,Chapter01: ProfessionalNursing
s ss s
Harding:Lewis’sMedical-SurgicalNursing,12thEdition
s s s s
MULTIPLECHOICE
1. The nurse completes an admission database and explains that the plan of care and discharge
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
goals will be developed with the patient‗s input. The patient asks, ―How is this different from
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
what the physician does?‖ Which response would the nurse provide?
ss ss ss ss ss ss ss ss ss ss
a. ―Theroleofthenurseistoadministermedicationsand othertreatmentsprescribed by l l ss
your physician.‖
ss ss
b. ―Inadditiontocaringfor youwhile you aresick,thenurseswillhelp youplanto l ss ss ll l ss
maintain your health.‖
s s ss ss
c. ―Thenurse‗sjobistocollectinformationandcommunicateanyproblemsthat l l s s
occur to the physician.‖
s s ss ss ss
d. ―Nursesperformmanyofthesameproceduresasthephysician,butnursesare with l s ss
the patients for a longer time than the physician.‖
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 the
ss ss ss ss ss ss ss ss ss ss ss ss
nursing role but do not accurately describe the nurse‗s unique role in the health care system.
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
DIF: CognitiveLevel:Analyze (Analysis) ll
TOP: NursingProcess: Implementation ss MSC: s s NCLEX:SafeandEffectiveCareEnvironment s s s s
2. Which statement bythe nurseaccuratelydescribes the useof evidence-based practice (EBP)?
ll ss ss ss s ss ss ss
a. ―Patientcareisbasedon clinicaljudgment,experience,andtraditions.‖ l l l
b. ―Dataareanalyzedlatertoshowthatthepatientoutcomesareconsistentlymet.‖
c. ―Researchfromallpublishedarticlesareusedas aguideforplanningpatientcare.‖ s ss
d. ―Recommendations arebasedonresearch,clinicalexpertise,andpatient ss s s s s s s
ss preferences.‖
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 incorporate
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
current researchand research-basedguidelines.Evaluation ofpatient outcomesis important, but
ss ss ss s ss ss ss ss
data analysis is not required to use EBP. All published articles do not provide research
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
evidence; interventionsshouldbebasedoncredibleresearch, preferablyrandomized controlled
ss ss ss ss
studies with a large number of subjects.
ss ss ss ss ss ss ss
DIF: Cognitive Level: Understand (Comprehension) ss ss ss TOP: Nursing Process:Planning ss ll
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
3. Whichstatement bythe nurseprovides a clear explanation ofthe nursingprocess? ss ss ss ss ss ss s ss
a. ―Thenursingprocessisaresearchmethodofdiagnosingthepatient‗shealthcare l l l s s
s s problems.‖
b. ―Thenursingprocessisusedprimarilytoexplainnursinginterventionstoother l l l l
ss health care professionals.‖ ss ss
c. ―Thenursing processis a problem-solvingtool used toidentifyandmanage the l ss ll ss
, patients‗healthcareneeds.‖ s
d. ―Thenursingprocessisbasedonnursingtheorythatincorporatesthe l l l l l l
ss 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
primaryuseof thenursingprocess is in patient care, not to establish nursingtheoryorexplain
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
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
4. Apatientadmittedtothehospitalforsurgerytellsthenurse,―Idonot feel comfortable l l s s
s s 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
a. Reassure thepatientthat thesefeelings arecommonforparents.l s s ss s s
b. Havethepatient call the children to ensurethat theyaredoing well.
s ss ss ss ss ss s ss ss
c. Gatherinformation on thepatient‗s concerns about thechild carearrangements. ss s s ss ss ss ss
d. Callthepatient‗s parents todeterminewhetheradequatechildcareisbeing ss 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 maybeappropriate,but moreassessmentisneeded beforethebest intervention can be
ss s s ss s s ss s s ss ss
chosen.
ss
DIF: Cognitive Level: Analyze (Analysis) ss ss ss
TOP: NursingProcess: Assessment MSC: ss s s NCLEX:PsychosocialIntegrity s
5. Apatient with abacterial infectionishypovolemic duetoafever and excessivediaphoresis.
ss ss ss ss ss ss
ss Which expected outcome would the nurse select for this patient?
