TestBankForLe
b
n b
n b
n bn
wis\'sMedical- b
n
SurgicalNursing,
bn b
n b
12thEditionbyM
n b
n b
n b
n bn
ariannM.Harding b
n b
n
,JeffreyKwong,D
b
n b
n b
n
ebraHagler b
n bn
Chapter1-69 b
n
,Chapter 01: Professional Nursing
bn bn bn
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
bn bn bn bn bn
MULTIPLE CHOICE bn
1. The nurse completes an admission database and explains that the plan of care and dischar ge
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
goals will be developed with the patient‘s input. The patient asks, “How is this different f ro
bv bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
mwhat the physician does?” Which response would the nurse provide?
bn bn bn bn bn bn b n bn bn
a. “The role of the nurse is to administer medications and other treatments prescribe
bn bn bn bn bn bn bn bn bn bn bn bn bn
dby your physician.” bn bn
b. “In addition to caring for you while you are sick, the nurses will help you plan
bn bn bn bn bn bn b n bn bn bn bn bn bn bn bn bn
tomaintain your health.” bn bn
c. “The nurse‘s job is to collect information and communicate anyproblems tha t
bn bn bn bv bn bn bn bn bn bn bn bn
occur to the physician.” bn bn bn
d. “Nurses perform many of the same procedures as the physician, but nurses ar
bn bn bn bn bn bn bn bn bn bn bn bn bn
e with the patients for a longer time than the physician.”
bn bn b n bn b n bn bn bn bn bn
ANS: B b n
The American Nurses Association (ANA) definition of nursing describes the role of nurses i
bn bn bn bn bn bn bn bn bn bn bn bn bn
npromoting health. The other responses describe dependent and collaborative functions of th
bn bn bn bn bn bn bn bn bn bn bn
e nursing role but do not accurately describe the nurse‘s unique role in the health care sy ste
bn bv bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
m.
DIF: Cognitive Level: Analyze (Analysis) bn bn bn
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment bn bn b n bn bn bn bn bn
2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
bn bn bn bn bn bn bn bn bn bn bn bn
a. “Patient care is based on clinical judgment, experience, and traditions.”
bn bn bn bn bn bn bn bn bn
b. “Data are analyzed later to show that the patient outcomes are consistently met.”
bn bn bn bn bn bn bn bn bn bn bn bn
c. “Research from all published articles are used as a guide for planning patient care.”
bn bn bn bn bn bn bn bn bn bn bn bn bn
d. “Recommendations are based on research, clinical expertise, and patien t bn bn bn bn bn bn bn bn bn
bn preferences.”
ANS: D b n
Evidence-based practice (EBP) is the use of the best research- bn bn bn bn bn bn bn bn bn
based evidence combined with clinician expertise and consideration of patient preferences.
bn bn bn bv bn bn bn bn bn bn bn
Clinical judgment based on the nurse‘s clinical experience is part of EBP, but clinical deci s
bn bn bn bn bn bn bn bn bn bn bn bn bn bn b n
ion making should also incorporate current research and research-
bn bn bn bn bn bn bn bn
based guidelines. Evaluation of patient outcomes is important, but data analysis is not requi
bn bn bn bn bn bn bv bn bn bn bn bn bn bn
red to use EBP. All published articles do not provide research evidence; interventions shou
bn bn bn bn bn bn bn bn bn bn bn bn bn b n
ld be based on credible research, preferably randomizedcontrolled studies with a large nu m
bn bn bn bn bn bn bn bn bn bn bn bn bn
ber of subjects.
bn bn
DIF: Cognitive Level: Understand (Comprehension) bn bn bn
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
b n bn bn bv b n bn bn bn bn bn
3. Which statement by the nurse provides a clear explanation of the nursing process?
bn bn bn bn bn bn bn bn bn bn bn bn
a. “The nursing process is a research method of diagnosing the patient‘s health car e
bn bn bn bv bn bn bn bn bv bn bn bn bn
problems.”
b. “The nursing process is used primarily to explain nursing interventions to othe r
bn bn bn bn bn bn bn bn bn bn bn bn
health care professionals.” bn bn
c. “The nursing process is a problem-solving tool used to identify and manage the
bn bn bn bn bn bn bn bn bn bn bv bn
, patients‘ health care needs.” bn bn bn
d. “The nursing process is based on nursing theory that incorporates th e
bn bn bn bv bn bn bv bn bn bn bn
biopsychosocial nature of humans.” bn bn bn
ANS: C b n
The nursing process is a problem-
bn bn bn bn bn
solving approach to the identification and treatment of patients‘ problems. Nursing process d
bn bn bn bn bn bn bn bn bn bn bn bn
oes not require research methods for diagnosis. The primary use of the nursing process is
bn b n b n b n b n b n b n bn bn bn bn bn bn bn b
in patient care, not to establish nursing theory or explain nursing interventions to other heal t
n bn bn bn bn bn bn bn bn bn bv bn bn bn bn bn
h care professionals.
