dpresence dof da dpressure dulcer. dThe dnurse dis dable dto dtreat dthe dcause dof daltered
dcirculation dand dpressure dby dfrequently drepositioning dthe dpatient. dAlthough dleft-sided
dweakness dis da dproblem dfor dthe dpatient,dthe dnurse dcannot dtreat dthe dweakness. dThe d“risk
dfor” ddiagnosis dis dnot dappropriate dfor dthis dpatient,dwho dalready dhas dimpaired dtissue
dintegrity. dThe dpatient ddoes dhave dineffective dtissue dperfusion, dbut dthe dimpaired dskin
dintegrity ddiagnosis dindicates dmore dclearly dwhat dthe dhealth dproblem dis.
DIF: Cognitive dLevel: dApply d(application) REF: 7
TOP: d Nursing dProcess: dDiagnosis MSC: d NCLEX: dPhysiological dIntegrity
, 6. A dpatient dwith da dbacterial dinfection dhas da dnursing ddiagnosis dof ddeficient dfluid dvolume
drelated dtodexcessive ddiaphoresis. dWhich doutcome dwould dthe dnurse drecognize das
dappropriate dfor dthis dpatient?
a. Patient dhas da dbalanced dintake dand doutput.
b. Patient’s dbedding dis dchanged dwhen dit dbecomes ddamp.
c. Patient dunderstands dthe dneed dfor dincreased dfluid dintake.
d. Patient’s dskin dremains dcool dand ddry dthroughout dhospitalization.
ANS: d A
This dstatement dgives dmeasurable ddata dshowing dresolution dof dthe dproblem dof ddeficient
dfluid dvolume dthat dwas didentified din dthe dnursing ddiagnosis dstatement. dThe dother
dstatements dwould dnotdindicate dthat dthe dproblem dof ddeficient dfluid dvolume dwas dresolved.
DIF: Cognitive dLevel: dApply d(application) REF: 7
TOP: d Nursing dProcess: dPlanning MSC: d NCLEX: dPhysiological dIntegrity
7. A dnurse dasks dthe dpatient dif dpain dwas drelieved dafter dreceiving dmedication. dWhat dis dthe
dpurposedof dthe devaluation dphase dof dthe dnursing dprocess?
a. To ddetermine dif dinterventions dhave dbeen deffective din dmeeting dpatient doutcomes
b. To ddocument dthe dnursing dcare dplan din dthe dprogress dnotes dof dthe dmedical drecord
c. To ddecide dwhether dthe dpatient’s dhealth dproblems dhave dbeen dcompletely dresolved
d. To destablish dif dthe dpatient dagrees dthat dthe dnursing dcare dprovided dwas dsatisfactory
ANS: d A
Evaluation dconsists dof ddetermining dwhether dthe ddesired dpatient doutcomes dhave dbeen
dmet dand dwhether dthe dnursing dinterventions dwere dappropriate. dThe dother dresponses ddo
dnot ddescribe dthedevaluation dphase.
DIF: d d d Cognitive dLevel: dUnderstand d(comprehension) REF: d 5
TOP: d Nursing dProcess: dEvaluation MSC: d NCLEX: dSafe dand dEffective dCare dEnvironment
8. The dnurse dinterviews da dpatient dwhile dcompleting dthe dhealth dhistory dand dphysical
dexamination.dWhat dis dthe dpurpose dof dthe dassessment dphase dof dthe dnursing dprocess?
a. To dteach dinterventions dthat drelieve dhealth dproblems
b. To duse dpatient ddata dto devaluate dpatient dcare doutcomes
c. To dobtain ddata dwith dwhich dto ddiagnose dpatient dproblems
d. To dhelp dthe dpatient didentify drealistic doutcomes dfor dhealth dproblems
ANS: d C
During dthe dassessment dphase, dthe dnurse dgathers dinformation dabout dthe dpatient dto
ddiagnosedpatient dproblems. dThe dother dresponses dare dexamples dof dthe dplanning,
dintervention, dand devaluation dphases dof dthe dnursing dprocess.
DIF: d d d Cognitive dLevel: dUnderstand d(comprehension) REF: d 5
TOP: d Nursing dProcess: dAssessment MSC: d NCLEX: dSafe dand dEffective dCare dEnvironment
9. Which dnursing ddiagnosis dstatement dis dwritten dcorrectly?
a. Altered dtissue dperfusion drelated dto dheart dfailure
b. Risk dfor dimpaired dtissue dintegrity drelated dto dsacral dredness
c. Ineffective dcoping drelated dto dresponse dto dbiopsy dtest dresults
d. Altered durinary delimination drelated dto durinary dtract dinfection
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 dpatient dhas dbeen dadmitted dto dthe dhospital dfor dsurgery dand dtells dthe dnurse, d“I ddo dnot
dfeel dcomfortable dleaving dmy dchildren dwith dmy dparents.” dWhich daction dshould dthe
dnurse dtake dnext?
a. Reassure dthe dpatient dthat dthese dfeelings dare dcommon dfor dparents.
b. Have dthe dpatient dcall dthe dchildren dto densure dthat dthey dare ddoing dwell.
c. Gather dmore ddata dabout dthe dpatient’s dfeelings dabout dthe dchild-care darrangements.
d. Call dthe dpatient’s dparents dto ddetermine dwhether dadequate dchild dcare
dis dbeingdprovided.
ANS: d C
Because da dcomplete dassessment dis dnecessary din dorder dto didentify da dproblem dand
dchoose dan dappropriate dintervention, dthe dnurse’s dfirst daction dshould dbe dto dobtain dmore
dinformation. dThe dother dactions dmay dbe dappropriate, dbut dmore dassessment dis dneeded
dbefore dthe dbest dinterventiondcan dbe dchosen.