ss ss ss ss ss ss ss ss ss
a. Patienthas abalanced intakeand output. ss ss ss
b. Patient‗s beddingis kept clean and freeof moisture. ss ss s ss ss ss
c. Patientunderstands theneed forincreased fluidintake.
s s s ss
d. Patient‗s skin remains cooland drythroughout hospitalization.
l ss ss ss ss
ANS: A s s
Balancedintake andoutputgivesmeasurabledata showingresolution oftheproblem of deficient ss ss 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:Planningss
MSC: NCLEX: Physiological Integrity
ss s s ss ss
6. Which statement describes the purposeoftheevaluation phase ofthe nursingprocess?
ll ss ss ss ss ss ss
a. Todocument the nursing careplan in theprogress notes of thehealth record
s ss ss ss ss ss s ss s s ss
b. Todetermineifinterventionshavebeen effective in meetingpatient outcomes s s s ss s ss ss
c. Todecidewhetherthepatient‗s health problems havebeen completelyresolved
s s s s s s ss
d. Toestablishifthepatient agreesthatthenursing careprovided was satisfactory s s ss s s s ll s ss ss
ANS: B s s
, Evaluation consists of determining whether the desired patient outcomes have been met and
ss ss ss ss ss ss ss ss ss ss ss ss
whether the nursing interventions were appropriate. The other responses do not describe the
ss ss ss ss ss ss ss ss ss ss ss ss ss
evaluation phase.
ss ss
DIF: s s s sCognitive Level: Understand (Comprehension) ss ss ss TOP: Nursing Process: Evaluation
ss ss ss
MSC:
ss s s NCLEX: Safe and Effective Care Environment ss ss ss ss ss
7. Which statement describes the purposeoftheassessment phaseofthenursingprocess?
l ss ss ss s ss s
a. Toteachinterventionsthatrelievehealthproblems s s
b. To usepatient datato evaluatepatient careoutcomes
ss ss ss ss
c. Toobtaindata todiagnosepatient strengths and problems s s ss ss ss
d. Tohelp thepatient identifyrealisticoutcomes for healthproblems
ss ss ss ss
ANS: C s s
Duringtheassessment phase,the nurse gathersinformation about thepatient todiagnose patient ss s ss s 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: ss s s NCLEX:SafeandEffectiveCareEnvironment s s
8. Whendevelopingtheplan ofcare, which components wouldthenurseincludein theclinical ss ss ss ss ss
ss problem statement? ss
a. Theproblem and thesuggested patient goalsor outcomes ss ss ss ss s
b. Theproblem, its causes, andthesigns and symptoms ofthe problem s ss ss ss s ss ss
c. Theproblemwith thepossibleetiologyandtheplanned interventions s s s s s s ss
d. Theproblem, itspathophysiology, and theexpected outcome ss ss ss ss
ANS: B s s
When writing clinical problems or nursing diagnoses, the subjective as well as objective data
ss ss ss ss ss ss ss ss ss ss ss ss ss
to support the problem‗s existence should be included. Goals, outcomes, and interventions are
ss ss ss ss ss ss ss ss ss ss ss ss ss
not included in the problem statement.
ss ss ss ss ss ss
DIF: Cognitive Level: Understand (Comprehension) ss ss ss TOP: NursingProcess:Diagnosis
ss
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
9. Which patient caretask wouldthe nursedelegate to experienced assistivepersonnel (AP)?
ll ss ss s ss s ss s ss
a. Instructthepatient about theneedto alternate activityand rest.
s s s ss s s ss ss ss
b. Monitorlevel ofshortness ofbreath or fatigueafterambulation. ss ss ss ss
c. Obtainthepatient‗sbloodpressureandpulserate afterambulation. s s s s ss s
d. Determinewhetherthe patient isreadytoincrease theactivitylevel. s ss s s ss
ANS: C s s
APeducationincludesaccuratevitalsignmeasurement.Assessmentandpatientteaching require
s 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: Nursing Process:Planning
ss ll
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
s ss s
Harding:Lewis’sMedical-SurgicalNursing,12thEdition
s s s s
MULTIPLECHOICE
1. The nurse completes an admission database and explains that the plan of care and discharge
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
goals will be developed with the patient‗s input. The patient asks, ―How is this different from
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
what the physician does?‖ Which response would the nurse provide?
