TEST BANK
Test Bank for Understanding Medical Surgical Nursing
6th Edition
N
U
R
SE
SH
AH
,TABLE OF CONTENTS
Unit 1 Understanding Health Care Issues
1. Critical Thinking andthe Nursing Process
2. Evidence-Based Practice
3. Issues in Nursing Practice
4. Cultural Influences on Nursing Care
5. Complementary and Alternative Modalities
Unit 2 Understanding Health and Illness
6. Nursing Care of Patients with Fluid, Electrolyte, and Acid-Base Imbalances
7. Nursing Care of Patients Receiving Intravenous Therapy
8. Nursing Care of Patients withInfections
N
9. Nursing Care of Patients inShock
10. Nursing Care of Patients inPain
11. Nursing Care of Patients WithCancer
U
12. Nursing Care of Patients HavingSurgery
13. Nursing Care of Patients with Emergent Conditions and Disaster/Bioterrorism Response
Unit 3 Understanding Life Span Influences on Health and Illness
R
14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults
15. Nursing Care of Older AdultPatients
16. Patient Care Settings
SE
17. Nursing Care of Patients at the End of Life
Unit 4 Understanding the Immune System
18. Immune System Function, Assessment and Therapeutic Measures
19. Nursing Care of Patients With Immune Disorders
SH
20. Nursing Care of Patients With HIV Disease and AIDS
Unit 5 Understanding the Cardiovascular System
21. Cardiovascular System Function, Assessment and Therapeutic Measures
22. Nursing Care of Patients WithHypertension
23. Nursing Care of Patients With Valvular, Inflammatory and Infectious Cardiac or Venous Disorders
AH
24. Nursing Care of Patients With Occlusive Cardiovascular Disorders
25. Nursing Care of Patients With Cardiac Arrhythmias
26. Nursing Care of Patients With Heart Failure
Unit 6 Understanding the Hematologic and Lymphatic Systems
27. Hematologic and Lymphatic System Function, Assessment, and Therapeutic Measures
28. Nursing Care of Patients With Hematologic and Lymphatic Disorders
Unit 7 Understanding the Respiratory System
29. Respiratory System Function, Assessment, and Therapeutic Measures
30. Nursing Care of Patients With Upper Respiratory Tract Disorders
31. Nursing Care of Patients With Lower Respiratory Tract Disorders
,Unit 8 Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
32. Gastrointestinal, Hepatobiliary, and Pancreatic Systems Function, Assessment and Therapeutic Measures
33. Nursing Care of Patients With Upper Gastrointestinal Disorders
34. Nursing Care of Patients With Lower Gastrointestinal Disorders
35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders
Unit 9 Understanding the Urinary System
36. Urinary System Function, Assessment, and Therapeutic Measures
37. Nursing Care of Patients With Disorders of the Urinary System
Unit 10 Understanding the Endocrine System
38. Endocrine System Function andAssessment
39. Nursing Care of Patients With Endocrine Disorders
40. Nursing Care of Patients With Disorders of the Endocrine Pancreas
N
Unit 11 Understanding the Genitourinary and Reproductive System
41. Genitourinary and Reproductive System Function and Assessment
U
42. Nursing Care of Women With Reproductive System Disorders
43. Nursing Care of Male Patients With Genitourinary Disorders
44. Nursing Care of Patients With Sexually Transmitted Infections
R
Unit 12 Understanding the Musculoskeletal System
45. Musculoskeletal Function and Assessment
SE
46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders
Unit 13 Understanding the Neurologic System
47. Neurologic System Function, Assessment, and Therapeutic Measures
48. Nursing Care of Patients With Central Nervous System Disorders
SH
49. Nursing Care of Patients With Cerebrovascular Disorders
50. Nursing Care of Patients With Peripheral Nervous System Disorders
Unit 14 Understanding the Sensory System
51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing
52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing
AH
Unit 15 Understanding the Integumentary System
53. Integumentary System Function, Assessment and Therapeutic Measures
54. Nursing Care of Patients With Skin Disorders
55. Nursing Care of Patients WithBurns
Unit 16 Understanding Mental Health Care
56. Mental Health Function, Assessment, and Therapeutic Measures
57. Nursing Care of Patients With Mental Health Disorders
,Linda S. Williams & Paula D. Hopper: Understanding Medical-Surgical Nursing
Chapter 1. Critical Thinking and the Nursing Process
MULTIPLE CHOICE
1. The nurse is caring for a group of patients on a medical-surgical unit. Which patient should
the licensed practical nurse/licensed vocational nurse (LPN/LVN) assess first?