DIF: Cognitive dLevel: dApply d(application) REF: 6
OBJ: d d d Special dQuestions: dPrioritization TOP: d Nursing dProcess:
dAssessmentdMSC: d NCLEX: dPsychosocial dIntegrity
5. A dpatient dwho dis dparalyzed don dthe dleft dside dof dthe dbody dafter da dstroke ddevelops da
dpressure dulcerdon dthe dleft dhip. dWhich dnursing ddiagnosis dis d most dappropriate?
a. Impaired dphysical dmobility drelated dto dleft-sided dparalysis
b. Risk dfor dimpaired dtissue dintegrity drelated dto dleft-sided dweakness
c. Impaired dskin dintegrity drelated dto daltered dcirculation dand dpressure
d. Ineffective dtissue dperfusion drelated dto dinability dto dmove dindependently
ANS: d C
The dpatient’s dmajor dproblem dis dthe dimpaired dskin dintegrity das ddemonstrated dby dthe
dpresence dof da dpressure dulcer. dThe dnurse dis dable dto dtreat dthe dcause dof daltered
dcirculation dand dpressure dby dfrequently drepositioning dthe dpatient. dAlthough dleft-sided
dweakness dis da dproblem dfor dthe dpatient,dthe dnurse dcannot dtreat dthe dweakness. dThe d“risk
dfor” ddiagnosis dis dnot dappropriate dfor dthis dpatient,dwho dalready dhas dimpaired dtissue
dintegrity. dThe dpatient ddoes dhave dineffective dtissue dperfusion, dbut dthe dimpaired dskin
dintegrity ddiagnosis dindicates dmore dclearly dwhat dthe dhealth dproblem dis.
DIF: Cognitive dLevel: dApply d(application) REF: 7
TOP: d Nursing dProcess: dDiagnosis MSC: d NCLEX: dPhysiological dIntegrity
, 6. A dpatient dwith da dbacterial dinfection dhas da dnursing ddiagnosis dof ddeficient dfluid dvolume
drelated dtodexcessive ddiaphoresis. dWhich doutcome dwould dthe dnurse drecognize das
dappropriate dfor dthis dpatient?
a. Patient dhas da dbalanced dintake dand doutput.
b. Patient’s dbedding dis dchanged dwhen dit dbecomes ddamp.
c. Patient dunderstands dthe dneed dfor dincreased dfluid dintake.
d. Patient’s dskin dremains dcool dand ddry dthroughout dhospitalization.
ANS: d A
This dstatement dgives dmeasurable ddata dshowing dresolution dof dthe dproblem dof ddeficient
dfluid dvolume dthat dwas didentified din dthe dnursing ddiagnosis dstatement. dThe dother
dstatements dwould dnotdindicate dthat dthe dproblem dof ddeficient dfluid dvolume dwas dresolved.
DIF: Cognitive dLevel: dApply d(application) REF: 7
TOP: d Nursing dProcess: dPlanning MSC: d NCLEX: dPhysiological dIntegrity
7. A dnurse dasks dthe dpatient dif dpain dwas drelieved dafter dreceiving dmedication. dWhat dis dthe
dpurposedof dthe devaluation dphase dof dthe dnursing dprocess?
a. To ddetermine dif dinterventions dhave dbeen deffective din dmeeting dpatient doutcomes
b. To ddocument dthe dnursing dcare dplan din dthe dprogress dnotes dof dthe dmedical drecord
c. To ddecide dwhether dthe dpatient’s dhealth dproblems dhave dbeen dcompletely dresolved
d. To destablish dif dthe dpatient dagrees dthat dthe dnursing dcare dprovided dwas dsatisfactory
ANS: d A
Evaluation dconsists dof ddetermining dwhether dthe ddesired dpatient doutcomes dhave dbeen
dmet dand dwhether dthe dnursing dinterventions dwere dappropriate. dThe dother dresponses ddo
dnot ddescribe dthedevaluation dphase.
DIF: d d d Cognitive dLevel: dUnderstand d(comprehension) REF: d 5
TOP: d Nursing dProcess: dEvaluation MSC: d NCLEX: dSafe dand dEffective dCare dEnvironment
8. The dnurse dinterviews da dpatient dwhile dcompleting dthe dhealth dhistory dand dphysical
dexamination.dWhat dis dthe dpurpose dof dthe dassessment dphase dof dthe dnursing dprocess?
a. To dteach dinterventions dthat drelieve dhealth dproblems
b. To duse dpatient ddata dto devaluate dpatient dcare doutcomes
c. To dobtain ddata dwith dwhich dto ddiagnose dpatient dproblems
d. To dhelp dthe dpatient didentify drealistic doutcomes dfor dhealth dproblems
ANS: d C
During dthe dassessment dphase, dthe dnurse dgathers dinformation dabout dthe dpatient dto
ddiagnosedpatient dproblems. dThe dother dresponses dare dexamples dof dthe dplanning,
dintervention, dand devaluation dphases dof dthe dnursing dprocess.
DIF: d d d Cognitive dLevel: dUnderstand d(comprehension) REF: d 5
TOP: d Nursing dProcess: dAssessment MSC: d NCLEX: dSafe dand dEffective dCare dEnvironment
9. Which dnursing ddiagnosis dstatement dis dwritten dcorrectly?
a. Altered dtissue dperfusion drelated dto dheart dfailure
b. Risk dfor dimpaired dtissue dintegrity drelated dto dsacral dredness
c. Ineffective dcoping drelated dto dresponse dto dbiopsy dtest dresults
d. Altered durinary delimination drelated dto durinary dtract dinfection
