,Chapter 01: Professional Nursing Practice
Ignatavicius Medical-Surgical Nursing, 10th
Edition
MULTIPLE CHOICE
1. The nurse completes an admission database and explains that the plan of care and discharge
goals will be developed with the patient’s input. The patient states, “How is this different from
what the doctor does?” Which response would be most appropriate for the nurse to make?
a. “The role of the nurse is to administer medications and other treatments prescribed
by your doctor.”
b. “The nurse’s job is to help the doctor by collecting information and
communicating any problems that occur.”
c. “Nurses perform many of the same procedures as the doctor, but nurses are with
the patients for a longer time than the doctor.”
d. “In addition to caring for you while you are sick, the nurses will assist you to
develop an individualized plan to maintain your health.”
ANS: D
This response is consistent with the American Nurses Association (ANA) definition of
nursing, which describes the role of nurses in promoting health. The other responses describe
some of the dependent and collaborative functions of the nursing role but do not accurately
describe the nurse’s role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
2. The nurse describes to a student nurse how to use evidence-based practice guidelines when
caring for patients. Which statement, if made by the nurse, would be the most accurate?
a. “Inferences from clinical research studies are used as a guide.”
b. “Patient care is based on clinical judgment, experience, and traditions.”
c. “Data are evaluated to show that the patient outcomes are consistently met.”
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. Clinical judgment based on the nurse’s clinical experience is part of EBP,
but clinical decision making should also incorporate current research and research-based
guidelines. Evaluation of patient outcomes is important, but interventions should be based on
research from randomized control studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 15
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teaches a student nurse about how to apply the nursing process when providing
patient care. Which statement, if made by the student nurse, indicates that teaching was
successful?
a. “The nursing process is a scientific-based method of diagnosing the patient’s
health care problems.”
b. “The nursing process is a problem-solving tool used to identify and treat patients’
, health care needs.”
c. “The nursing process is used primarily to explain nursing interventions to other
health care professionals.”
d. “The nursing process is based on nursing theory that incorporates the
biopsychosocial nature of humans.”
ANS: B
The nursing process is a problem-solving approach to the identification and treatment of
patients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the
nursing process is in patient care, not to establish nursing theory or explain nursing
interventions to other health care professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A apatient ahas abeen aadmitted ato athe ahospital afor asurgery aand atells athe anurse, a“I ado anot
afeel acomfortable aleaving amy achildren awith amy aparents.” aWhich aaction ashould athe
anurse atake anext?
a. Reassure athe apatient athat athese afeelings aare acommon afor aparents.
b. Have athe apatient acall athe achildren ato aensure athat athey aare adoing awell.
c. Gather amore adata aabout athe apatient’s afeelings aabout athe achild-care aarrangements.
d. Call athe apatient’s aparents ato adetermine awhether aadequate achild acare ais
abeingaprovided.
ANS: a C
Because aa acomplete aassessment ais anecessary ain aorder ato aidentify aa aproblem aand
achoose aan aappropriate aintervention, athe anurse’s afirst aaction ashould abe ato aobtain amore
ainformation. aThe aother aactions amay abe aappropriate, abut amore aassessment ais aneeded
abefore athe abest ainterventionacan abe achosen.
DIF: Cognitive aLevel: aApply a(application) REF: 6
OBJ: a a a Special aQuestions: aPrioritization TOP: a Nursing aProcess:
aAssessmentaMSC: a NCLEX: aPsychosocial aIntegrity
5. A apatient awho ais aparalyzed aon athe aleft aside aof athe abody aafter aa astroke adevelops aa
apressure aulceraon athe aleft ahip. aWhich anursing adiagnosis ais a most aappropriate?
a. Impaired aphysical amobility arelated ato aleft-sided aparalysis
b. Risk afor aimpaired atissue aintegrity arelated ato aleft-sided aweakness
c. Impaired askin aintegrity arelated ato aaltered acirculation aand apressure
d. Ineffective atissue aperfusion arelated ato ainability ato amove aindependently
ANS: a C
The apatient’s amajor aproblem ais athe aimpaired askin aintegrity aas ademonstrated aby athe
apresence aof aa apressure aulcer. aThe anurse ais aable ato atreat athe acause aof aaltered acirculation
aand apressure aby afrequently arepositioning athe apatient. aAlthough aleft-sided aweakness ais aa
aproblem afor athe apatient,athe anurse acannot atreat athe aweakness. aThe a“risk afor” adiagnosis ais
anot aappropriate afor athis apatient,awho aalready ahas aimpaired atissue aintegrity. aThe apatient
adoes ahave aineffective atissue aperfusion, abut athe aimpaired askin aintegrity adiagnosis
aindicates amore aclearly awhat athe ahealth aproblem ais.