1. A patient with a blood glucose of 42 mg/dL
2. A patient who reports a pain level of 2
3. A patient who has just received a diagnosis of cancer
4. A patient who has a respiratory rate of 22
ANS: 1
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human
needs.
N
Pages: 6–7
Heading: Prioritize Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
U
Client Need: SECE—Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
R
Difficulty: Difficult
Feedback
SE
1 This patient has a dangerously low blood glucose level and requires immediate
intervention.
2 This patient will need to be assessed, but is not as high a priority.
3 According to Maslow, psychosocial needs are not as high of a priority as
physiological needs.
4 A respiratory rate of 22 is within normal range.
SH
PTS: 1 CON: Patient-Centered Care
2. The LPN/LVN enters the room of a patient who is angry and yells, ―I asked 5 minutes ago
for my pain medication. I’m going to call the CEO of the hospital if you don’t get it for me
AH
now.‖ Which statement by the nurse demonstrates intellectual empathy?
1. ―We are short-staffed today, so it will take me longer to meet your needs.‖
2. ―I am sorry you had to wait, I know you must be in a lot of pain.‖
3. ―I had another patient who had severe pain, and I had to get to them first.‖
4. ―I will get you the number for the CEO, but he is aware of how busy we are.‖
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 2. Describe attitudes and skills that promote good critical thinking
Page: 2
Heading: Intellectual Empathy
Integrated Process: Communication and Documentation
Client Need: Psychosocial Integrity
, Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1 This statement does not consider an individual’s situation.
2 This statement demonstrates intellectual empathy by considering this patient’s
situation and will likely alleviate the patient’s anger.
3 This statement does not consider a patient’s situation and does not demonstrate
intellectual empathy.
4 This statement addresses the patient’s statement of wanting to call the CEO, but
does not demonstrate intellectual empathy by considering the patient’s situation.
PTS: 1 CON: Communication
3. The nurse is collecting data on a patient. Which data are described as subjective?
1. Respiratory rate of 26 per minute
2. Patient report of shortness of breath
N
3. Coarse lung sounds bilaterally
4. Cough producing green sputum
U
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 5. Differentiate between objective and subjective data.
R
Page: 4
Heading: Subjective Data
Integrated Process: Communication and Documentation
SE
Client Need: Communication and Documentation
Cognitive Level: Application (Applying)
Concept: Communication
Difficulty: Moderate
SH
Feedback
1 Respiratory rate of 26 per minute is an example of objective data.
2 A patient reporting symptoms to the nurse is an example of subjective data.
3 Coarse lung sounds is an example of objective data.
4 A productive cough is an example of objective data.
AH
PTS: 1 CON: Communication
4. A patient with a newly fractured femur reports a pain level of 8/10 and analgesic medication
is not due for another 50 minutes. Which action should the nurse take first?
1. Reposition the patient.
2. Give the medication in 30 minutes.
3. Notify the registered nurse (RN) or physician.
4. Tell the patient it is too early for pain medication.
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
, Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using
the nursing process.
Page: 3
Heading: Clinical Judgement
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE—Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 The patient who has a fractured femur is having acute pain. Repositioning a
patient with a new fracture is not likely to relieve pain.
2 Giving the medication before the prescribed time is beyond the nurse’s scope of
practice.
3 The patient should not have to wait for pain relief, so the LPN should inform the
RN or physician so new pain relief orders can be obtained.
N
4 The nurse needs to do more than expect the patient to wait for pain relief.
U
PTS: 1 CON: Patient-Centered Care
5. The nurse is prioritizing care based on Maslow hierarchy of needs. Which need does the
R
nurse identify as having the highest priority?