bn bn
DIF: b n b n Cognitive Level: Understand (Comprehension) bn bn bn
TOP: Nursing Process: EvaluationMSC: NCLEX: Safe and Effective Care Environment
b n bn bn b n bn bn b n bn bn
4. A patient admitted to the hospital for surgery tells the nurse, “I do not feel comfortab l
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
eleaving my children with my parents.” Which action would the nurse take next?
bn bn bn bn bn bn bn bn bn bn b n b n
a. Reassure the patient that these feelings are common for parents. bn bn bn bn bn bn bn bn bn
b. Have the patient call the children to ensure that they are doing well.
bn bn bn bn bn bn bn bn bn bn bn bn
c. Gather information on the patient‘s concerns about the child care arrangements.
bn bn bn bn bn bn bn bn bn bn
d. Call the patient‘s parents to determine whether adequate child care is bein
bn bn bn bn bn bn bn bn bn bn bn bn
g provided. bv
ANS: C b n
Because a complete assessment is necessary in order to identify a problem and choose an a
bn bn bn bn bn bn bn bn bn bn bn bn bn bn b n
ppropriate intervention, the nurse‘s first action should be to obtain more information. The ot
bn bn bn bn bn bn bn bn bn bn bn bn bn
her actions may be appropriate, but more assessment is needed before the best interventi on
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bv
can be chosen. bn bn
DIF: b n b n Cognitive Level: Analyze (Analysis) bn bn bn
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
bn bn b n bn bn
5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresi
bn bn bn bn bn bv bn bn bn bn bn bn bn bn bn
s.Which expected outcome would the nurse select for this patient?
bn bn bn bn b n bn bn bn bn
a. Patient has a balanced intake and output. bn bn bn bn bn bn
b. Patient‘s bedding is kept clean and free of moisture. bn bn bn bn bn bn bn bn
c. Patient understands the need for increased fluid intake. bn bn bn bn bn bn bn
d. Patient‘s skin remains cool and dry throughout hospitalization. bn bn bn bn bn bn bn
ANS: A b n
Balanced intake and output gives measurable data showing resolution of the problem ofdefi
bn bn bn bn bn bn bn bn bn bn bn bn bn
cient fluid volume. The other statements would not indicate that the problem of hypovole mi
bn bn bn bn bn bn bn bn bn bn bn bn bn bn
a was resolved.
bn bn
DIF: Cognitive Level: Apply (Application) bn bn bn
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
b n bn bn bv b n bn bn
6. Which statement describes the purpose of the evaluation phase of the nursing process?
bn bn bn bn bn bn bn bn bn bn bn bn
a. To document the nursing care plan in the progress notes of the health record
bn bn bn bn bn bn bn bn b n bn bn bn bn
b. To determine if interventions have been effective in meeting patient outcomes
bn bn bn bn bn bn bn bn bn bn
c. To decide whether the patient‘s health problems have been completely resolved
bn bn bn bn bn bn bn bn bn bn
d. To establish if the patient agrees that the nursing care provided was satisfactory
bn bn bn bn bn bn bn bn bv bn bn bn
ANS: B b n
, Evaluation consists of determining whether the desired patient outcomes have been met a n
bn bn bn bn bn bn bn bn bn bn bn bn bn
d whether the nursing interventions were appropriate. The other responses do not describ e
bv bn bn bn bn bn bn bn bn bn bn bn b n
the evaluation phase.
bn bv bn
DIF: b n b n Cognitive Level: Understand (Comprehension) bn bn bn
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
b n bn bn bv b n bn bn bn bn bn
7. Which statement describes the purpose of the assessment phase of the nursing process?
bn bn bn bn bn bn bn bn bn bn bn bn
a. To teach interventions that relieve health problems
bn bn bn bn bn bn
b. To use patient data to evaluate patient care outcomes
bn bn bn bn bn bn bn bn
c. To obtain data to diagnose patient strengths and problems
bn bn bn bn bn bn bn bn
d. To help the patient identify realistic outcomes for health problems
bn bn bn bn bn bn bn bn bn
ANS: C b n
During the assessment phase, the nurse gathers information about the patient to diagnose pat
bn bn bn bn bn bn bn bn bn bn bn bn bv bn
ient strengths and problems. The other responses are examples of the planning, interventio
bn bn bn bn bn bn bn bn bn bn bn bn b n
n, and evaluation phases of the nursing process.
