,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 1
Table of Contents
Table of Contents 1
Chapter 01: Professional Nursing Practice 3
Chapter 02: Health Disparities and Culturally Competent Care 13
Chapter 03: Health History and Physical Examination 21
Chapter 04: Patient and Caregiver Teaching 28
Chapter 05: Chronic Illness and Older Adults 38
Chapter 06: Stress and Stress Management 48
Chapter 07: Sleep and Sleep Disorders 54
Chapter 08: Pain 59
Chapter 09: Palliative Care at End of Life 71
Chapter 10: Substance Use Disorders 79
Chapter 11: Inflammation and Wound Healing 91
Chapter 12: Genetics and Genomics 101
Chapter 13: Altered Immune Responses and Transplantation 105
Chapter 14: Infection and Human Immunodeficiency Virus Infection 117
Chapter 15: Cancer 129
Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances 148
Chapter 17: Preoperative Care 165
Chapter 18: Intraoperative Care 175
Chapter 19: Postoperative Care 184
Chapter 20: Assessment of Visual and Auditory Systems 196
Chapter 21: Visual and Auditory Problems 208
Chapter 22: Assessment of Integumentary System 229
Chapter 23: Integumentary Problems 235
Chapter 24: Burns 247
Chapter 25: Assessment of Respiratory System 261
Chapter 26: Upper Respiratory Problems 272
Chapter 27: Lower Respiratory Problems 284
Chapter 28: Obstructive Pulmonary Diseases 307
Chapter 29: Assessment of Hematologic System 327
Chapter 30: Hematologic Problems 334
Chapter 31: Assessment of Cardiovascular System 355
Chapter 32: Hypertension 366
Chapter 33: Coronary Artery Disease and Acute Coronary Syndrome 377
Chapter 34: Heart Failure 397
Chapter 35: Dysrhythmias 409
Chapter 36: Inflammatory and Structural Heart Disorders 423
Chapter 37: Vascular Disorders 439
Chapter 38: Assessment of Gastrointestinal System 455
Chapter 39: Nutritional Problems 463
Chapter 40: Obesity 474
Chapter 41: Upper Gastrointestinal Problems 483
Chapter 42: Lower Gastrointestinal Problems 504
Chapter 43: Liver, Pancreas, and Biliary Tract Problems 529
Chapter 44: Urinary System 549
Chapter 45: Renal and Urologic Problems 560
Chapter 46: Acute Kidney Injury and Chronic Kidney Disease 580
Chapter 47: Assessment of Endocrine System 597
Chapter 48: Diabetes Mellitus 607
Chapter 49: Endocrine Problems 629
Chapter 50: Assessment of Reproductive System 649
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 2
Chapter 51: Breast Disorders 657
Chapter 52: Sexually Transmitted Infections 669
Chapter 53: Female Reproductive and Genital Problems 678
Chapter 54: Male Reproductive and Genital Problems 700
Chapter 55: Assessment of Nervous System 716
Chapter 56: Acute Intracranial Problems 725
Chapter 57: Stroke 743
Chapter 58: Chronic Neurologic Problems 757
Chapter 59: Dementia and Delirium 773
Chapter 60: Spinal Cord and Peripheral Nerve Problems 783
Chapter 61: Assessment of Musculoskeletal System 798
Chapter 62: Musculoskeletal Trauma and Orthopedic Surgery 805
Chapter 63: Musculoskeletal Problems 826
Chapter 64: Arthritis and Connective Tissue Diseases 837
Chapter 65: Critical Care 858
Chapter 66: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome 877
Chapter 67: Acute Respiratory Failure and Acute Respiratory Distress Syndrome 890
Chapter 68: Emergency and Disaster Nursing 903
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 3
This Is A Test Bank Of Test (Study Questions) To Help You Prepare For the Tests
To Clarify, This Is A Test Bank, Not A Textbook You Have Immediate
Access To Download Your Test Bank.
No Delays In Loading Is Fast And Instant Immediately After Purchase! You Will
Receive A Full Bank Of Tests, In Other Words, All Chapters Will Be There.
Test Banks Are Presented In PDF Format Therefore, No Special Software
Is Required To Download Them
Chapter 01: Professional Nursing Practice
Test Bank
MULTIPLE CHOICE
1. 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 patients 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 based on nursing theory that incorporates the biopsychosocial nature of
humans.
d. The nursing process is used primarily to explain nursing interventions to other health care
professionals.
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: 7
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.
