,Chapter 01: Professional Nursing
ss ss ss
Harding: Lewis’sMedical-Surgical Nursing, 12th Edition
ss s ss ss ss
MULTIPLE CHOICE ss
1. The nurse completes an admission database and explains that the plan of care
s s s s s s s s s s s s s s s s s s s s s s s s
and discharge goals will be developed with the patient‗s input. The patient asks, ―How is
s s ss ss ss ss ss ss ss ss ss ss ss ss ss ss
this different from what the physician does?‖ Which response would the nurse provide?
ss ss ss ss ss ss ss ss ss ss ss ss ss
a. ―Therole ofthenurseis to administermedications and othertreatments prescribed cc ss ss ss ss
by your physician.‖
s s ss ss
b. ―Inaddition tocaring for youwhile youaresick,thenurseswill help youplanto
s ss s cc ss s ss s s s s ss s s
maintain your health.‖
ss ss ss
c. ―Thenurse‗sjobisto collectinformationand communicateanyproblems that s ss ss ss
occur to the physician.‖
ss ss ss ss
d. ―Nursesperformmanyof thesameprocedures as thephysician, but nurses are s s ss s s s ss
with the patients for a longer time than the physician.‖
ss ss ss ss ss ss ss ss ss ss
ANS: B s s
The American Nurses Association (ANA) definition of nursing describes the role of nurses in
ss ss ss ss ss ss ss ss ss ss ss ss ss
promoting health. The other responses describe dependent and collaborative functions of
ss ss ss ss ss ss ss ss ss ss ss
s the nursing role but do not accurately describe the nurse‗s unique role in the health care
s ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
system.
ss
DIF: Cognitive Level: Analyze (Analysis) ss s ss
TOP: NursingProcess: Implementation s ss MSC: s s NCLEX: Safe and Effective Care Environment ss s ss ss ss
2. Whichstatement bythe nurse accuratelydescribes the use of evidence-based practice (EBP)?
s ss ss ss s s s ss ss ss ss ss
a. ―Patient care is based on clinical judgment, experience, and traditions.‖ cc ss ss ss ss ss cc
b. ―Data areanalyzed latertoshowthat thepatient outcomes areconsistentlymet.‖
ss ss s s s ss s ss ss s
c. ―Researchfrom allpublishedarticles areused as a guideforplanningpatientcare.‖ s ss s s ss s ss ss ss s s
d. ―Recommendations arebased on research, clinical expertise, and patient ss s ss ss ss ss ss ss
preferences.‖
ss
ANS: D s s
Evidence-based practice (EBP) is the use of the best research-based evidence combined with ss ss ss ss ss ss ss ss ss ss ss ss
clinician expertise and consideration of patient preferences. Clinical judgment based on the
ss ss ss ss ss ss ss ss ss ss ss ss
nurse‗s clinical experience is part of EBP, but clinical decision making should also
ss ss ss ss ss ss ss ss ss ss ss ss ss
incorporate current research and research-based guidelines. Evaluation ofpatient outcomes is
ss ss ss ss ss ss ss ss s ss ss
important, but data analysis is not required to use EBP. All published articles do not
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
provide research evidence; interventions should be based on credible research, preferably
ss s s ss ss ss ss ss ss ss ss ss
randomized controlled studies with a large number of subjects.
ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Understand (Comprehension) ss ss ss TOP: NursingProcess:Planning ss s s
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
3. Which statement bythe nurse provides a clear explanation of the nursing process?
ss ss ss s ss ss ss ss ss ss ss
a. ―The nursing process is a research method of diagnosingthepatient‗s health care cc cc s cc ss cc s ss ss
problems.‖ ss
b. ―The nursing process is usedprimarilyto explain nursing interventions to other cc cc ss ss ss cc ss ss
health care professionals.‖
ss ss ss
c. ―Thenursingprocess is a problem-solvingtool used toidentifyand manage the s ss ss ss ss s cc ss
, patients‗ health care needs.‖ ss ss ss
d. ―The nursing process isbased onnursingtheorythatincorporates the cc cc s cc s cc
s s biopsychosocial nature of humans.‖ ss ss ss
ANS: C s s
The nursing process is a problem-solving approach to the identification and treatment of
ss ss ss ss ss ss ss ss ss ss ss ss
patients‗ problems. Nursing process does not require research methods for diagnosis. The
ss ss ss ss ss ss ss ss ss ss ss ss
primaryuse of the nursingprocess is in patient care, not to establish nursing theoryor explain
ss ss ss s s ss ss ss ss ss ss ss ss ss ss
nursing interventions to other health care professionals.
