Test Bank
For Lewis Medical-Surgical Nursing in
Canada 4th Edition
MULTIPLE CHOICE :
1. The nurse is caring for a client with a new diagnosis of pneumonia and
explains to the client that together they will plan the client’s care and set
goals for discharge. The client asks, “How is that different from what the
doctor does?” Which response by the nurse is most appropriate?
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 data and communicating when
there are problems.”
c. “Nurses perform many of the procedures done by physicians, but nurses are here in
the hospital for a longer time than doctors.”
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 Canadian Nurses Association (CNA) definition of nursing.
Registered nurses are self-regulated health care professionals who work autonomously and in
collaboration with others. RNs enable individuals, families, groups, communities and populations to
achieve their optimal level of health. RNs coordinate health care, deliver direct services, and support
clients in their self-care decisions and actions in situations of health, illness, injury, and disability in all
stages of life. 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: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
2. When caring for clients using evidence-informed practice, which of the following does the nurse use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the client outcomes are met
ANS: C
Evidence-informed nursing practice is a continuous interactive process involving the explicit,
conscientious, and judicious consideration of the best available evidence to provide care. Four primary
elements are: (a) clinical state, setting, and circumstances; (b) client preferences and actions; (c) best
research evidence, and (d) health care resources. Clinical judgement based on the nurse’s clinical
experience is part of EIP, but clinical decision making also should incorporate current research and
research-based guidelines. Evidence from one clinical research study does not provide an adequate
substantiation for interventions. Evaluation of client outcomes is important, but interventions should be
based on research from randomized control studies with a large number of subjects.
, DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
3. Which of the following would the nurse perform during the assessment phase of the nursing process?
a. Obtains data with which to diagnose client problems.
b. Uses client data to develop priority nursing diagnoses.
c. Teaches interventions to relieve client health problems.
d. Assists the client to identify realistic outcomes to health problems.
ANS: A
During the assessment phase, the nurse gathers information about the client. The other responses are
examples of the intervention, diagnosis, and planning phases of the nursing process.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
4. Which of the following is an example of a correctly written nursing diagnosis statement?
a. Altered tissue perfusion related to heart failure.
b. Risk for impaired tissue integrity related to sacral redness.
c. Ineffective coping related to insufficient sense of control.
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 client’s
response to a health problem that can be treated by nursing. The use of a medical diagnosis (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 characteristics as the
etiology.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
5. Which of these nursing actions for the client with heart failure is appropriate for the nurse to delegate
to experienced unregulated care providers?
a. Assess for shortness of breath or fatigue after ambulation.
b. Instruct the client about the need to alternate activity and rest.
c. Obtain the client’s blood pressure and pulse rate after ambulation.
d. Determine whether the client is ready to increase the activity level.
ANS: C
Unregulated care provider education varies according to the type of worker; however, unregulated care
providers are able to measure vital signs. Assessment and client teaching require RN education and
scope of practice and cannot be delegated.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
6. Which action by a newly graduated RN working on the postsurgical unit indicates that more education
about delegation and assignment is needed?
a. The nurse delegates measurement of client oral intake and urine output to an
unregulated care provider.
, b. The nurse delegates assessment of a client’s bowel sounds to an experienced
unregulated care provider.
c. The nurse assigns an LPN/LVN to administer oral medications to several clients.
d. The nurse assigns a “float” RN from pediatrics to care for a client with diabetes.
ANS: B
Assessment requires RN education and scope of practice and cannot be delegated to an unregulated
care provider. The other actions by the new RN are appropriate.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
7. Which of these tasks is appropriate for the registered nurse to delegate to an unregulated care provider?
a. Perform a sterile dressing change for an infected wound.
b. Complete the clients’ initial bath.
c. Teach a client about the effects of prescribed medications.
d. Document client teaching about a routine surgical procedure.
, ANS: B
Unregulated care providers are able to provide personal care to clients. Client teaching and the initial
assessment and development of the plan of care are nursing actions that require RN-level education
and scope of practice when working with clients that are not stable.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
8. Which of the following includes the components required for a complete nursing diagnosis statement?
a. A problem and the suggested client goals or outcomes.
b. A problem, its cause, and objective data that support the problem.
c. A problem with all its possible causes and the planned interventions.
d. A problem with its etiology and the signs and symptoms of the problem.
