Test Bank for Lewis\'s Medical-Surgical Nursing, 12th
qb qb qb qb qb qb
Edition by Mariann M. Harding, Jeffrey Kwong, Debra
qb qb qb qb qb qb qb qb qb
Hagler Chapter 1-69
qb qb qb
,Chapter 01: Professional Nursing
qb qb qb
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
qb qb qb qb qb
MULTIPLE CHOICE qb
1. The nurse completes an admission database and explains that the plan of care and discharge
qb qb qb qb qb qb qb qb qb qb qb qb qb qb
goals will be developed with the patient‘s input. The patient asks, “How is this different from
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
what the physician does?” Which response would the nurse provide?
qb qb qb qb qb qb qb qb qb qb
a. “Therole of the nurse is to administermedications and other treatments prescribed by
qb qb qb qb qb qb qb qb qb qb qb qb qb
your physician.”
qb qb
b. “In addition to caringfor you while you are sick, thenurses will help you plan to
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
maintain your health.”
qb qb qb
c. “Thenurse‘s job is to collect informationand communicate anyproblems that
qb qb qb qb qb qb qb qb qb qb qb
occur to the physician.”
qb qb qb qb
d. “Nurses perform many of the sameprocedures as the physician, but nurses are qb qb qb qb qb qb qb qb qb qb qb qb
with the patients for a longer time than the physician.”
qb qb qb qb qb qb qb qb qb qb
ANS: B qb
The American Nurses Association (ANA) definition of nursing describes the role of nurses in
qb qb qb qb qb qb qb qb qb qb qb qb qb
promoting health. The other responses describe dependent and collaborative functions of the
qb qb qb qb qb qb qb qb qb qb qb qb
nursing role but do not accurately describe the nurse‘s unique role in the health care system.
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
DIF: q b q Cognitive Level: Analyze (Analysis)
b qb qb qb
TOP: q b Nursing Process: Implementation qb qb q b q b q b MSC: NCLEX: Safe and Effective Care Environment q b qb qb qb qb qb
2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
qb qb qb qb qb qb qb qb qb qb qb qb
a. “Patient care is based on clinical judgment,experience, and traditions.” qb qb qb qb qb qb qb qb qb
b. “Data areanalyzed later to show that the patient outcomes areconsistently met.”
qb qb qb qb qb qb qb qb qb qb qb qb
c. “Research from all published articles are used as a guide for planning patient care.” qb qb qb qb qb qb qb qb qb qb qb qb qb
d. “Recommendations are based on research, clinical expertise, and patient qb qb qb qb qb qb qb qb
preferences.”
qb
ANS: D qb
Evidence-based practice (EBP) is the use of the best research-based evidence combined with qb qb qb qb qb qb qb qb qb qb qb qb
clinician expertise and consideration of patient preferences. Clinical judgment based on the
qb qb qb qb qb qb qb qb qb qb qb qb
nurse‘s clinical experience is part of EBP, but clinical decision making should also
qb qb qb qb qb qb qb qb qb qb qb qb qb
incorporate current research and research-based guidelines. Evaluation of patient outcomes is
qb qb qb qb qb qb qb qb qb qb qb
important, but data analysis is not required to use EBP. All published articles do not provide
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
research evidence; interventions should be based on credible research, preferably randomized
qb qb qb qb qb qb qb qb qb qb qb
controlled studies with a large number of subjects.
qb qb qb qb qb qb qb qb
DIF: Cognitive Level: Understand (Comprehension) qb qb qb TOP: Nursing Process: Planning qb qb qb
MSC: NCLEX: Safe and Effective Care Environment
qb q b qb qb qb qb qb
3. Which statement by the nurse provides a clear explanation of the nursing process?
qb qb qb qb qb qb qb qb qb qb qb qb
a. “Thenursing process is a research method of diagnosingthe patient‘s health care
qb qb qb qb qb qb qb qb qb qb qb qb
problems.”