DIF: Cognitive aLevel: aApply a(application) REF: 7
TOP: a Nursing aProcess: aDiagnosis MSC: a NCLEX: aPhysiological aIntegrity
, 6. A apatient awith aa abacterial ainfection ahas aa anursing adiagnosis aof adeficient afluid avolume
arelated atoaexcessive adiaphoresis. aWhich aoutcome awould athe anurse arecognize aas
aappropriate afor athis apatient?
a. Patient ahas aa abalanced aintake aand aoutput.
b. Patient’s abedding ais achanged awhen ait abecomes adamp.
c. Patient aunderstands athe aneed afor aincreased afluid aintake.
d. Patient’s askin aremains acool aand adry athroughout ahospitalization.
ANS: a A
This astatement agives ameasurable adata ashowing aresolution aof athe aproblem aof adeficient
afluid avolume athat awas aidentified ain athe anursing adiagnosis astatement. aThe aother
astatements awould anotaindicate athat athe aproblem aof adeficient afluid avolume awas aresolved.
DIF: Cognitive aLevel: aApply a(application) REF: 7
TOP: a Nursing aProcess: aPlanning MSC: a NCLEX: aPhysiological aIntegrity
7. A anurse aasks athe apatient aif apain awas arelieved aafter areceiving amedication. aWhat ais athe
apurposeaof athe aevaluation aphase aof athe anursing aprocess?
a. To adetermine aif ainterventions ahave abeen aeffective ain ameeting apatient aoutcomes
b. To adocument athe anursing acare aplan ain athe aprogress anotes aof athe amedical arecord
c. To adecide awhether athe apatient’s ahealth aproblems ahave abeen acompletely aresolved
d. To aestablish aif athe apatient aagrees athat athe anursing acare aprovided awas asatisfactory
ANS: a A
Evaluation aconsists aof adetermining awhether athe adesired apatient aoutcomes ahave abeen
amet aand awhether athe anursing ainterventions awere aappropriate. aThe aother aresponses ado
anot adescribe atheaevaluation aphase.
DIF: a a a Cognitive aLevel: aUnderstand a(comprehension) REF: a 5
TOP: a Nursing aProcess: aEvaluation MSC: a NCLEX: aSafe aand aEffective aCare aEnvironment
8. The anurse ainterviews aa apatient awhile acompleting athe ahealth ahistory aand aphysical
aexamination.aWhat ais athe apurpose aof athe aassessment aphase aof athe anursing aprocess?
a. To ateach ainterventions athat arelieve ahealth aproblems
b. To ause apatient adata ato aevaluate apatient acare aoutcomes
c. To aobtain adata awith awhich ato adiagnose apatient aproblems
d. To ahelp athe apatient aidentify arealistic aoutcomes afor ahealth aproblems
ANS: a C
During athe aassessment aphase, athe anurse agathers ainformation aabout athe apatient ato
adiagnoseapatient aproblems. aThe aother aresponses aare aexamples aof athe aplanning,
aintervention, aand aevaluation aphases aof athe anursing aprocess.
