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