bn bn bn bn bn bn bn
DIF: Cognitive Level: Understand (Comprehension) bn bn bn
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
bn bn b n bn bn bn bn bn
8. When developing the plan of care, which components would the nurse include in the clinic
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
alproblem statement? bn
a. The problem and the suggested patient goals or outcomes
bn bn bn bn bn bn bn bn
b. The problem, its causes, and the signs and symptoms of the problem
bn bn bn bn bn bn bn bn bn bn bn
c. The problem with the possible etiology and the planned interventions
bn bn bn bn bn bn bn bn bn
d. The problem, its pathophysiology, and the expected outcome
bn bn bn bn bn bn bn
ANS: B b n
When writing clinical problems or nursing diagnoses, the subjective as well as objective da
bn bn bn bn bn bn bn bn bn bn bn bn bn b n
ta to support the problem‘s existence should be included. Goals, outcomes, and interventions
bn bn bn bn bn bn bn bn bn bn bn bn bn
arenot included in the problem statement.
bn bn bn bn bn
DIF: b n b n Cognitive Level: Understand (Comprehension) bn bn bn
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
b n bn bn bv b n bn bn bn bn bb n
9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
bn bn bn bn bn bn bn bn bn bn bn bn
a. Instruct the patient about the need to alternate activity and rest.
bn bn bn bn bn bn bn bn bn bn
b. Monitor level of shortness of breath or fatigue after ambulation.
bn bn bn bn bn bn bn bn bn
c. Obtain the patient‘s blood pressure and pulse rate after ambulation.
bn bn bn bn bn bn bn bn bn
d. Determine whether the patient is ready to increase the activity level.
bn bn bn bn bn bn bn bn bn bn
ANS: C b n
AP education includes accurate vital sign measurement. Assessment and patient teaching req
bn bn bn bn bn bn bn bn bn bn bv bn
uire registered nurse education and scope of practice and cannot be delegated.
bn bn bn b n bn bn bn bn bn bn b n
DIF: Cognitive Level: Apply (Application) bn bn bn
TOP: Nursing Process: PlanningMSC:
b n bn bn b n NCLEX: Safe and Effective Care Environment bn bn b n bn b n
b
n b
n b
n bn
wis\'sMedical- b
n
SurgicalNursing,
bn b
n b
12thEditionbyM
n b
n b
n b
n bn
ariannM.Harding b
n b
n
,JeffreyKwong,D
b
n b
n b
n
ebraHagler b
n bn
Chapter1-69 b
n
,Chapter 01: Professional Nursing
bn bn bn
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
bn bn bn bn bn
MULTIPLE CHOICE bn
1. The nurse completes an admission database and explains that the plan of care and dischar ge
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
goals will be developed with the patient‘s input. The patient asks, “How is this different f ro
bv bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
mwhat the physician does?” Which response would the nurse provide?
bn bn bn bn bn bn b n bn bn
a. “The role of the nurse is to administer medications and other treatments prescribe
bn bn bn bn bn bn bn bn bn bn bn bn bn
dby your physician.” bn bn
b. “In addition to caring for you while you are sick, the nurses will help you plan
bn bn bn bn bn bn b n bn bn bn bn bn bn bn bn bn
tomaintain your health.” bn bn
c. “The nurse‘s job is to collect information and communicate anyproblems tha t
bn bn bn bv bn bn bn bn bn bn bn bn
occur to the physician.” bn bn bn
d. “Nurses perform many of the same procedures as the physician, but nurses ar
bn bn bn bn bn bn bn bn bn bn bn bn bn
e with the patients for a longer time than the physician.”
bn bn b n bn b n bn bn bn bn bn
ANS: B b n
The American Nurses Association (ANA) definition of nursing describes the role of nurses i
bn bn bn bn bn bn bn bn bn bn bn bn bn
npromoting health. The other responses describe dependent and collaborative functions of th
bn bn bn bn bn bn bn bn bn bn bn
e nursing role but do not accurately describe the nurse‘s unique role in the health care sy ste
bn bv bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
m.