DIF: a a a Cognitive aLevel: aUnderstand a(comprehension) REF: a 5
TOP: a Nursing aProcess: aAssessment MSC: a NCLEX: aSafe aand aEffective aCare aEnvironment
9. Which anursing adiagnosis astatement ais awritten acorrectly?
a. Altered atissue aperfusion arelated ato aheart afailure
b. Risk afor aimpaired atissue aintegrity arelated ato asacral aredness
c. Ineffective acoping arelated ato aresponse ato abiopsy atest aresults
d. Altered aurinary aelimination arelated ato aurinary atract ainfection
Ignatavicius Medical-Surgical Nursing, 10th
Edition
MULTIPLE CHOICE
1. The nurse completes an admission database and explains that the plan of care and discharge
goals will be developed with the patient’s input. The patient states, “How is this different from
what the doctor does?” Which response would be most appropriate for the nurse to make?
a. “The role of the nurse is to administer medications and other treatments prescribed
by your doctor.”
b. “The nurse’s job is to help the doctor by collecting information and
communicating any problems that occur.”
c. “Nurses perform many of the same procedures as the doctor, but nurses are with
the patients for a longer time than the doctor.”
d. “In addition to caring for you while you are sick, the nurses will assist you to
develop an individualized plan to maintain your health.”
ANS: D
This response is consistent with the American Nurses Association (ANA) definition of
nursing, which describes the role of nurses in promoting health. The other responses describe
some of the dependent and collaborative functions of the nursing role but do not accurately
describe the nurse’s role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
2. The nurse describes to a student nurse how to use evidence-based practice guidelines when
caring for patients. Which statement, if made by the nurse, would be the most accurate?
a. “Inferences from clinical research studies are used as a guide.”
b. “Patient care is based on clinical judgment, experience, and traditions.”
c. “Data are evaluated to show that the patient outcomes are consistently met.”
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. Clinical judgment based on the nurse’s clinical experience is part of EBP,
but clinical decision making should also incorporate current research and research-based
guidelines. Evaluation of patient outcomes is important, but interventions should be based on
research from randomized control studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 15
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teaches a student nurse about how to apply the nursing process when providing
patient care. Which statement, if made by the student nurse, indicates that teaching was
successful?
a. “The nursing process is a scientific-based method of diagnosing the patient’s
health care problems.”
b. “The nursing process is a problem-solving tool used to identify and treat patients’
, health care needs.”
c. “The nursing process is used primarily to explain nursing interventions to other
health care professionals.”
d. “The nursing process is based on nursing theory that incorporates the
biopsychosocial nature of humans.”
ANS: B
The nursing process is a problem-solving approach to the identification and treatment of
patients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the
nursing process is in patient care, not to establish nursing theory or explain nursing
interventions to other health care professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A apatient ahas abeen aadmitted ato athe ahospital afor asurgery aand atells athe anurse, a“I ado anot
afeel acomfortable aleaving amy achildren awith amy aparents.” aWhich aaction ashould athe
anurse atake anext?
a. Reassure athe apatient athat athese afeelings aare acommon afor aparents.
b. Have athe apatient acall athe achildren ato aensure athat athey aare adoing awell.
c. Gather amore adata aabout athe apatient’s afeelings aabout athe achild-care aarrangements.
d. Call athe apatient’s aparents ato adetermine awhether aadequate achild acare ais
abeingaprovided.
ANS: a C
Because aa acomplete aassessment ais anecessary ain aorder ato aidentify aa aproblem aand
achoose aan aappropriate aintervention, athe anurse’s afirst aaction ashould abe ato aobtain amore
ainformation. aThe aother aactions amay abe aappropriate, abut amore aassessment ais aneeded
abefore athe abest ainterventionacan abe achosen.
DIF: Cognitive aLevel: aApply a(application) REF: 6
OBJ: a a a Special aQuestions: aPrioritization TOP: a Nursing aProcess:
aAssessmentaMSC: a NCLEX: aPsychosocial aIntegrity
5. A apatient awho ais aparalyzed aon athe aleft aside aof athe abody aafter aa astroke adevelops aa
apressure aulceraon athe aleft ahip. aWhich anursing adiagnosis ais a most aappropriate?
a. Impaired aphysical amobility arelated ato aleft-sided aparalysis
b. Risk afor aimpaired atissue aintegrity arelated ato aleft-sided aweakness
c. Impaired askin aintegrity arelated ato aaltered acirculation aand apressure
d. Ineffective atissue aperfusion arelated ato ainability ato amove aindependently
ANS: a C
The apatient’s amajor aproblem ais athe aimpaired askin aintegrity aas ademonstrated aby athe
apresence aof aa apressure aulcer. aThe anurse ais aable ato atreat athe acause aof aaltered acirculation
aand apressure aby afrequently arepositioning athe apatient. aAlthough aleft-sided aweakness ais aa
aproblem afor athe apatient,athe anurse acannot atreat athe aweakness. aThe a“risk afor” adiagnosis ais
anot aappropriate afor athis apatient,awho aalready ahas aimpaired atissue aintegrity. aThe apatient
adoes ahave aineffective atissue aperfusion, abut athe aimpaired askin aintegrity adiagnosis
aindicates amore aclearly awhat athe ahealth aproblem ais.