1. Job-related stress
2. Feeling of loneliness
SE
3. Pain level of 9 on 0-to-10 scale
4. Lack of confidence
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human
SH
needs
Page: 7
Heading: Prioritize Care
Integrated Process: Caring
Client Need: SECE – Coordinated Care
Cognitive Level: Application [Applying]
AH
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 Job-related stress falls under safety according to Maslow and is addressed after
physiological needs.
2 According to Maslow, loneliness is addressed under social needs following
physiological and safety.
3 Pain is a physiological need and is the highest priority.
4 Lack of confidence falls under esteem according to Maslow and is addressed
following physiological, safety, and social needs.
, PTS: 1 CON: Patient-Centered Care
6. The nurse is planning care and setting goals for a newly admitted patient. Who should the
nurse include when conducting these nursing actions?
1. Patient
2. Nurse manager
3. Hospital chaplain
4. Patient’s health care provider (HCP)
ANS: 1
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse is using
the nursing process.
Page: 6
Heading: Prioritize Care
Integrated Process: Communication and Documentation
Client Need: SECE—Management of Care
N
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
U
Feedback
1 Planning care and setting goals is an action performed with the patient. The
R
patient must be in agreement with the plan for it to be successful in meeting the
desired outcomes.
2 The nurse manager may or may not be aware of the patient’s care needs.
SE
3 The hospital chaplain may not be aware of the patient’s needs.
4 The focus of nursing care is different from that of the HCP.
PTS: 1 CON: Communication
SH
7. While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes
serosanguineous drainage on the dressing. Which statement should the nurse use to
document this finding?
1. ―Normal drainage noted.‖
2. ―Moderate drainage recently noted.‖
3. ―Scant serosanguineous drainage seen on dressing.‖
AH
4. ―Pale pink drainage 2 cm by 1 cm noted on dressing.‖
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 6. Document subjective and objective data.
Page: 5
Heading: Documentation of Data
Integrated Process: Communication and Documentation
Client Need: PHYS—Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
, Feedback
1 These statements are interpretations of the data and use words that have vague
meanings, which should be avoided when documenting.
2 These statements are interpretations of the data and use words that have vague
meanings, which should be avoided when documenting.
3 These statements are interpretations of the data and use words that have vague
meanings, which should be avoided when documenting.
4 Objective data are pieces of factual information obtained through physical
assessment and diagnostic tests that are observable or knowable through the five
senses. The nurse should document exactly what is seen.
PTS: 1 CON: Communication
8. The nurse is caring for a patient using the nursing process. Which step should the nurse take
first?
1. Implementation
2. Planning
3. Nursing diagnosis
N
4. Assessment
ANS: 4
U
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using
the nursing process.
R
Page: 4
Heading: Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
SE
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
SH
Feedback
1 The steps of the nursing process are data collection/assessment, nursing
diagnosis, planning, implementation, and evaluation.
2 The steps of the nursing process are data collection/assessment, nursing
diagnosis, planning, implementation, and evaluation.
3 The steps of the nursing process are data collection/assessment, nursing
AH
diagnosis, planning, implementation, and evaluation.
4 Assessment, or data collection, is the first step in the nursing process and is used
to evaluate a patient’s condition before providing care. The other steps, in order,
are nursing diagnosis, planning, implementation, and evaluation.
PTS: 1 CON: Patient-Centered Care
9. The nurse is administering morphine to a patient reporting a pain level of 8 on a 0-to-10
scale. This describes which step of the nursing process?
1. Assessment
, 2. Nursing diagnosis
3. Implementation
4. Evaluation
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using
the nursing process.
Page: 8
Heading: Identify Interventions
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE – Coordination of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
N
1 Administering medication does not describe assessment.
2 Administering medication does not describe nursing diagnosis.
3 Administering medication describes the implementation process, since an action
U
is being taken to help the patient meet a desired outcome.
4 Administering medication does not describe the evaluation phase of the nursing
process.