qb
b. “Thenursing process is used primarily to explain nursing interventions to other
qb qb qb qb qb qb qb qb qb qb qb
health care professionals.”
qb qb qb
c. “Thenursing process is a problem-solving tool used to identify and manage the
qb qb qb qb qb qb qb qb qb qb qb qb
, patients‘ health care needs.” qb qb qb
d. “Thenursing process is based on nursing theorythatincorporatesthe
qb qb qb qb qb qb qb qb qb qb
qbbiopsychosocial nature of humans.” qb qb qb
ANS: C qb
The nursing process is a problem-solving approach to the identification and treatment of
qb qb qb qb qb qb qb qb qb qb qb qb
patients‘ problems. Nursing process does not require research methods for diagnosis. The
qb qb qb qb qb qb qb qb qb qb qb qb
primaryuse of the nursing process is in patient care, not to establish nursing theory or explain
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
nursing interventions to other health care professionals.
qb qb qb qb qb qb qb
DIF: Cognitive Level: Understand (Comprehension) qb qb qb TOP: NursingProcess: Evaluation qb qb qb
MSC: NCLEX: Safe and Effective Care Environment
qb q b qb qb qb qb qb
4. A patient admitted to the hospital for surgery tells the nurse, “I do not feel comfortable
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
leaving my children with my parents.” Which action would the nurse take next?
qb qb qb qb qb qb qb qb qb qb qb qb qb
a. Reassure the patient that these feelings are common for parents. qb qb qb qb qb qb qb qb qb
b. Have the patient call the children to ensure that they are doing well.
qb qb qb qb qb qb qb qb qb qb qb qb
c. Gatherinformation on the patient‘s concerns about the child care arrangements.
qb qb qb qb qb qb qb qb qb qb
d. Call the patient‘s parents to determine whether adequate child care is being
qb qb qb qb qb qb qb qb qb qb qb
provided. qb
ANS: C qb
Because a complete assessment is necessary in order to identify a problem and choose an
qb qb qb qb qb qb qb qb qb qb qb qb qb qb
appropriate intervention, the nurse‘s first action should be to obtain more information. The
qb qb qb qb qb qb qb qb qb qb qb qb qb
other actions maybe appropriate, but more assessment is needed before the best intervention can
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
be chosen.
qb qb
DIF: Cognitive Level: Analyze (Analysis) qb qb qb
TOP: Nursing Process: Assessment
q b MSC: NCLEX: Psychosocial Integrity qb qb q b qb qb
5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis.
qb qb qb qb qb qb qb qb qb qb qb qb qb qb
Which expected outcome would the nurse select for this patient?
qb qb qb qb qb qb qb qb qb qb
a. Patient has a balanced intake and output. qb qb qb qb qb qb
b. Patient‘s bedding is kept clean and free of moisture. qb qb qb qb qb qb qb qb
c. Patient understands the need for increased fluid intake. qb qb qb qb qb qb qb
d. Patient‘s skin remains cool and drythroughout hospitalization. qb qb qb qb qb qb qb
ANS: A qb
Balanced intake and output gives measurable data showing resolution of the problem of deficient
qb qb qb qb qb qb qb qb qb qb qb qb qb
fluid volume. The other statements would not indicate that the problem of hypovolemia was
qb qb qb qb qb qb qb qb qb qb qb qb qb qb
resolved.
qb
DIF: Cognitive Level: Apply (Application) qb qb qb TOP: Nursing Process: Planning qb qb qb
MSC: NCLEX: Physiological Integrity
qb q b qb qb
6. Which statement describes the purpose of the evaluation phase of the nursing process?
qb qb qb qb qb qb qb qb qb qb qb qb
a. To document the nursing care plan in the progress notes of the health record
qb qb qb qb qb qb qb qb qb qb qb qb qb
b. To determine if interventions have been effective in meeting patient outcomes
qb qb qb qb qb qb qb qb qb qb
c. To decide whether the patient‘s health problems have been completely resolved
qb qb qb qb qb qb qb qb qb qb
d. To establish if the patient agrees that the nursing care provided was satisfactory
qb qb qb qb qb qb qb qb qb qb qb qb
ANS: B qb
, Evaluation consists of determining whether the desired patient outcomes have been met and
qb qb qb qb qb qb qb qb qb qb qb qb
whether the nursing interventions were appropriate. The other responses do not describe the
qb qb qb qb qb qb qb qb qb qb qb qb qb
evaluation phase.
