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