R
PTS: 1 CON: Patient-Centered Care
SE
10. The nurse is developing an outcome for a patient with exacerbation of asthma. Which is the
most appropriate outcome for this patient?
1. The patient will not experience shortness of breath.
2. The patient will have a respiratory rate of 16 to 20 per minute.
3. The patient will ambulate without reporting shortness of breath.
SH
4. The patient will not require use of an inhaler.
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 8
AH
Heading: Establish Outcomes
Integrated Process: Clinical Problem-solving (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 This is a vague outcome and is not measurable.
2 This is a measurable outcome and is not vague.
3 This is a vague outcome and is not measurable.
4 This is a vague outcome and is not measurable.
, PTS: 1 CON: Patient-Centered Care
11. The nurse suspects a patient is experiencing adverse effects to a newly prescribed
antihypertensive medication. After being informed that the effects are expected, the nurse
remains concerned and conducts an Internet search on the patient’s manifestations. Which
critical thinking behavior did the nurse implement?
1. Sense of justice
2. Intellectual courage
3. Intellectual empathy
4. Intellectual perseverance
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 2. Describe attitudes and skills that promote critical thinking.
Page: 2
Heading: Intellectual Perseverance
N
Integrated Process: Caring
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
U
Concept: Patient-Centered Care
Difficulty: Moderate
R
Feedback
1 A sense of justice examines motives when making decisions.
2 Intellectual courage looks at other points of view, even when the nurse does not
SE
agree with them.
3 Intellectual empathy understands how another person feels when making
decisions.
4 Intellectual perseverance is not giving up.
SH
PTS: 1 CON: Patient-Centered Care
12. The nurse is identifying outcomes for a patient with fluid volume deficit. Which outcome
should the nurse use to guide this patient’s care?
1. Patient’s intake will be measured daily.
2. Patient’s intake will be 3,000 mL daily.
AH
3. Fluids will be at the bedside for the patient.
4. Fluids the patient likes will be at the bedside.
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 7
Heading: Establish Outcomes
Integrated Process: Clinical Problem-solving (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Test Bank for Understanding Medical Surgical Nursing
6th Edition
N
U
R
SE
SH
AH
,TABLE OF CONTENTS
Unit 1 Understanding Health Care Issues
1. Critical Thinking andthe Nursing Process
2. Evidence-Based Practice
3. Issues in Nursing Practice
4. Cultural Influences on Nursing Care
5. Complementary and Alternative Modalities
Unit 2 Understanding Health and Illness
6. Nursing Care of Patients with Fluid, Electrolyte, and Acid-Base Imbalances
7. Nursing Care of Patients Receiving Intravenous Therapy
8. Nursing Care of Patients withInfections
N
9. Nursing Care of Patients inShock
10. Nursing Care of Patients inPain
11. Nursing Care of Patients WithCancer
U
12. Nursing Care of Patients HavingSurgery
13. Nursing Care of Patients with Emergent Conditions and Disaster/Bioterrorism Response
Unit 3 Understanding Life Span Influences on Health and Illness
R
14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults
15. Nursing Care of Older AdultPatients
16. Patient Care Settings
SE
17. Nursing Care of Patients at the End of Life
Unit 4 Understanding the Immune System
18. Immune System Function, Assessment and Therapeutic Measures
19. Nursing Care of Patients With Immune Disorders
SH
20. Nursing Care of Patients With HIV Disease and AIDS
Unit 5 Understanding the Cardiovascular System
21. Cardiovascular System Function, Assessment and Therapeutic Measures
22. Nursing Care of Patients WithHypertension
23. Nursing Care of Patients With Valvular, Inflammatory and Infectious Cardiac or Venous Disorders
AH
24. Nursing Care of Patients With Occlusive Cardiovascular Disorders
25. Nursing Care of Patients With Cardiac Arrhythmias
26. Nursing Care of Patients With Heart Failure
Unit 6 Understanding the Hematologic and Lymphatic Systems
27. Hematologic and Lymphatic System Function, Assessment, and Therapeutic Measures
28. Nursing Care of Patients With Hematologic and Lymphatic Disorders
Unit 7 Understanding the Respiratory System