qb qb
DIF: Cognitive Level: Understand (Comprehension)
q b qb qb qb TOP: Nursing Process: Evaluation qb qb qb
MSC: NCLEX: Safe and Effective Care Environment
qb q b qb qb qb qb qb
7. Which statement describes the purpose of the assessment phase of the nursing process?
qb qb qb qb qb qb qb qb qb qb qb qb
a. To teach interventions that relieve health problems
qb qb qb qb qb qb
b. To use patient data to evaluate patient care outcomes
qb qb qb qb qb qb qb qb
c. To obtain data to diagnose patient strengths and problems
qb qb qb qb qb qb qb qb
d. To help the patient identify realistic outcomes for health problems
qb qb qb qb qb qb qb qb qb
ANS: C qb
During the assessment phase, the nurse gathers information about the patient to diagnose patient
qb qb qb qb qb qb qb qb qb qb qb qb qb
strengths and problems. The other responses are examples of the planning, intervention, and
qb qb qb qb qb qb qb qb qb qb qb qb qb
evaluation phases of the nursing process.
qb qb qb qb qb qb
DIF: Cognitive Level: Understand (Comprehension) qb qb qb
TOP: Nursing Process: Assessment
q b MSC: NCLEX: Safe and Effective Care Environment qb qb q b qb qb qb qb qb
8. When developing the plan of care, which components would the nurse include in the clinical
qb qb qb qb qb qb qb qb qb qb qb qb qb qb
problem statement?
qb qb
a. Theproblem and the suggested patient goals or outcomes
qb qb qb qb qb qb qb qb
b. The problem, its causes, and the signs and symptoms of the problem
qb qb qb qb qb qb qb qb qb qb qb
c. The problem with the possible etiology and the planned interventions
qb qb qb qb qb qb qb qb qb
d. The problem, its pathophysiology, and the expected outcome
qb qb qb qb qb qb qb
ANS: B qb
When writing clinical problems or nursing diagnoses, the subjective as well as objective data
qb qb qb qb qb qb qb qb qb qb qb qb qb
to support the problem‘s existence should be included. Goals, outcomes, and interventions are
qb qb qb qb qb qb qb qb qb qb qb qb qb
not included in the problem statement.
qb qb qb qb qb qb
DIF: Cognitive Level: Understand (Comprehension) qb qb qb TOP: Nursing Process: Diagnosis qb qb qb
MSC: NCLEX: Safe and Effective Care Environment
qb q b qb qb qb qb qb
9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
qb qb qb qb qb qb qb qb qb qb qb qb
a. Instruct the patient about the need to alternate activity and rest.
qb qb qb qb qb qb qb qb qb qb
b. Monitor level of shortness of breath or fatigue after ambulation. qb qb qb qb qb qb qb qb qb
c. Obtain the patient‘s blood pressure and pulse rate after ambulation.
qb qb qb qb qb qb qb qb qb
d. Determine whether the patient is ready to increase the activity level. qb qb qb qb qb qb qb qb qb qb
ANS: C qb
AP education includes accurate vital sign measurement. Assessment and patient teaching require
qb qb qb qb qb qb qb qb qb qb qb
registered nurse education and scope of practice and cannot be delegated.
