Test Bank for Fundamentals of Nursing 12th Edition – Potter, Perry, Stockert, Hall, Ostendorf | Complete Exam Preparation | Chapters 1–50 | Verified Questions & Answers

Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank




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, Medical-
Chapter 01: Introduction
+i to Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
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Surgical Nursing Practice in Canada Lewis: Medical-
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Surgical Nursing in Canada, 5th Canadian Edition
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MULTIPLE CHOICE +i




1. When caring for clients using evidence-
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informed practice, which of the following does the nurse use?
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a. Clinical judgement based on experience +i +i +i +i


b. Evidence from a clinical research study +i +i +i +i +i


c. The best available evidence to guide clinical expertise
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d. Evaluation of data showing that the client outcomes are met +i +i +i +i +i +i +i +i +i




ANS: C + i


Evidence-
informed nursing practice is a continuous interactive process involving the explicit, conscient
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ious, and judicious consideration of the best available evidence to provide care. Four primary e
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lements are: (a) clinical state, setting, and circumstances; (b) client preferences and actions; (
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c) best research evidence; and (d) health care resources. Clinical judgement based on the nurse
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‘s clinical experience is part of EIP, but clinical decision making also should incorporate cur
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rent research and research-
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based guidelines. Evidence from one clinical research study does not provide an adequate su
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bstantiation for interventions. Evaluation of client outcomes is important, but interventions s
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hould be based on research from randomized control studies with a large number of subjects.
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DIF: Cognitive Level: Comprehension +i +i TOP: + i Nursing Process: Planning +i +i




2. Which of the following best e xpl a ins the nu r s e s ‘ primary use of the nursing process when
N R I G B . C M
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providing care to clients? USNT O +i +i +i
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a. To explain nursing interventions to other health care professionals
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b. As a problem-solving tool to identify and treat clients‘ health care needs
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c. As a scientific-based process of diagnosing the client‘s health care problems
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d. To establish nursing theory that incorporates the biopsychosocial nature of humans
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ANS: B + i


The nursing process is an assertive problem-
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solving approach to the identification and treatment of clients‘ problems. Diagnosis is only o
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ne phase of the nursing process. The primary use of the nursing process is in client care, not t
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o establish nursing theory or explain nursing interventions to other health care professionals.
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DIF: Cognitive Level: Comprehension +i +i TOP: + i Nursing Process: Implementation +i +i




3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-
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hour turning schedule to prevent skin breakdown. Which type of nursing function is demonst
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rated with this turning schedule?
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a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D + i




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, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
When implementing collaborative nursing actions, the nurse is responsible primarily for moni
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toring for complications of acute illness or providing care to prevent or treat complications. I
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ndependent nursing actions are focused on health promotion, illness prevention, and client ad
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vocacy. A dependent action would require a physician order to implement. Cooperative nursi
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ng functions are not described as one of the formal nursing functions.
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DIF: Cognitive Level: Application +i +i TOP: + i Nursing Process: Implementation +i +i




4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the
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nurse, ―I do not feel right about leaving my children with my neighbour.‖ Which action s
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hould the nurse take next?
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a. Reassure the client that these feelings are common for parents. +i +i +i +i +i +i +i +i +i


b. Have the client call the children to ensure that they are doing well.
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c. Call the neighbour to determine whether adequate childcare is being provided.
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d. Gather more data about the client‘s feelings about the childcare arrangements.
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ANS: D + i


Since a complete assessment is necessary in order to identify a problem and choose an appro
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priate intervention, the nurse‘s first action should be to obtain more information. The other a
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ctions may be appropriate, but more assessment is needed before the best intervention can be
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chosen.