29. Respiratory System Function, Assessment, and Therapeutic Measures
30. Nursing Care of Patients With Upper Respiratory Tract Disorders
31. Nursing Care of Patients With Lower Respiratory Tract Disorders
,Unit 8 Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
32. Gastrointestinal, Hepatobiliary, and Pancreatic Systems Function, Assessment and Therapeutic Measures
33. Nursing Care of Patients With Upper Gastrointestinal Disorders
34. Nursing Care of Patients With Lower Gastrointestinal Disorders
35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders
Unit 9 Understanding the Urinary System
36. Urinary System Function, Assessment, and Therapeutic Measures
37. Nursing Care of Patients With Disorders of the Urinary System
Unit 10 Understanding the Endocrine System
38. Endocrine System Function andAssessment
39. Nursing Care of Patients With Endocrine Disorders
40. Nursing Care of Patients With Disorders of the Endocrine Pancreas
N
Unit 11 Understanding the Genitourinary and Reproductive System
41. Genitourinary and Reproductive System Function and Assessment
U
42. Nursing Care of Women With Reproductive System Disorders
43. Nursing Care of Male Patients With Genitourinary Disorders
44. Nursing Care of Patients With Sexually Transmitted Infections
R
Unit 12 Understanding the Musculoskeletal System
45. Musculoskeletal Function and Assessment
SE
46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders
Unit 13 Understanding the Neurologic System
47. Neurologic System Function, Assessment, and Therapeutic Measures
48. Nursing Care of Patients With Central Nervous System Disorders
SH
49. Nursing Care of Patients With Cerebrovascular Disorders
50. Nursing Care of Patients With Peripheral Nervous System Disorders
Unit 14 Understanding the Sensory System
51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing
52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing
AH
Unit 15 Understanding the Integumentary System
53. Integumentary System Function, Assessment and Therapeutic Measures
54. Nursing Care of Patients With Skin Disorders
55. Nursing Care of Patients WithBurns
Unit 16 Understanding Mental Health Care
56. Mental Health Function, Assessment, and Therapeutic Measures
57. Nursing Care of Patients With Mental Health Disorders
,Linda S. Williams & Paula D. Hopper: Understanding Medical-Surgical Nursing
Chapter 1. Critical Thinking and the Nursing Process
MULTIPLE CHOICE
1. The nurse is caring for a group of patients on a medical-surgical unit. Which patient should
the licensed practical nurse/licensed vocational nurse (LPN/LVN) assess first?
1. A patient with a blood glucose of 42 mg/dL
2. A patient who reports a pain level of 2
3. A patient who has just received a diagnosis of cancer
4. A patient who has a respiratory rate of 22
ANS: 1
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human
needs.
N
Pages: 6–7
Heading: Prioritize Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
U
Client Need: SECE—Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
R
Difficulty: Difficult
Feedback
SE
1 This patient has a dangerously low blood glucose level and requires immediate
intervention.
2 This patient will need to be assessed, but is not as high a priority.
3 According to Maslow, psychosocial needs are not as high of a priority as
physiological needs.
4 A respiratory rate of 22 is within normal range.
SH
PTS: 1 CON: Patient-Centered Care
2. The LPN/LVN enters the room of a patient who is angry and yells, ―I asked 5 minutes ago
for my pain medication. I’m going to call the CEO of the hospital if you don’t get it for me
AH
now.‖ Which statement by the nurse demonstrates intellectual empathy?
1. ―We are short-staffed today, so it will take me longer to meet your needs.‖
2. ―I am sorry you had to wait, I know you must be in a lot of pain.‖
3. ―I had another patient who had severe pain, and I had to get to them first.‖
4. ―I will get you the number for the CEO, but he is aware of how busy we are.‖
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 2. Describe attitudes and skills that promote good critical thinking
Page: 2
Heading: Intellectual Empathy
Integrated Process: Communication and Documentation
Client Need: Psychosocial Integrity
, Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1 This statement does not consider an individual’s situation.