qb qb qb qb qb qb qb qb qb qb qb
DIF: Cognitive Level: Apply (Application) qb qb qb TOP: Nursing Process: Planning qb qb qb
MSC: NCLEX: Safe and Effective Care Environment
qb q b qb qb qb qb qb
qb qb qb qb qb qb
Edition by Mariann M. Harding, Jeffrey Kwong, Debra
qb qb qb qb qb qb qb qb qb
Hagler Chapter 1-69
qb qb qb
,Chapter 01: Professional Nursing
qb qb qb
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
qb qb qb qb qb
MULTIPLE CHOICE qb
1. The nurse completes an admission database and explains that the plan of care and discharge
qb qb qb qb qb qb qb qb qb qb qb qb qb qb
goals will be developed with the patient‘s input. The patient asks, “How is this different from
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
what the physician does?” Which response would the nurse provide?
qb qb qb qb qb qb qb qb qb qb
a. “Therole of the nurse is to administermedications and other treatments prescribed by
qb qb qb qb qb qb qb qb qb qb qb qb qb
your physician.”
qb qb
b. “In addition to caringfor you while you are sick, thenurses will help you plan to
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
maintain your health.”
qb qb qb
c. “Thenurse‘s job is to collect informationand communicate anyproblems that
qb qb qb qb qb qb qb qb qb qb qb
occur to the physician.”
qb qb qb qb
d. “Nurses perform many of the sameprocedures as the physician, but nurses are qb qb qb qb qb qb qb qb qb qb qb qb
with the patients for a longer time than the physician.”
qb qb qb qb qb qb qb qb qb qb
ANS: B qb
The American Nurses Association (ANA) definition of nursing describes the role of nurses in
qb qb qb qb qb qb qb qb qb qb qb qb qb
promoting health. The other responses describe dependent and collaborative functions of the
qb qb qb qb qb qb qb qb qb qb qb qb
nursing role but do not accurately describe the nurse‘s unique role in the health care system.
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
DIF: q b q Cognitive Level: Analyze (Analysis)
b qb qb qb
TOP: q b Nursing Process: Implementation qb qb q b q b q b MSC: NCLEX: Safe and Effective Care Environment q b qb qb qb qb qb
2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
qb qb qb qb qb qb qb qb qb qb qb qb
a. “Patient care is based on clinical judgment,experience, and traditions.” qb qb qb qb qb qb qb qb qb
b. “Data areanalyzed later to show that the patient outcomes areconsistently met.”
qb qb qb qb qb qb qb qb qb qb qb qb
c. “Research from all published articles are used as a guide for planning patient care.” qb qb qb qb qb qb qb qb qb qb qb qb qb
d. “Recommendations are based on research, clinical expertise, and patient qb qb qb qb qb qb qb qb
preferences.”
qb
ANS: D qb
Evidence-based practice (EBP) is the use of the best research-based evidence combined with qb qb qb qb qb qb qb qb qb qb qb qb
clinician expertise and consideration of patient preferences. Clinical judgment based on the
qb qb qb qb qb qb qb qb qb qb qb qb
nurse‘s clinical experience is part of EBP, but clinical decision making should also
qb qb qb qb qb qb qb qb qb qb qb qb qb
incorporate current research and research-based guidelines. Evaluation of patient outcomes is
qb qb qb qb qb qb qb qb qb qb qb
important, but data analysis is not required to use EBP. All published articles do not provide
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
research evidence; interventions should be based on credible research, preferably randomized
qb qb qb qb qb qb qb qb qb qb qb
controlled studies with a large number of subjects.
qb qb qb qb qb qb qb qb
DIF: Cognitive Level: Understand (Comprehension) qb qb qb TOP: Nursing Process: Planning qb qb qb
MSC: NCLEX: Safe and Effective Care Environment
qb q b qb qb qb qb qb
3. Which statement by the nurse provides a clear explanation of the nursing process?
qb qb qb qb qb qb qb qb qb qb qb qb
a. “Thenursing process is a research method of diagnosingthe patient‘s health care
qb qb qb qb qb qb qb qb qb qb qb qb
problems.”
qb
b. “Thenursing process is used primarily to explain nursing interventions to other
qb qb qb qb qb qb qb qb qb qb qb
health care professionals.”