DIF: Cognitive aLevel: aApply a(application) REF: 7
TOP: a Nursing aProcess: aDiagnosis MSC: a NCLEX: aPhysiological aIntegrity
, 6. A apatient awith aa abacterial ainfection ahas aa anursing adiagnosis aof adeficient afluid avolume
arelated atoaexcessive adiaphoresis. aWhich aoutcome awould athe anurse arecognize aas
aappropriate afor athis apatient?
a. Patient ahas aa abalanced aintake aand aoutput.
b. Patient’s abedding ais achanged awhen ait abecomes adamp.
c. Patient aunderstands athe aneed afor aincreased afluid aintake.
d. Patient’s askin aremains acool aand adry athroughout ahospitalization.
ANS: a A
This astatement agives ameasurable adata ashowing aresolution aof athe aproblem aof adeficient
afluid avolume athat awas aidentified ain athe anursing adiagnosis astatement. aThe aother
astatements awould anotaindicate athat athe aproblem aof adeficient afluid avolume awas aresolved.
DIF: Cognitive aLevel: aApply a(application) REF: 7
TOP: a Nursing aProcess: aPlanning MSC: a NCLEX: aPhysiological aIntegrity
7. A anurse aasks athe apatient aif apain awas arelieved aafter areceiving amedication. aWhat ais athe
apurposeaof athe aevaluation aphase aof athe anursing aprocess?
a. To adetermine aif ainterventions ahave abeen aeffective ain ameeting apatient aoutcomes
b. To adocument athe anursing acare aplan ain athe aprogress anotes aof athe amedical arecord
c. To adecide awhether athe apatient’s ahealth aproblems ahave abeen acompletely aresolved
d. To aestablish aif athe apatient aagrees athat athe anursing acare aprovided awas asatisfactory
ANS: a A
Evaluation aconsists aof adetermining awhether athe adesired apatient aoutcomes ahave abeen
amet aand awhether athe anursing ainterventions awere aappropriate. aThe aother aresponses ado
anot adescribe atheaevaluation aphase.
DIF: a a a Cognitive aLevel: aUnderstand a(comprehension) REF: a 5
TOP: a Nursing aProcess: aEvaluation MSC: a NCLEX: aSafe aand aEffective aCare aEnvironment
8. The anurse ainterviews aa apatient awhile acompleting athe ahealth ahistory aand aphysical
aexamination.aWhat ais athe apurpose aof athe aassessment aphase aof athe anursing aprocess?
a. To ateach ainterventions athat arelieve ahealth aproblems
b. To ause apatient adata ato aevaluate apatient acare aoutcomes
c. To aobtain adata awith awhich ato adiagnose apatient aproblems
d. To ahelp athe apatient aidentify arealistic aoutcomes afor ahealth aproblems
ANS: a C
During athe aassessment aphase, athe anurse agathers ainformation aabout athe apatient ato
adiagnoseapatient aproblems. aThe aother aresponses aare aexamples aof athe aplanning,
aintervention, aand aevaluation aphases aof athe anursing aprocess.
DIF: a a a Cognitive aLevel: aUnderstand a(comprehension) REF: a 5
TOP: a Nursing aProcess: aAssessment MSC: a NCLEX: aSafe aand aEffective aCare aEnvironment
9. Which anursing adiagnosis astatement ais awritten acorrectly?
a. Altered atissue aperfusion arelated ato aheart afailure
b. Risk afor aimpaired atissue aintegrity arelated ato asacral aredness
c. Ineffective acoping arelated ato aresponse ato abiopsy atest aresults
d. Altered aurinary aelimination arelated ato aurinary atract ainfection