2 This statement demonstrates intellectual empathy by considering this patient’s
situation and will likely alleviate the patient’s anger.
3 This statement does not consider a patient’s situation and does not demonstrate
intellectual empathy.
4 This statement addresses the patient’s statement of wanting to call the CEO, but
does not demonstrate intellectual empathy by considering the patient’s situation.
PTS: 1 CON: Communication
3. The nurse is collecting data on a patient. Which data are described as subjective?
1. Respiratory rate of 26 per minute
2. Patient report of shortness of breath
N
3. Coarse lung sounds bilaterally
4. Cough producing green sputum
U
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 5. Differentiate between objective and subjective data.
R
Page: 4
Heading: Subjective Data
Integrated Process: Communication and Documentation
SE
Client Need: Communication and Documentation
Cognitive Level: Application (Applying)
Concept: Communication
Difficulty: Moderate
SH
Feedback
1 Respiratory rate of 26 per minute is an example of objective data.
2 A patient reporting symptoms to the nurse is an example of subjective data.
3 Coarse lung sounds is an example of objective data.
4 A productive cough is an example of objective data.
AH
PTS: 1 CON: Communication
4. A patient with a newly fractured femur reports a pain level of 8/10 and analgesic medication
is not due for another 50 minutes. Which action should the nurse take first?
1. Reposition the patient.
2. Give the medication in 30 minutes.
3. Notify the registered nurse (RN) or physician.
4. Tell the patient it is too early for pain medication.
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
, Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using
the nursing process.
Page: 3
Heading: Clinical Judgement
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE—Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 The patient who has a fractured femur is having acute pain. Repositioning a
patient with a new fracture is not likely to relieve pain.
2 Giving the medication before the prescribed time is beyond the nurse’s scope of
practice.
3 The patient should not have to wait for pain relief, so the LPN should inform the
RN or physician so new pain relief orders can be obtained.
N
4 The nurse needs to do more than expect the patient to wait for pain relief.
U
PTS: 1 CON: Patient-Centered Care
5. The nurse is prioritizing care based on Maslow hierarchy of needs. Which need does the
R
nurse identify as having the highest priority?
1. Job-related stress
2. Feeling of loneliness
SE
3. Pain level of 9 on 0-to-10 scale
4. Lack of confidence
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human
SH
needs
Page: 7
Heading: Prioritize Care
Integrated Process: Caring
Client Need: SECE – Coordinated Care
Cognitive Level: Application [Applying]
AH
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 Job-related stress falls under safety according to Maslow and is addressed after
physiological needs.
2 According to Maslow, loneliness is addressed under social needs following
physiological and safety.
3 Pain is a physiological need and is the highest priority.
4 Lack of confidence falls under esteem according to Maslow and is addressed
following physiological, safety, and social needs.
, PTS: 1 CON: Patient-Centered Care
6. The nurse is planning care and setting goals for a newly admitted patient. Who should the
nurse include when conducting these nursing actions?
1. Patient
2. Nurse manager
3. Hospital chaplain
4. Patient’s health care provider (HCP)
ANS: 1
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse is using
the nursing process.
Page: 6
Heading: Prioritize Care
Integrated Process: Communication and Documentation
Client Need: SECE—Management of Care
N
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
U
Feedback
1 Planning care and setting goals is an action performed with the patient. The
R
patient must be in agreement with the plan for it to be successful in meeting the
desired outcomes.
2 The nurse manager may or may not be aware of the patient’s care needs.
SE
3 The hospital chaplain may not be aware of the patient’s needs.
4 The focus of nursing care is different from that of the HCP.
PTS: 1 CON: Communication
SH
7. While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes
serosanguineous drainage on the dressing. Which statement should the nurse use to
document this finding?
1. ―Normal drainage noted.‖
2. ―Moderate drainage recently noted.‖
3. ―Scant serosanguineous drainage seen on dressing.‖
AH
4. ―Pale pink drainage 2 cm by 1 cm noted on dressing.‖
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 6. Document subjective and objective data.