ss ss ss ss ss ss ss
DIF: Cognitive Level: Understand (Comprehension) ss ss ss TOP: NursingProcess:Evaluation ss s s
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
4. Apatientadmitted tothe hospital forsurgerytells thenurse, ―I do not feel comfortable ss s cc ss ss s ss cc ss ss ss
leaving my children with my parents.‖ Which action would the nurse take next?
ss ss ss ss ss ss ss ss ss ss ss ss ss
a. Reassurethe patient that these feelings are common for parents. ss ss ss s ss ss ss s
b. Havethe patient call the children to ensure that theyare doing well.
s ss ss ss ss ss ss ss ss s ss ss
c. Gatherinformation on the patient‗s concerns about the child care arrangements. ss ss ss ss ss ss s ss ss
d. Call the patient‗s parents to determine whether adequate child careis being
ss ss ss ss ss ss ss ss ss s ss
provided.
ss
ANS: C s s
Because a complete assessment is necessary in order to identify a problem and choose an
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
appropriate intervention, the nurse‗s first action should be to obtain more information. The
ss ss ss ss ss ss ss ss ss ss ss ss ss
otheractions maybe appropriate, but more assessment is needed before the best intervention
ss s ss ss ss ss ss ss ss ss ss ss ss
can be chosen.
ss ss ss
DIF: Cognitive Level: Analyze (Analysis) ss ss ss
TOP: NursingProcess: Assessment MSC: s ss s s NCLEX: Psychosocial Integrity ss ss
5. A patient with a bacterial infection is hypovolemic dueto a fever and excessivediaphoresis.
ss ss ss ss ss ss ss ss s ss ss ss ss s
ss Which expected outcome would the nurse select for this patient?
ss ss ss ss ss ss ss ss ss
a. Patient has abalanced intake and output. ss ss s ss s ss
b. Patient‗s bedding is kept clean and free of moisture. ss ss ss ss ss ss ss ss
c. Patient understands the need forincreased fluid intake.
ss ss s ss s ss ss
d. Patient‗sskin remains cool and drythroughout hospitalization. s ss ss ss ss ss
ANS: A s s
Balanced intake and output gives measurable data showingresolution ofthe problem of deficient
ss ss ss ss ss ss ss s ss s ss ss ss
fluid volume. The other statements would not indicate that the problem of hypovolemia was
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
resolved.
ss
DIF: Cognitive Level: Apply (Application) ss ss ss TOP: NursingProcess:Planning ss s s
MSC: NCLEX: Physiological Integrity
ss s s ss ss
6. Whichstatement describes the purpose of the evaluation phase of the nursing process?
s ss ss ss ss ss ss ss ss ss ss ss
a. To document the nursing care plan in the progress notes of the health record
ss ss ss ss ss ss ss ss ss ss ss ss ss
b. Todetermine if interventions have been effective in meetingpatient outcomes
s ss ss ss s ss ss ss s ss
c. To decide whether the patient‗s health problems have been completely resolved
ss ss ss ss ss ss ss ss ss ss
d. Toestablish if the patient agrees that the nursing care provided was satisfactory
s ss ss ss ss ss ss ss s ss ss ss
ANS: B s s
, Evaluation consists of determining whether the desired patient outcomes have been met
ss ss ss ss ss ss ss ss ss ss ss
sand whether the nursing interventions were appropriate. The other responses do not
s ss ss ss ss ss ss ss ss ss ss ss
describe the evaluation phase.
ss ss ss ss
DIF: s s s sCognitive Level: Understand (Comprehension) ss ss ss TOP: Nursing Process: Evaluationss ss ss
MSC:
ss s s NCLEX: Safe and Effective Care Environment ss ss ss ss ss
7. Whichstatement describes the purpose of the assessment phase of the nursing process?
s ss ss ss ss ss ss ss ss ss ss ss
a. Toteach interventions that relieve health problems
s ss ss ss ss ss
b. To use patient data to evaluate patient care outcomes
ss s ss ss ss s ss s
c. Toobtain data to diagnose patient strengths and problems
s ss ss ss ss ss ss ss
d. Tohelp the patient identifyrealistic outcomes for health problems
s ss ss ss s ss ss ss ss
ANS: C s s
During the assessment phase, the nurse gathers information about the patient to diagnose patient
s ss ss ss ss ss ss ss ss ss ss ss ss
strengths and problems. The other responses are examples of the planning, intervention, and
ss ss ss ss ss ss ss ss ss ss ss ss ss
evaluation phases of the nursing process.