DIF: Cognitive Level: Application +i +i TOP: + i Nursing Process: Assessment +i +i




5. The nurse is caring for a client who has left-
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sided paralysis as the result of a stroke and assesses a pressure injury on the clie nt‘s le
N Ris the
I mG B.C Mnursing diagnosis f Uo r t Sh is cNlie
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ft h i p . W hich of the following
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+ i
+i
+ i
+i
+ i
+i
+ i
+i
i
+ i
+ + i
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nTt? +i O
a. Impaired physical mobility related to decrease in muscle control (left-sided
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paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
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protecting tissue integrity
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c. Impaired skin integrity related to pressure over bony prominence (impaired
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circulation)
d. Ineffective tissue perfusion related to sedentary lifestyle +i +i +i +i +i +i




ANS: C + i


The client‘s major problem is the impaired skin integrity as demonstrated by the presence of a
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pressure injury. The nurse is able to treat the cause of altered circulation and pressure by fre
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quently repositioning the client. Although left-
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sided weakness is a problem for the client, the nurse cannot treat the weakness. The ―risk for
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‖ diagnosis is not appropriate for this client, who already has impaired tissue integrity. The cli
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ent does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates
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more clearly what the health problem is.
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DIF: Cognitive Level: Application +i +i TOP: + i Nursing Process: Diagnosis +i +i




6. The nurse caring for a client with an infection has a nursing diagnosis of deficient flui
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d volume related to excessive diaphoresis. Which of the following is an appropriate cli
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ent outcome?+i


a. Client has a balanced intake and output. +i +i +i +i +i +i


b. Client‘s bedding is changed when it becomes damp. +i +i +i +i +i +i +i




NURSINGTB.COM

, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
c. Client understands the need for increased fluid intake.
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d. Client‘s skin remains cool and dry throughout hospitalization.
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ANS: A + i


This statement gives measurable data showing resolution of the problem of deficient fluid vo
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lume that was identified in the nursing diagnosis statement. The other statements would not in
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dicate that the problem of deficient fluid volume was resolved.
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DIF: Cognitive Level: Application +i +i TOP: + i Nursing Process: Planning +i +i




7. Which of the following represents a nursing activity that is carried out during the evaluation
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phase of the nursing process?
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a. Determining if interventions have been effective in meeting client outcomes +i +i +i +i +i +i +i +i +i


b. Documenting the nursing care plan in the progress notes in the medical record +i +i +i +i +i +i +i +i +i +i +i +i


c. Deciding whether the client‘s health problems have been completely resolved
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d. Asking the client to evaluate whether the nursing care provided was satisfactory
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ANS: A + i


Evaluation consists of determining whether the desired client outcomes have been met and w
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hether the nursing interventions were appropriate. The other responses do not describe the eval
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uation phase. +i




DIF: Cognitive Level: Comprehension +i +i TOP: + i Nursing Process: Evaluation +i +i




8. Which of the following would the nurse perform during the assessment phase of the nursing
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+i process?
a. Obtains data with which to diagnose client problems
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b. Uses client data to develoNp p R
+iri o riIt y nGursB
in.
gCdiagMnoses
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+i +i +i
c. Teaches interventions to relieve client health problems
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d. Assists the client to identify realistic outcomes to health problems
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ANS: A + i


During the assessment phase, the nurse gathers information about the client. The other respo
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nses are examples of the intervention, diagnosis, and planning phases of the nursing process.
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DIF: Cognitive Level: Knowledge +i +i TOP: + i Nursing Process: Assessment +i +i




9. Which of the following is an example of a correctly written nursing diagnosis statement?
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a. Altered tissue perfusion related to heart failure +i +i +i +i +i +i


b. Risk for impaired tissue integrity related to sacral redness
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c. Ineffective coping related to insufficient sense of control. +i +i +i +i +i +i +i


d. Altered urinary elimination related to urinary tract infection
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ANS: C + i


This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes
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a client‘s response to a health problem that can be treated by nursing. The use of a medical
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diagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Altered urinary eli
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mination‖) is not appropriate. The response beginning ―Risk for impaired tissue integrity‖ u
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ses the defining characteristics as the etiology.
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DIF: Cognitive Level: Comprehension +i +i TOP: + i Nursing Process: Diagnosis +i +i





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