ss ss ss ss ss ss ss ss ss ss
a. ―Theroleofthenurseistoadministermedicationsand othertreatmentsprescribed by l l ss
your physician.‖
ss ss
b. ―Inadditiontocaringfor youwhile you aresick,thenurseswillhelp youplanto l ss ss ll l ss
maintain your health.‖
s s ss ss
c. ―Thenurse‗sjobistocollectinformationandcommunicateanyproblemsthat l l s s
occur to the physician.‖
s s ss ss ss
d. ―Nursesperformmanyofthesameproceduresasthephysician,butnursesare with l s ss
the patients for a longer time than the physician.‖
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 the
ss ss ss ss ss ss ss ss ss ss ss ss
nursing role but do not accurately describe the nurse‗s unique role in the health care system.
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
DIF: CognitiveLevel:Analyze (Analysis) ll
TOP: NursingProcess: Implementation ss MSC: s s NCLEX:SafeandEffectiveCareEnvironment s s s s
2. Which statement bythe nurseaccuratelydescribes the useof evidence-based practice (EBP)?
ll ss ss ss s ss ss ss
a. ―Patientcareisbasedon clinicaljudgment,experience,andtraditions.‖ l l l
b. ―Dataareanalyzedlatertoshowthatthepatientoutcomesareconsistentlymet.‖
c. ―Researchfromallpublishedarticlesareusedas aguideforplanningpatientcare.‖ s ss
d. ―Recommendations arebasedonresearch,clinicalexpertise,andpatient ss s s s s s s
ss preferences.‖
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 incorporate
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
current researchand research-basedguidelines.Evaluation ofpatient outcomesis important, but
ss ss ss s ss ss ss ss
data analysis is not required to use EBP. All published articles do not provide research
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
evidence; interventionsshouldbebasedoncredibleresearch, preferablyrandomized controlled
ss ss ss ss
studies with a large number of subjects.
ss ss ss ss ss ss ss
DIF: Cognitive Level: Understand (Comprehension) ss ss ss TOP: Nursing Process:Planning ss ll
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
3. Whichstatement bythe nurseprovides a clear explanation ofthe nursingprocess? ss ss ss ss ss ss s ss
a. ―Thenursingprocessisaresearchmethodofdiagnosingthepatient‗shealthcare l l l s s
s s problems.‖
b. ―Thenursingprocessisusedprimarilytoexplainnursinginterventionstoother l l l l
ss health care professionals.‖ ss ss
c. ―Thenursing processis a problem-solvingtool used toidentifyandmanage the l ss ll ss
, patients‗healthcareneeds.‖ s
d. ―Thenursingprocessisbasedonnursingtheorythatincorporatesthe l l l l l l
ss 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
primaryuseof thenursingprocess is in patient care, not to establish nursingtheoryorexplain
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
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
4. Apatientadmittedtothehospitalforsurgerytellsthenurse,―Idonot feel comfortable l l s s
s s 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
a. Reassure thepatientthat thesefeelings arecommonforparents.l s s ss s s
b. Havethepatient call the children to ensurethat theyaredoing well.
s ss ss ss ss ss s ss ss
c. Gatherinformation on thepatient‗s concerns about thechild carearrangements. ss s s ss ss ss ss
d. Callthepatient‗s parents todeterminewhetheradequatechildcareisbeing ss 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 maybeappropriate,but moreassessmentisneeded beforethebest intervention can be
ss s s ss s s ss s s ss ss
chosen.
ss
DIF: Cognitive Level: Analyze (Analysis) ss ss ss
TOP: NursingProcess: Assessment MSC: ss s s NCLEX:PsychosocialIntegrity s
5. Apatient with abacterial infectionishypovolemic duetoafever and excessivediaphoresis.
ss ss ss ss ss ss
ss Which expected outcome would the nurse select for this patient?