ss ss ss ss ss ss
DIF: Cognitive Level: Understand (Comprehension) ss ss ss
TOP: NursingProcess: Assessment MSC: NCLEX: Safeand Effective Care Environment s ss s s ss s ss ss ss
8. When developingthe plan of care, which components would the nurseincludein theclinical
ss s ss ss ss ss ss ss ss ss s s ss s
ss problem statement? ss
a. Theproblem and the suggested patient goals or outcomes ss ss ss ss ss ss ss
b. Theproblem, its causes, and the signs and symptoms of the problem
s ss ss ss ss ss ss ss ss s ss
c. Theproblem with the possible etiologyand the planned interventions
s ss ss ss ss s ss ss ss
d. Theproblem, its pathophysiology, and the expected outcome
s ss ss ss ss ss ss
ANS: B s s
When writing clinical problems or nursing diagnoses, the subjective as well as
s s s s s s s s s s s s s s s s s s s s s s
objective data to support the problem‗s existence should be included. Goals, outcomes, and
s s ss ss ss ss ss ss ss ss ss ss ss ss
interventions are not included in the problem statement.
ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Understand (Comprehension) ss ss ss TOP: NursingProcess:Diagnosis ss s s
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
9. Whichpatient care task would the nursedelegate to experienced assistive personnel (AP)?
s ss s ss ss ss s ss ss ss ss ss
a. Instruct the patient about the need to alternate activityand rest.
ss ss ss ss ss ss ss ss ss
b. Monitor level of shortness of breath or fatigue after ambulation.
ss ss ss ss ss ss ss ss ss
c. Obtainthe patient‗s blood pressure and pulse rate after ambulation.
s ss ss ss ss ss ss ss ss
d. Determine whether the patient is readyto increase the activitylevel. s ss ss ss ss ss ss ss
ANS: C s s
AP educationincludes accurate vital sign measurement.Assessment and patient teaching require
ss s ss ss ss ss s ss s ss ss
registered nurse education and scope of practice and cannot be delegated.
ss ss ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Apply (Application) ss ss ss TOP: NursingProcess:Planning ss s s
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
ss ss ss
Harding: Lewis’sMedical-Surgical Nursing, 12th Edition
ss s ss ss ss
MULTIPLE CHOICE ss
1. The nurse completes an admission database and explains that the plan of care
s s s s s s s s s s s s s s s s s s s s s s s s
and discharge goals will be developed with the patient‗s input. The patient asks, ―How is
s s ss ss ss ss ss ss ss ss ss ss ss ss ss ss
this different from what the physician does?‖ Which response would the nurse provide?
ss ss ss ss ss ss ss ss ss ss ss ss ss
a. ―Therole ofthenurseis to administermedications and othertreatments prescribed cc ss ss ss ss
by your physician.‖
s s ss ss
b. ―Inaddition tocaring for youwhile youaresick,thenurseswill help youplanto
s ss s cc ss s ss s s s s ss s s
maintain your health.‖
ss ss ss
c. ―Thenurse‗sjobisto collectinformationand communicateanyproblems that s ss ss ss
occur to the physician.‖
ss ss ss ss
d. ―Nursesperformmanyof thesameprocedures as thephysician, but nurses are s s ss s s s ss
with the patients for a longer time than the physician.‖
ss ss ss ss ss ss ss ss ss ss
ANS: B s s
The American Nurses Association (ANA) definition of nursing describes the role of nurses in
ss ss ss ss ss ss ss ss ss ss ss ss ss
promoting health. The other responses describe dependent and collaborative functions of
ss ss ss ss ss ss ss ss ss ss ss
s the nursing role but do not accurately describe the nurse‗s unique role in the health care
s ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
system.