qb qb qb
c. “Thenursing process is a problem-solving tool used to identify and manage the
qb qb qb qb qb qb qb qb qb qb qb qb
, patients‘ health care needs.” qb qb qb
d. “Thenursing process is based on nursing theorythatincorporatesthe
qb qb qb qb qb qb qb qb qb qb
qbbiopsychosocial nature of humans.” qb qb qb
ANS: C qb
The nursing process is a problem-solving approach to the identification and treatment of
qb qb qb qb qb qb qb qb qb qb qb qb
patients‘ problems. Nursing process does not require research methods for diagnosis. The
qb qb qb qb qb qb qb qb qb qb qb qb
primaryuse of the nursing process is in patient care, not to establish nursing theory or explain
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
nursing interventions to other health care professionals.
qb qb qb qb qb qb qb
DIF: Cognitive Level: Understand (Comprehension) qb qb qb TOP: NursingProcess: Evaluation qb qb qb
MSC: NCLEX: Safe and Effective Care Environment
qb q b qb qb qb qb qb
4. A patient admitted to the hospital for surgery tells the nurse, “I do not feel comfortable
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
leaving my children with my parents.” Which action would the nurse take next?
qb qb qb qb qb qb qb qb qb qb qb qb qb
a. Reassure the patient that these feelings are common for parents. qb qb qb qb qb qb qb qb qb
b. Have the patient call the children to ensure that they are doing well.
qb qb qb qb qb qb qb qb qb qb qb qb
c. Gatherinformation on the patient‘s concerns about the child care arrangements.
qb qb qb qb qb qb qb qb qb qb
d. Call the patient‘s parents to determine whether adequate child care is being
qb qb qb qb qb qb qb qb qb qb qb
provided. qb
ANS: C qb
Because a complete assessment is necessary in order to identify a problem and choose an
qb qb qb qb qb qb qb qb qb qb qb qb qb qb
appropriate intervention, the nurse‘s first action should be to obtain more information. The
qb qb qb qb qb qb qb qb qb qb qb qb qb
other actions maybe appropriate, but more assessment is needed before the best intervention can
qb qb qb qb qb qb qb qb qb qb qb qb qb qb qb
be chosen.
qb qb
DIF: Cognitive Level: Analyze (Analysis) qb qb qb
TOP: Nursing Process: Assessment
q b MSC: NCLEX: Psychosocial Integrity qb qb q b qb qb
5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis.
qb qb qb qb qb qb qb qb qb qb qb qb qb qb
Which expected outcome would the nurse select for this patient?
qb qb qb qb qb qb qb qb qb qb
a. Patient has a balanced intake and output. qb qb qb qb qb qb
b. Patient‘s bedding is kept clean and free of moisture. qb qb qb qb qb qb qb qb
c. Patient understands the need for increased fluid intake. qb qb qb qb qb qb qb
d. Patient‘s skin remains cool and drythroughout hospitalization. qb qb qb qb qb qb qb
ANS: A qb
Balanced intake and output gives measurable data showing resolution of the problem of deficient
qb qb qb qb qb qb qb qb qb qb qb qb qb
fluid volume. The other statements would not indicate that the problem of hypovolemia was
qb qb qb qb qb qb qb qb qb qb qb qb qb qb
resolved.
qb
DIF: Cognitive Level: Apply (Application) qb qb qb TOP: Nursing Process: Planning qb qb qb
MSC: NCLEX: Physiological Integrity
qb q b qb qb
6. Which statement describes the purpose of the evaluation phase of the nursing process?
qb qb qb qb qb qb qb qb qb qb qb qb
a. To document the nursing care plan in the progress notes of the health record
qb qb qb qb qb qb qb qb qb qb qb qb qb
b. To determine if interventions have been effective in meeting patient outcomes
qb qb qb qb qb qb qb qb qb qb
c. To decide whether the patient‘s health problems have been completely resolved
qb qb qb qb qb qb qb qb qb qb
d. To establish if the patient agrees that the nursing care provided was satisfactory
qb qb qb qb qb qb qb qb qb qb qb qb
ANS: B qb
, Evaluation consists of determining whether the desired patient outcomes have been met and
qb qb qb qb qb qb qb qb qb qb qb qb
whether the nursing interventions were appropriate. The other responses do not describe the
qb qb qb qb qb qb qb qb qb qb qb qb qb
evaluation phase.