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 4
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician
expertise. Clinical judgment based on the nurses 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: 11
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 5
3. The nurse completes an admission database and explains that the plan of care and discharge goals will be
developed with the patients 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 nurses 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 nurses role in the health care
system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip
Which nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patients major problem is the impaired skin integrity as demonstrated by the presence of a pressure ulcer.
The nurse is able to treat the cause of altered circulation and pressure by frequently repositioning the patient.
Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The risk for
diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have
ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health
problem is.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
5. A patient has been admitted to the hospital for surgery and tells the nurse, I do not feel comfortable leaving
my children with my parents. Which action should the nurse take next?
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 6
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 more data about the patients feelings about the child-care arrangements.
d. Call the patients parents to determine whether adequate child care is being provided.
ANS: C
Since a complete assessment is necessary in order to identify a problem and choose an appropriate
intervention, the nurses 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: Apply (application) REF: 6
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive
diaphoresis. Which outcome would the nurse recognize as most appropriate for this patient?
a. Patient has a balanced intake and output.
b. Patients bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patients skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid volume that was
identified in the nursing diagnosis statement. The other statements would not indicate that the problem of
deficient fluid volume was resolved.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the
evaluation phase of the nursing process?
a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care plan in the progress notes of the medical record
c. To decide whether the patients health problems have been completely resolved
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 7
d. To establish if the patient agrees that the nursing care provided was satisfactory
ANS: A
Evaluation consists of determining whether the desired patient outcomes have been met and whether the
nursing interventions were appropriate. The other responses do not describe the evaluation phase.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
8. The nurse interviews a patient while completing the health history and physical examination. What is 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 with which to diagnose patient 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 patient problems. The
other responses are examples of the planning, intervention, and evaluation phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
9. Which nursing diagnosis statement is written correctly?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to response to biopsy test results
d. Altered urinary elimination related to urinary tract infection
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patients
response to a health problem that can be treated by nursing. The use of a medical diagnosis as an etiology (as
in the responses beginning Altered tissue perfusion and Altered urinary elimination) is not appropriate. The
response beginning Risk for impaired tissue integrity uses the defining characteristic as the etiology.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 8
10. The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse
include in the nursing diagnosis statement?
a. The problem and the suggested patient goals or outcomes
b. The problem with possible causes and the planned interventions
c. The problem, its cause, and objective data that support the problem
d. The problem with an etiology and the signs and symptoms of the problem
ANS: D
When writing nursing diagnoses, this format should be used: problem, etiology, and signs and symptoms. The
subjective, as well as objective, data should be included in the defining characteristics. Interventions and
outcomes are not included in the nursing diagnosis statement.
DIF: Cognitive Level: Remember (knowledge) REF: 8
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
11. A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to delegate to
experienced unlicensed assistive personnel (UAP)?
a. Monitor for shortness of breath or fatigue after ambulation.
b. Instruct the patient about the need to alternate activity and rest.
c. Obtain the patients blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level.
ANS: C
UAP education includes accurate vital sign measurement. Assessment and patient teaching require registered
nurse education and scope of practice and cannot be delegated.
DIF: Cognitive Level: Apply (application) REF: 15
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
12. A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered
nurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse
(LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate?
a. Measurement of a patients urine output by UAP
b. Administration of oral medications by LPN/LVN
, Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 9
c. Check for the presence of bowel sounds and flatulence by UAP
d. Care of a patient with diabetes by RN who usually works on the pediatric unit
ANS: C
Assessment requires RN education and scope of practice and cannot be delegated to an LPN/LVN or UAP.
The other assignments made by the RN are appropriate.
DIF: Cognitive Level: Apply (application) REF: 15
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
13. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Complete the initial admission assessment and plan of care.
b. Document teaching completed before a diagnostic procedure.
c. Instruct a patient about low-fat, reduced sodium dietary restrictions.
d. Obtain bedside blood glucose on a patient before insulin administration.
ANS: D
The education and scope of practice of the LPN/LVN include activities such as obtaining glucose testing using
a finger stick. Patient teaching and the initial assessment and development of the plan of care are nursing
actions that require registered nurse education and scope of practice.
DIF: Cognitive Level: Apply (application) REF: 15
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
14. A nurse is assigned as a case manager for a hospitalized patient with a spinal cord injury. The patient can
expect the nurse functioning in this role to perform which activity?
a. Care for the patient during hospitalization for the injuries.
b. Assist the patient with home care activities during recovery.
c. Determine what medical care the patient needs for optimal rehabilitation.
d. Coordinate the services that the patient receives in the hospital and at home.