DIF: Cognitive Level: Analyze (Analysis) bn bn bn
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment bn bn b n bn bn bn bn bn
2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
bn bn bn bn bn bn bn bn bn bn bn bn
a. “Patient care is based on clinical judgment, experience, and traditions.”
bn bn bn bn bn bn bn bn bn
b. “Data are analyzed later to show that the patient outcomes are consistently met.”
bn bn bn bn bn bn bn bn bn bn bn bn
c. “Research from all published articles are used as a guide for planning patient care.”
bn bn bn bn bn bn bn bn bn bn bn bn bn
d. “Recommendations are based on research, clinical expertise, and patien t bn bn bn bn bn bn bn bn bn
bn preferences.”
ANS: D b n
Evidence-based practice (EBP) is the use of the best research- bn bn bn bn bn bn bn bn bn
based evidence combined with clinician expertise and consideration of patient preferences.
bn bn bn bv bn bn bn bn bn bn bn
Clinical judgment based on the nurse‘s clinical experience is part of EBP, but clinical deci s
bn bn bn bn bn bn bn bn bn bn bn bn bn bn b n
ion making should also incorporate current research and research-
bn bn bn bn bn bn bn bn
based guidelines. Evaluation of patient outcomes is important, but data analysis is not requi
bn bn bn bn bn bn bv bn bn bn bn bn bn bn
red to use EBP. All published articles do not provide research evidence; interventions shou
bn bn bn bn bn bn bn bn bn bn bn bn bn b n
ld be based on credible research, preferably randomizedcontrolled studies with a large nu m
bn bn bn bn bn bn bn bn bn bn bn bn bn
ber of subjects.
bn bn
DIF: Cognitive Level: Understand (Comprehension) bn bn bn
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
b n bn bn bv b n bn bn bn bn bn
3. Which statement by the nurse provides a clear explanation of the nursing process?
bn bn bn bn bn bn bn bn bn bn bn bn
a. “The nursing process is a research method of diagnosing the patient‘s health car e
bn bn bn bv bn bn bn bn bv bn bn bn bn
problems.”
b. “The nursing process is used primarily to explain nursing interventions to othe r
bn bn bn bn bn bn bn bn bn bn bn bn
health care professionals.” bn bn
c. “The nursing process is a problem-solving tool used to identify and manage the
bn bn bn bn bn bn bn bn bn bn bv bn
, patients‘ health care needs.” bn bn bn
d. “The nursing process is based on nursing theory that incorporates th e
bn bn bn bv bn bn bv bn bn bn bn
biopsychosocial nature of humans.” bn bn bn
ANS: C b n
The nursing process is a problem-
bn bn bn bn bn
solving approach to the identification and treatment of patients‘ problems. Nursing process d
bn bn bn bn bn bn bn bn bn bn bn bn
oes not require research methods for diagnosis. The primary use of the nursing process is
bn b n b n b n b n b n b n bn bn bn bn bn bn bn b
in patient care, not to establish nursing theory or explain nursing interventions to other heal t
n bn bn bn bn bn bn bn bn bn bv bn bn bn bn bn
h care professionals.
bn bn
DIF: b n b n Cognitive Level: Understand (Comprehension) bn bn bn
TOP: Nursing Process: EvaluationMSC: NCLEX: Safe and Effective Care Environment
b n bn bn b n bn bn b n bn bn
4. A patient admitted to the hospital for surgery tells the nurse, “I do not feel comfortab l
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
eleaving my children with my parents.” Which action would the nurse take next?
bn bn bn bn bn bn bn bn bn bn b n b n
a. Reassure the patient that these feelings are common for parents. bn bn bn bn bn bn bn bn bn
b. Have the patient call the children to ensure that they are doing well.
bn bn bn bn bn bn bn bn bn bn bn bn
c. Gather information on the patient‘s concerns about the child care arrangements.
bn bn bn bn bn bn bn bn bn bn
d. Call the patient‘s parents to determine whether adequate child care is bein
bn bn bn bn bn bn bn bn bn bn bn bn
g provided. bv
ANS: C b n
Because a complete assessment is necessary in order to identify a problem and choose an a
bn bn bn bn bn bn bn bn bn bn bn bn bn bn b n
ppropriate intervention, the nurse‘s first action should be to obtain more information. The ot
bn bn bn bn bn bn bn bn bn bn bn bn bn
her actions may be appropriate, but more assessment is needed before the best interventi on
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bv
can be chosen. bn bn
DIF: b n b n Cognitive Level: Analyze (Analysis) bn bn bn
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
bn bn b n bn bn
5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresi
bn bn bn bn bn bv bn bn bn bn bn bn bn bn bn
s.Which expected outcome would the nurse select for this patient?