ss ss ss ss ss ss ss ss ss
a. Patienthas abalanced intakeand output. ss ss ss
b. Patient‗s beddingis kept clean and freeof moisture. ss ss s ss ss ss
c. Patientunderstands theneed forincreased fluidintake.
s s s ss
d. Patient‗s skin remains cooland drythroughout hospitalization.
l ss ss ss ss
ANS: A s s
Balancedintake andoutputgivesmeasurabledata showingresolution oftheproblem of deficient ss ss 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:Planningss
MSC: NCLEX: Physiological Integrity
ss s s ss ss
6. Which statement describes the purposeoftheevaluation phase ofthe nursingprocess?
ll ss ss ss ss ss ss
a. Todocument the nursing careplan in theprogress notes of thehealth record
s ss ss ss ss ss s ss s s ss
b. Todetermineifinterventionshavebeen effective in meetingpatient outcomes s s s ss s ss ss
c. Todecidewhetherthepatient‗s health problems havebeen completelyresolved
s s s s s s ss
d. Toestablishifthepatient agreesthatthenursing careprovided was satisfactory s s ss s s s ll s ss ss
ANS: B s s
, Evaluation consists of determining whether the desired patient outcomes have been met and
ss ss ss ss ss ss ss ss ss ss ss ss
whether the nursing interventions were appropriate. The other responses do not describe the
ss ss ss ss ss ss ss ss ss ss ss ss ss
evaluation phase.
ss ss
DIF: s s s sCognitive Level: Understand (Comprehension) ss ss ss TOP: Nursing Process: Evaluation
ss ss ss
MSC:
ss s s NCLEX: Safe and Effective Care Environment ss ss ss ss ss
7. Which statement describes the purposeoftheassessment phaseofthenursingprocess?
l ss ss ss s ss s
a. Toteachinterventionsthatrelievehealthproblems s s
b. To usepatient datato evaluatepatient careoutcomes
ss ss ss ss
c. Toobtaindata todiagnosepatient strengths and problems s s ss ss ss
d. Tohelp thepatient identifyrealisticoutcomes for healthproblems
ss ss ss ss
ANS: C s s
Duringtheassessment phase,the nurse gathersinformation about thepatient todiagnose patient ss s ss s 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: ss s s NCLEX:SafeandEffectiveCareEnvironment s s
8. Whendevelopingtheplan ofcare, which components wouldthenurseincludein theclinical ss ss ss ss ss
ss problem statement? ss
a. Theproblem and thesuggested patient goalsor outcomes ss ss ss ss s
b. Theproblem, its causes, andthesigns and symptoms ofthe problem s ss ss ss s ss ss
c. Theproblemwith thepossibleetiologyandtheplanned interventions s s s s s s ss
d. Theproblem, itspathophysiology, and theexpected outcome ss ss ss ss
ANS: B s s
When writing clinical problems or nursing diagnoses, the subjective as well as objective data
ss ss ss ss ss ss ss ss ss ss ss ss ss
to support the problem‗s existence should be included. Goals, outcomes, and interventions are
ss ss ss ss ss ss ss ss ss ss ss ss ss
not included in the problem statement.
ss ss ss ss ss ss
DIF: Cognitive Level: Understand (Comprehension) ss ss ss TOP: NursingProcess:Diagnosis
ss
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
9. Which patient caretask wouldthe nursedelegate to experienced assistivepersonnel (AP)?
ll ss ss s ss s ss s ss
a. Instructthepatient about theneedto alternate activityand rest.
s s s ss s s ss ss ss
b. Monitorlevel ofshortness ofbreath or fatigueafterambulation. ss ss ss ss
c. Obtainthepatient‗sbloodpressureandpulserate afterambulation. s s s s ss s
d. Determinewhetherthe patient isreadytoincrease theactivitylevel. s ss s s ss
ANS: C s s
APeducationincludesaccuratevitalsignmeasurement.Assessmentandpatientteaching require
s 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: Nursing Process:Planning
ss ll
MSC: NCLEX: Safe and Effective Care Environment
ss s s ss ss ss ss ss