ANS: D
The role of the case manager is to coordinate the patients care through multiple settings and levels of care to
Table of Contents
Table of Contents 1
Chapter 01: Professional Nursing Practice 3
Chapter 02: Health Disparities and Culturally Competent Care 13
Chapter 03: Health History and Physical Examination 21
Chapter 04: Patient and Caregiver Teaching 28
Chapter 05: Chronic Illness and Older Adults 38
Chapter 06: Stress and Stress Management 48
Chapter 07: Sleep and Sleep Disorders 54
Chapter 08: Pain 59
Chapter 09: Palliative Care at End of Life 71
Chapter 10: Substance Use Disorders 79
Chapter 11: Inflammation and Wound Healing 91
Chapter 12: Genetics and Genomics 101
Chapter 13: Altered Immune Responses and Transplantation 105
Chapter 14: Infection and Human Immunodeficiency Virus Infection 117
Chapter 15: Cancer 129
Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances 148
Chapter 17: Preoperative Care 165
Chapter 18: Intraoperative Care 175
Chapter 19: Postoperative Care 184
Chapter 20: Assessment of Visual and Auditory Systems 196
Chapter 21: Visual and Auditory Problems 208
Chapter 22: Assessment of Integumentary System 229
Chapter 23: Integumentary Problems 235
Chapter 24: Burns 247
Chapter 25: Assessment of Respiratory System 261
Chapter 26: Upper Respiratory Problems 272
Chapter 27: Lower Respiratory Problems 284
Chapter 28: Obstructive Pulmonary Diseases 307
Chapter 29: Assessment of Hematologic System 327
Chapter 30: Hematologic Problems 334
Chapter 31: Assessment of Cardiovascular System 355
Chapter 32: Hypertension 366
Chapter 33: Coronary Artery Disease and Acute Coronary Syndrome 377
Chapter 34: Heart Failure 397
Chapter 35: Dysrhythmias 409
Chapter 36: Inflammatory and Structural Heart Disorders 423
Chapter 37: Vascular Disorders 439
Chapter 38: Assessment of Gastrointestinal System 455
Chapter 39: Nutritional Problems 463
Chapter 40: Obesity 474
Chapter 41: Upper Gastrointestinal Problems 483
Chapter 42: Lower Gastrointestinal Problems 504
Chapter 43: Liver, Pancreas, and Biliary Tract Problems 529
Chapter 44: Urinary System 549
Chapter 45: Renal and Urologic Problems 560
Chapter 46: Acute Kidney Injury and Chronic Kidney Disease 580
Chapter 47: Assessment of Endocrine System 597
Chapter 48: Diabetes Mellitus 607
Chapter 49: Endocrine Problems 629
Chapter 50: Assessment of Reproductive System 649
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 2
Chapter 51: Breast Disorders 657
Chapter 52: Sexually Transmitted Infections 669
Chapter 53: Female Reproductive and Genital Problems 678
Chapter 54: Male Reproductive and Genital Problems 700
Chapter 55: Assessment of Nervous System 716
Chapter 56: Acute Intracranial Problems 725
Chapter 57: Stroke 743
Chapter 58: Chronic Neurologic Problems 757
Chapter 59: Dementia and Delirium 773
Chapter 60: Spinal Cord and Peripheral Nerve Problems 783
Chapter 61: Assessment of Musculoskeletal System 798
Chapter 62: Musculoskeletal Trauma and Orthopedic Surgery 805
Chapter 63: Musculoskeletal Problems 826
Chapter 64: Arthritis and Connective Tissue Diseases 837
Chapter 65: Critical Care 858
Chapter 66: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome 877
Chapter 67: Acute Respiratory Failure and Acute Respiratory Distress Syndrome 890
Chapter 68: Emergency and Disaster Nursing 903
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 3
This Is A Test Bank Of Test (Study Questions) To Help You Prepare For the Tests
To Clarify, This Is A Test Bank, Not A Textbook You Have Immediate
Access To Download Your Test Bank.
No Delays In Loading Is Fast And Instant Immediately After Purchase! You Will
Receive A Full Bank Of Tests, In Other Words, All Chapters Will Be There.
Test Banks Are Presented In PDF Format Therefore, No Special Software
Is Required To Download Them
Chapter 01: Professional Nursing Practice
Test Bank
MULTIPLE CHOICE
1. 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 patients 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 based on nursing theory that incorporates the biopsychosocial nature of
humans.
d. The nursing process is used primarily to explain nursing interventions to other health care
professionals.
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: 7
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.
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 4
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician
expertise. Clinical judgment based on the nurses 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: 11
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 5
3. The nurse completes an admission database and explains that the plan of care and discharge goals will be
developed with the patients 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 nurses 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 nurses role in the health care
system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip
Which nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patients major problem is the impaired skin integrity as demonstrated by the presence of a pressure ulcer.