qb qb
DIF: Cognitive Level: Understand (Comprehension)
q b qb qb qb TOP: Nursing Process: Evaluation qb qb qb
MSC: NCLEX: Safe and Effective Care Environment
qb q b qb qb qb qb qb
7. Which statement describes the purpose of the assessment phase of the nursing process?
qb qb qb qb qb qb qb qb qb qb qb qb
a. To teach interventions that relieve health problems
qb qb qb qb qb qb
b. To use patient data to evaluate patient care outcomes
qb qb qb qb qb qb qb qb
c. To obtain data to diagnose patient strengths and problems
qb qb qb qb qb qb qb qb
d. To help the patient identify realistic outcomes for health problems
qb qb qb qb qb qb qb qb qb
ANS: C qb
During the assessment phase, the nurse gathers information about the patient to diagnose patient
qb qb qb qb qb qb qb qb qb qb qb qb qb
strengths and problems. The other responses are examples of the planning, intervention, and
qb qb qb qb qb qb qb qb qb qb qb qb qb
evaluation phases of the nursing process.
qb qb qb qb qb qb
DIF: Cognitive Level: Understand (Comprehension) qb qb qb
TOP: Nursing Process: Assessment
q b MSC: NCLEX: Safe and Effective Care Environment qb qb q b qb qb qb qb qb
8. When developing the plan of care, which components would the nurse include in the clinical
qb qb qb qb qb qb qb qb qb qb qb qb qb qb
problem statement?
qb qb
a. Theproblem and the suggested patient goals or outcomes
qb qb qb qb qb qb qb qb
b. The problem, its causes, and the signs and symptoms of the problem
qb qb qb qb qb qb qb qb qb qb qb
c. The problem with the possible etiology and the planned interventions
qb qb qb qb qb qb qb qb qb
d. The problem, its pathophysiology, and the expected outcome
qb qb qb qb qb qb qb
ANS: B qb
When writing clinical problems or nursing diagnoses, the subjective as well as objective data
qb qb qb qb qb qb qb qb qb qb qb qb qb
to support the problem‘s existence should be included. Goals, outcomes, and interventions are
qb qb qb qb qb qb qb qb qb qb qb qb qb
not included in the problem statement.
qb qb qb qb qb qb
DIF: Cognitive Level: Understand (Comprehension) qb qb qb TOP: Nursing Process: Diagnosis qb qb qb
MSC: NCLEX: Safe and Effective Care Environment
qb q b qb qb qb qb qb
9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
qb qb qb qb qb qb qb qb qb qb qb qb
a. Instruct the patient about the need to alternate activity and rest.
qb qb qb qb qb qb qb qb qb qb
b. Monitor level of shortness of breath or fatigue after ambulation. qb qb qb qb qb qb qb qb qb
c. Obtain the patient‘s blood pressure and pulse rate after ambulation.
qb qb qb qb qb qb qb qb qb
d. Determine whether the patient is ready to increase the activity level. qb qb qb qb qb qb qb qb qb qb
ANS: C qb
AP education includes accurate vital sign measurement. Assessment and patient teaching require
qb qb qb qb qb qb qb qb qb qb qb
registered nurse education and scope of practice and cannot be delegated.
qb qb qb qb qb qb qb qb qb qb qb
DIF: Cognitive Level: Apply (Application) qb qb qb TOP: Nursing Process: Planning qb qb qb
MSC: NCLEX: Safe and Effective Care Environment
qb q b qb qb qb qb qb