ss
DIF: Cognitive Level: Analyze (Analysis) ss s ss
TOP: NursingProcess: Implementation s ss MSC: s s NCLEX: Safe and Effective Care Environment ss s ss ss ss
2. Whichstatement bythe nurse accuratelydescribes the use of evidence-based practice (EBP)?
s ss ss ss s s s ss ss ss ss ss
a. ―Patient care is based on clinical judgment, experience, and traditions.‖ cc ss ss ss ss ss cc
b. ―Data areanalyzed latertoshowthat thepatient outcomes areconsistentlymet.‖
ss ss s s s ss s ss ss s
c. ―Researchfrom allpublishedarticles areused as a guideforplanningpatientcare.‖ s ss s s ss s ss ss ss s s
d. ―Recommendations arebased on research, clinical expertise, and patient ss s ss ss ss ss ss ss
preferences.‖
ss
ANS: D s s
Evidence-based practice (EBP) is the use of the best research-based evidence combined with ss ss ss ss ss ss ss ss ss ss ss ss
clinician expertise and consideration of patient preferences. Clinical judgment based on the
ss ss ss ss ss ss ss ss ss ss ss ss
nurse‗s clinical experience is part of EBP, but clinical decision making should also
ss ss ss ss ss ss ss ss ss ss ss ss ss
incorporate current research and research-based guidelines. Evaluation ofpatient outcomes is
ss ss ss ss ss ss ss ss s ss ss
important, but data analysis is not required to use EBP. All published articles do not
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
provide research evidence; interventions should be based on credible research, preferably
ss s s ss ss ss ss ss ss ss ss ss
randomized controlled studies with a large number of subjects.
ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Understand (Comprehension) ss ss ss TOP: NursingProcess:Planning ss s s
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
3. Which statement bythe nurse provides a clear explanation of the nursing process?
ss ss ss s ss ss ss ss ss ss ss
a. ―The nursing process is a research method of diagnosingthepatient‗s health care cc cc s cc ss cc s ss ss
problems.‖ ss
b. ―The nursing process is usedprimarilyto explain nursing interventions to other cc cc ss ss ss cc ss ss
health care professionals.‖
ss ss ss
c. ―Thenursingprocess is a problem-solvingtool used toidentifyand manage the s ss ss ss ss s cc ss
, patients‗ health care needs.‖ ss ss ss
d. ―The nursing process isbased onnursingtheorythatincorporates the cc cc s cc s cc
s s biopsychosocial nature of humans.‖ ss ss ss
ANS: C s s
The nursing process is a problem-solving approach to the identification and treatment of
ss ss ss ss ss ss ss ss ss ss ss ss
patients‗ problems. Nursing process does not require research methods for diagnosis. The
ss ss ss ss ss ss ss ss ss ss ss ss
primaryuse of the nursingprocess is in patient care, not to establish nursing theoryor explain
ss ss ss s s ss ss ss ss ss ss ss ss ss ss
nursing interventions to other health care professionals.
ss ss ss ss ss ss ss
DIF: Cognitive Level: Understand (Comprehension) ss ss ss TOP: NursingProcess:Evaluation ss s s
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
4. Apatientadmitted tothe hospital forsurgerytells thenurse, ―I do not feel comfortable ss s cc ss ss s ss cc ss ss ss
leaving my children with my parents.‖ Which action would the nurse take next?
ss ss ss ss ss ss ss ss ss ss ss ss ss
a. Reassurethe patient that these feelings are common for parents. ss ss ss s ss ss ss s
b. Havethe patient call the children to ensure that theyare doing well.
s ss ss ss ss ss ss ss ss s ss ss
c. Gatherinformation on the patient‗s concerns about the child care arrangements. ss ss ss ss ss ss s ss ss
d. Call the patient‗s parents to determine whether adequate child careis being
ss ss ss ss ss ss ss ss ss s ss
provided.
ss
ANS: C s s
Because a complete assessment is necessary in order to identify a problem and choose an
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
appropriate intervention, the nurse‗s first action should be to obtain more information. The
ss ss ss ss ss ss ss ss ss ss ss ss ss
otheractions maybe appropriate, but more assessment is needed before the best intervention
ss s ss ss ss ss ss ss ss ss ss ss ss
can be chosen.
ss ss ss
DIF: Cognitive Level: Analyze (Analysis) ss ss ss
TOP: NursingProcess: Assessment MSC: s ss s s NCLEX: Psychosocial Integrity ss ss
5. A patient with a bacterial infection is hypovolemic dueto a fever and excessivediaphoresis.
ss ss ss ss ss ss ss ss s ss ss ss ss s
ss Which expected outcome would the nurse select for this patient?
ss ss ss ss ss ss ss ss ss
a. Patient has abalanced intake and output. ss ss s ss s ss
b. Patient‗s bedding is kept clean and free of moisture. ss ss ss ss ss ss ss ss
c. Patient understands the need forincreased fluid intake.