The nurse is able to treat the cause of altered circulation and pressure by frequently repositioning the patient.
Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The risk for
diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have
ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health
problem is.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
5. A patient has been admitted to the hospital for surgery and tells the nurse, I do not feel comfortable leaving
my children with my parents. Which action should the nurse take next?
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 6
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 more data about the patients feelings about the child-care arrangements.
d. Call the patients parents to determine whether adequate child care is being provided.
ANS: C
Since a complete assessment is necessary in order to identify a problem and choose an appropriate
intervention, the nurses 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: Apply (application) REF: 6
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive
diaphoresis. Which outcome would the nurse recognize as most appropriate for this patient?
a. Patient has a balanced intake and output.
b. Patients bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patients skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid volume that was
identified in the nursing diagnosis statement. The other statements would not indicate that the problem of
deficient fluid volume was resolved.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the
evaluation phase of the nursing process?
a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care plan in the progress notes of the medical record
c. To decide whether the patients health problems have been completely resolved
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 7
d. To establish if the patient agrees that the nursing care provided was satisfactory
ANS: A
Evaluation consists of determining whether the desired patient outcomes have been met and whether the
nursing interventions were appropriate. The other responses do not describe the evaluation phase.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
8. The nurse interviews a patient while completing the health history and physical examination. What is 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 with which to diagnose patient 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 patient problems. The
other responses are examples of the planning, intervention, and evaluation phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
9. Which nursing diagnosis statement is written correctly?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to response to biopsy test results
d. Altered urinary elimination related to urinary tract infection
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patients
response to a health problem that can be treated by nursing. The use of a medical diagnosis as an etiology (as
in the responses beginning Altered tissue perfusion and Altered urinary elimination) is not appropriate. The
response beginning Risk for impaired tissue integrity uses the defining characteristic as the etiology.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
,Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 8
10. The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse
include in the nursing diagnosis statement?
a. The problem and the suggested patient goals or outcomes
b. The problem with possible causes and the planned interventions
c. The problem, its cause, and objective data that support the problem
d. The problem with an etiology and the signs and symptoms of the problem
ANS: D
When writing nursing diagnoses, this format should be used: problem, etiology, and signs and symptoms. The
subjective, as well as objective, data should be included in the defining characteristics. Interventions and
outcomes are not included in the nursing diagnosis statement.
DIF: Cognitive Level: Remember (knowledge) REF: 8
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
11. A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to delegate to
experienced unlicensed assistive personnel (UAP)?
a. Monitor for shortness of breath or fatigue after ambulation.
b. Instruct the patient about the need to alternate activity and rest.
c. Obtain the patients blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level.
ANS: C
UAP education includes accurate vital sign measurement. Assessment and patient teaching require registered
nurse education and scope of practice and cannot be delegated.
DIF: Cognitive Level: Apply (application) REF: 15
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
12. A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered
nurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse
(LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate?
a. Measurement of a patients urine output by UAP
b. Administration of oral medications by LPN/LVN
, Test Bank - Medical-Surgical Nursing: Assessment and Management of Clinical Problems 10e 9
c. Check for the presence of bowel sounds and flatulence by UAP
d. Care of a patient with diabetes by RN who usually works on the pediatric unit
ANS: C
Assessment requires RN education and scope of practice and cannot be delegated to an LPN/LVN or UAP.
The other assignments made by the RN are appropriate.
DIF: Cognitive Level: Apply (application) REF: 15
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
13. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Complete the initial admission assessment and plan of care.
b. Document teaching completed before a diagnostic procedure.
c. Instruct a patient about low-fat, reduced sodium dietary restrictions.
d. Obtain bedside blood glucose on a patient before insulin administration.
ANS: D
The education and scope of practice of the LPN/LVN include activities such as obtaining glucose testing using
a finger stick. Patient teaching and the initial assessment and development of the plan of care are nursing
actions that require registered nurse education and scope of practice.
DIF: Cognitive Level: Apply (application) REF: 15
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
14. A nurse is assigned as a case manager for a hospitalized patient with a spinal cord injury. The patient can
expect the nurse functioning in this role to perform which activity?
a. Care for the patient during hospitalization for the injuries.
b. Assist the patient with home care activities during recovery.
c. Determine what medical care the patient needs for optimal rehabilitation.
d. Coordinate the services that the patient receives in the hospital and at home.
ANS: D
The role of the case manager is to coordinate the patients care through multiple settings and levels of care to