ANS: D
The PES format is used when writing nursing diagnoses. 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: Knowledge TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
For Lewis Medical-Surgical Nursing in
Canada 4th Edition
MULTIPLE CHOICE :
1. The nurse is caring for a client with a new diagnosis of pneumonia and
explains to the client that together they will plan the client’s care and set
goals for discharge. The client asks, “How is that different from what the
doctor does?” Which response by the nurse is most appropriate?
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 data and communicating when
there are problems.”
c. “Nurses perform many of the procedures done by physicians, but nurses are here in
the hospital for a longer time than doctors.”
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 Canadian Nurses Association (CNA) definition of nursing.
Registered nurses are self-regulated health care professionals who work autonomously and in
collaboration with others. RNs enable individuals, families, groups, communities and populations to
achieve their optimal level of health. RNs coordinate health care, deliver direct services, and support
clients in their self-care decisions and actions in situations of health, illness, injury, and disability in all
stages of life. 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: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
2. When caring for clients using evidence-informed practice, which of the following does the nurse use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the client outcomes are met
ANS: C
Evidence-informed nursing practice is a continuous interactive process involving the explicit,
conscientious, and judicious consideration of the best available evidence to provide care. Four primary
elements are: (a) clinical state, setting, and circumstances; (b) client preferences and actions; (c) best
research evidence, and (d) health care resources. Clinical judgement based on the nurse’s clinical
experience is part of EIP, but clinical decision making also should incorporate current research and
research-based guidelines. Evidence from one clinical research study does not provide an adequate
substantiation for interventions. Evaluation of client outcomes is important, but interventions should be
based on research from randomized control studies with a large number of subjects.
, DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
3. Which of the following would the nurse perform during the assessment phase of the nursing process?
a. Obtains data with which to diagnose client problems.
b. Uses client data to develop priority nursing diagnoses.
c. Teaches interventions to relieve client health problems.
d. Assists the client to identify realistic outcomes to health problems.
ANS: A
During the assessment phase, the nurse gathers information about the client. The other responses are
examples of the intervention, diagnosis, and planning phases of the nursing process.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
4. Which of the following is an example of a correctly written nursing diagnosis statement?
a. Altered tissue perfusion related to heart failure.
b. Risk for impaired tissue integrity related to sacral redness.
c. Ineffective coping related to insufficient sense of control.
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 client’s
response to a health problem that can be treated by nursing. The use of a medical diagnosis (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 characteristics as the
etiology.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
5. Which of these nursing actions for the client with heart failure is appropriate for the nurse to delegate
to experienced unregulated care providers?
a. Assess for shortness of breath or fatigue after ambulation.
b. Instruct the client about the need to alternate activity and rest.
c. Obtain the client’s blood pressure and pulse rate after ambulation.
d. Determine whether the client is ready to increase the activity level.
ANS: C
Unregulated care provider education varies according to the type of worker; however, unregulated care
providers are able to measure vital signs. Assessment and client teaching require RN education and
scope of practice and cannot be delegated.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
6. Which action by a newly graduated RN working on the postsurgical unit indicates that more education
about delegation and assignment is needed?
a. The nurse delegates measurement of client oral intake and urine output to an
unregulated care provider.
, b. The nurse delegates assessment of a client’s bowel sounds to an experienced
unregulated care provider.
c. The nurse assigns an LPN/LVN to administer oral medications to several clients.
d. The nurse assigns a “float” RN from pediatrics to care for a client with diabetes.
ANS: B
Assessment requires RN education and scope of practice and cannot be delegated to an unregulated
care provider. The other actions by the new RN are appropriate.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
7. Which of these tasks is appropriate for the registered nurse to delegate to an unregulated care provider?
a. Perform a sterile dressing change for an infected wound.
b. Complete the clients’ initial bath.
c. Teach a client about the effects of prescribed medications.
d. Document client teaching about a routine surgical procedure.
, ANS: B
Unregulated care providers are able to provide personal care to clients. Client teaching and the initial
assessment and development of the plan of care are nursing actions that require RN-level education
and scope of practice when working with clients that are not stable.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
8. Which of the following includes the components required for a complete nursing diagnosis statement?
a. A problem and the suggested client goals or outcomes.
b. A problem, its cause, and objective data that support the problem.
c. A problem with all its possible causes and the planned interventions.
d. A problem with its etiology and the signs and symptoms of the problem.
ANS: D
The PES format is used when writing nursing diagnoses. 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: Knowledge TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