ss ss s ss s ss ss
d. Patient‗sskin remains cool and drythroughout hospitalization. s ss ss ss ss ss
ANS: A s s
Balanced intake and output gives measurable data showingresolution ofthe problem of deficient
ss ss ss ss ss ss ss s ss s ss ss ss
fluid volume. The other statements would not indicate that the problem of hypovolemia was
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
resolved.
ss
DIF: Cognitive Level: Apply (Application) ss ss ss TOP: NursingProcess:Planning ss s s
MSC: NCLEX: Physiological Integrity
ss s s ss ss
6. Whichstatement describes the purpose of the evaluation phase of the nursing process?
s ss ss ss ss ss ss ss ss ss ss ss
a. To document the nursing care plan in the progress notes of the health record
ss ss ss ss ss ss ss ss ss ss ss ss ss
b. Todetermine if interventions have been effective in meetingpatient outcomes
s ss ss ss s ss ss ss s ss
c. To decide whether the patient‗s health problems have been completely resolved
ss ss ss ss ss ss ss ss ss ss
d. Toestablish if the patient agrees that the nursing care provided was satisfactory
s ss ss ss ss ss ss ss s ss ss ss
ANS: B s s
, Evaluation consists of determining whether the desired patient outcomes have been met
ss ss ss ss ss ss ss ss ss ss ss
sand whether the nursing interventions were appropriate. The other responses do not
s ss ss ss ss ss ss ss ss ss ss ss
describe the evaluation phase.
ss ss ss ss
DIF: s s s sCognitive Level: Understand (Comprehension) ss ss ss TOP: Nursing Process: Evaluationss ss ss
MSC:
ss s s NCLEX: Safe and Effective Care Environment ss ss ss ss ss
7. Whichstatement describes the purpose of the assessment phase of the nursing process?
s ss ss ss ss ss ss ss ss ss ss ss
a. Toteach interventions that relieve health problems
s ss ss ss ss ss
b. To use patient data to evaluate patient care outcomes
ss s ss ss ss s ss s
c. Toobtain data to diagnose patient strengths and problems
s ss ss ss ss ss ss ss
d. Tohelp the patient identifyrealistic outcomes for health problems
s ss ss ss s ss ss ss ss
ANS: C s s
During the assessment phase, the nurse gathers information about the patient to diagnose patient
s ss ss ss ss ss ss ss ss ss ss ss ss
strengths and problems. The other responses are examples of the planning, intervention, and
ss ss ss ss ss ss ss ss ss ss ss ss ss
evaluation phases of the nursing process.
ss ss ss ss ss ss
DIF: Cognitive Level: Understand (Comprehension) ss ss ss
TOP: NursingProcess: Assessment MSC: NCLEX: Safeand Effective Care Environment s ss s s ss s ss ss ss
8. When developingthe plan of care, which components would the nurseincludein theclinical
ss s ss ss ss ss ss ss ss ss s s ss s
ss problem statement? ss
a. Theproblem and the suggested patient goals or outcomes ss ss ss ss ss ss ss
b. Theproblem, its causes, and the signs and symptoms of the problem
s ss ss ss ss ss ss ss ss s ss
c. Theproblem with the possible etiologyand the planned interventions
s ss ss ss ss s ss ss ss
d. Theproblem, its pathophysiology, and the expected outcome
s ss ss ss ss ss ss
ANS: B s s
When writing clinical problems or nursing diagnoses, the subjective as well as
s s s s s s s s s s s s s s s s s s s s s s
objective data to support the problem‗s existence should be included. Goals, outcomes, and
s s ss ss ss ss ss ss ss ss ss ss ss ss
interventions are not included in the problem statement.
ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Understand (Comprehension) ss ss ss TOP: NursingProcess:Diagnosis ss s s
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
9. Whichpatient care task would the nursedelegate to experienced assistive personnel (AP)?
s ss s ss ss ss s ss ss ss ss ss
a. Instruct the patient about the need to alternate activityand rest.
ss ss ss ss ss ss ss ss ss
b. Monitor level of shortness of breath or fatigue after ambulation.
ss ss ss ss ss ss ss ss ss
c. Obtainthe patient‗s blood pressure and pulse rate after ambulation.
s ss ss ss ss ss ss ss ss
d. Determine whether the patient is readyto increase the activitylevel. s ss ss ss ss ss ss ss
ANS: C s s
AP educationincludes accurate vital sign measurement.Assessment and patient teaching require
ss s ss ss ss ss s ss s ss ss
registered nurse education and scope of practice and cannot be delegated.
ss ss ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Apply (Application) ss ss ss TOP: NursingProcess:Planning ss s s
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