bn bn bn bn b n bn bn bn bn
a. Patient has a balanced intake and output. bn bn bn bn bn bn
b. Patient‘s bedding is kept clean and free of moisture. bn bn bn bn bn bn bn bn
c. Patient understands the need for increased fluid intake. bn bn bn bn bn bn bn
d. Patient‘s skin remains cool and dry throughout hospitalization. bn bn bn bn bn bn bn
ANS: A b n
Balanced intake and output gives measurable data showing resolution of the problem ofdefi
bn bn bn bn bn bn bn bn bn bn bn bn bn
cient fluid volume. The other statements would not indicate that the problem of hypovole mi
bn bn bn bn bn bn bn bn bn bn bn bn bn bn
a was resolved.
bn bn
DIF: Cognitive Level: Apply (Application) bn bn bn
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
b n bn bn bv b n bn bn
6. Which statement describes the purpose of the evaluation phase of the nursing process?
bn bn bn bn bn bn bn bn bn bn bn bn
a. To document the nursing care plan in the progress notes of the health record
bn bn bn bn bn bn bn bn b n bn bn bn bn
b. To determine if interventions have been effective in meeting patient outcomes
bn bn bn bn bn bn bn bn bn bn
c. To decide whether the patient‘s health problems have been completely resolved
bn bn bn bn bn bn bn bn bn bn
d. To establish if the patient agrees that the nursing care provided was satisfactory
bn bn bn bn bn bn bn bn bv bn bn bn
ANS: B b n
, Evaluation consists of determining whether the desired patient outcomes have been met a n
bn bn bn bn bn bn bn bn bn bn bn bn bn
d whether the nursing interventions were appropriate. The other responses do not describ e
bv bn bn bn bn bn bn bn bn bn bn bn b n
the evaluation phase.
bn bv bn
DIF: b n b n Cognitive Level: Understand (Comprehension) bn bn bn
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
b n bn bn bv b n bn bn bn bn bn
7. Which statement describes the purpose of the assessment phase of the nursing process?
bn bn bn bn bn bn bn bn bn bn bn bn
a. To teach interventions that relieve health problems
bn bn bn bn bn bn
b. To use patient data to evaluate patient care outcomes
bn bn bn bn bn bn bn bn
c. To obtain data to diagnose patient strengths and problems
bn bn bn bn bn bn bn bn
d. To help the patient identify realistic outcomes for health problems
bn bn bn bn bn bn bn bn bn
ANS: C b n
During the assessment phase, the nurse gathers information about the patient to diagnose pat
bn bn bn bn bn bn bn bn bn bn bn bn bv bn
ient strengths and problems. The other responses are examples of the planning, interventio
bn bn bn bn bn bn bn bn bn bn bn bn b n
n, and evaluation phases of the nursing process.
bn bn bn bn bn bn bn
DIF: Cognitive Level: Understand (Comprehension) bn bn bn
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
bn bn b n bn bn bn bn bn
8. When developing the plan of care, which components would the nurse include in the clinic
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
alproblem statement? bn
a. The problem and the suggested patient goals or outcomes
bn bn bn bn bn bn bn bn
b. The problem, its causes, and the signs and symptoms of the problem
bn bn bn bn bn bn bn bn bn bn bn
c. The problem with the possible etiology and the planned interventions
bn bn bn bn bn bn bn bn bn
d. The problem, its pathophysiology, and the expected outcome
bn bn bn bn bn bn bn
ANS: B b n
When writing clinical problems or nursing diagnoses, the subjective as well as objective da
bn bn bn bn bn bn bn bn bn bn bn bn bn b n
ta to support the problem‘s existence should be included. Goals, outcomes, and interventions
bn bn bn bn bn bn bn bn bn bn bn bn bn
arenot included in the problem statement.
bn bn bn bn bn
DIF: b n b n Cognitive Level: Understand (Comprehension) bn bn bn
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
b n bn bn bv b n bn bn bn bn bb n
9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
bn bn bn bn bn bn bn bn bn bn bn bn
a. Instruct the patient about the need to alternate activity and rest.
bn bn bn bn bn bn bn bn bn bn
b. Monitor level of shortness of breath or fatigue after ambulation.
bn bn bn bn bn bn bn bn bn
c. Obtain the patient‘s blood pressure and pulse rate after ambulation.
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d. Determine whether the patient is ready to increase the activity level.
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ANS: C b n
AP education includes accurate vital sign measurement. Assessment and patient teaching req
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uire registered nurse education and scope of practice and cannot be delegated.
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DIF: Cognitive Level: Apply (Application) bn bn bn
TOP: Nursing Process: PlanningMSC:
b n bn bn b n NCLEX: Safe and Effective Care Environment bn bn b n bn b n