Page: 5
Heading: Documentation of Data
Integrated Process: Communication and Documentation
Client Need: PHYS—Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
, Feedback
1 These statements are interpretations of the data and use words that have vague
meanings, which should be avoided when documenting.
2 These statements are interpretations of the data and use words that have vague
meanings, which should be avoided when documenting.
3 These statements are interpretations of the data and use words that have vague
meanings, which should be avoided when documenting.
4 Objective data are pieces of factual information obtained through physical
assessment and diagnostic tests that are observable or knowable through the five
senses. The nurse should document exactly what is seen.
PTS: 1 CON: Communication
8. The nurse is caring for a patient using the nursing process. Which step should the nurse take
first?
1. Implementation
2. Planning
3. Nursing diagnosis
N
4. Assessment
ANS: 4
U
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using
the nursing process.
R
Page: 4
Heading: Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
SE
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
SH
Feedback
1 The steps of the nursing process are data collection/assessment, nursing
diagnosis, planning, implementation, and evaluation.
2 The steps of the nursing process are data collection/assessment, nursing
diagnosis, planning, implementation, and evaluation.
3 The steps of the nursing process are data collection/assessment, nursing
AH
diagnosis, planning, implementation, and evaluation.
4 Assessment, or data collection, is the first step in the nursing process and is used
to evaluate a patient’s condition before providing care. The other steps, in order,
are nursing diagnosis, planning, implementation, and evaluation.
PTS: 1 CON: Patient-Centered Care
9. The nurse is administering morphine to a patient reporting a pain level of 8 on a 0-to-10
scale. This describes which step of the nursing process?
1. Assessment
, 2. Nursing diagnosis
3. Implementation
4. Evaluation
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using
the nursing process.
Page: 8
Heading: Identify Interventions
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE – Coordination of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
N
1 Administering medication does not describe assessment.
2 Administering medication does not describe nursing diagnosis.
3 Administering medication describes the implementation process, since an action
U
is being taken to help the patient meet a desired outcome.
4 Administering medication does not describe the evaluation phase of the nursing
process.
R
PTS: 1 CON: Patient-Centered Care
SE
10. The nurse is developing an outcome for a patient with exacerbation of asthma. Which is the
most appropriate outcome for this patient?
1. The patient will not experience shortness of breath.
2. The patient will have a respiratory rate of 16 to 20 per minute.
3. The patient will ambulate without reporting shortness of breath.
SH
4. The patient will not require use of an inhaler.
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 8
AH
Heading: Establish Outcomes
Integrated Process: Clinical Problem-solving (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 This is a vague outcome and is not measurable.
2 This is a measurable outcome and is not vague.
3 This is a vague outcome and is not measurable.
4 This is a vague outcome and is not measurable.
, PTS: 1 CON: Patient-Centered Care
11. The nurse suspects a patient is experiencing adverse effects to a newly prescribed
antihypertensive medication. After being informed that the effects are expected, the nurse
remains concerned and conducts an Internet search on the patient’s manifestations. Which
critical thinking behavior did the nurse implement?
1. Sense of justice
2. Intellectual courage
3. Intellectual empathy
4. Intellectual perseverance
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 2. Describe attitudes and skills that promote critical thinking.
Page: 2
Heading: Intellectual Perseverance
N
Integrated Process: Caring
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
U
Concept: Patient-Centered Care
Difficulty: Moderate
R
Feedback
1 A sense of justice examines motives when making decisions.
2 Intellectual courage looks at other points of view, even when the nurse does not
SE
agree with them.
3 Intellectual empathy understands how another person feels when making
decisions.
4 Intellectual perseverance is not giving up.
SH
PTS: 1 CON: Patient-Centered Care
12. The nurse is identifying outcomes for a patient with fluid volume deficit. Which outcome
should the nurse use to guide this patient’s care?
1. Patient’s intake will be measured daily.
2. Patient’s intake will be 3,000 mL daily.
AH
3. Fluids will be at the bedside for the patient.
4. Fluids the patient likes will be at the bedside.
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 7
Heading: Establish Outcomes
Integrated Process: Clinical Problem-solving (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
