Medical Surgical Nursing 2nd
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MULTIPLE CHOICE
• 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 appropriate for this
patient?
a. Patient has a balanced intake and output.
b. Patient’s bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patient’s 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
notindicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
• A nurse asks the patient if pain was relieved after receiving medication. What is the
purposeof 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 patient’s health problems have been completely resolved
NURSING MISC Medical Surgical Nursing 10th Edition
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, 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 theevaluation phase.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
• 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
diagnosepatient problems. The other responses are examples of the planning,
intervention, and evaluation phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
• 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 describesa
patient’s 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
NURSING MISC Medical Surgical Nursing 10th Edition
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, • The nurse admits a patient to the hospital and develops a plan of care. What
componentsshould 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: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
• A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse
todelegate 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 patient’s 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
teachingrequire registered nurse education and scope of practice and cannot be
delegated.
DIF: Cognitive Level: Apply (application) REF: 11
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
• 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 patient’s urine output by UAP
b. Administration of oral medications by LPN/LVN
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
NURSING MISC Medical Surgical Nursing 10th Edition
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, ANS: C
Assessment requires RN education and scope of practice and cannot be delegated to
anLPN/LVN or UAP. The other assignments made by the RN are appropriate.
DIF: Cognitive Level: Apply (application) REF: 11
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
• The nurse completes an admission database and explains that the plan of care and discharge
goals will be developed with the patient’s input. The patient states, “How is this different from
what the doctor does?” Which response would be most appropriate for the nurse to make?
a. “The role of the nurse is to administer medications and other treatments
prescribedby your doctor.”
b. “The nurse’s job is to help the doctor by collecting information and
communicating any problems that occur.”
c. “Nurses perform many of the same procedures as the doctor, but nurses are
withthe 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 describesome
of the dependent and collaborative functions of the nursing role but do not accurately
describe the nurse’s role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
• The nurse describes to a student nurse how to use evidence-based practice guidelines
whencaring 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
patientpreferences.”
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with
NURSING MISC Medical Surgical Nursing 10th Edition
Lewis Test-Bank Questions and Answers best Rated A+
guaranteed success Latest update 2022/2023
Edition Hoffman Test Bank All
Chapters Complete Questions and
Answers graded A+guaranteed
pass
MULTIPLE CHOICE
• 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 appropriate for this
patient?
a. Patient has a balanced intake and output.
b. Patient’s bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patient’s 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
notindicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
• A nurse asks the patient if pain was relieved after receiving medication. What is the
purposeof 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 patient’s health problems have been completely resolved
NURSING MISC Medical Surgical Nursing 10th Edition
Lewis Test-Bank Questions and Answers best Rated A+
guaranteed success Latest update 2022/2023
, 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 theevaluation phase.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
• 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
diagnosepatient problems. The other responses are examples of the planning,
intervention, and evaluation phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
• 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 describesa
patient’s 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
NURSING MISC Medical Surgical Nursing 10th Edition
Lewis Test-Bank Questions and Answers best Rated A+
guaranteed success Latest update 2022/2023
, • The nurse admits a patient to the hospital and develops a plan of care. What
componentsshould 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: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
• A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse
todelegate 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 patient’s 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
teachingrequire registered nurse education and scope of practice and cannot be
delegated.
DIF: Cognitive Level: Apply (application) REF: 11
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
• 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 patient’s urine output by UAP
b. Administration of oral medications by LPN/LVN
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
NURSING MISC Medical Surgical Nursing 10th Edition
Lewis Test-Bank Questions and Answers best Rated A+
guaranteed success Latest update 2022/2023
, ANS: C
Assessment requires RN education and scope of practice and cannot be delegated to
anLPN/LVN or UAP. The other assignments made by the RN are appropriate.
DIF: Cognitive Level: Apply (application) REF: 11
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
• The nurse completes an admission database and explains that the plan of care and discharge
goals will be developed with the patient’s input. The patient states, “How is this different from
what the doctor does?” Which response would be most appropriate for the nurse to make?
a. “The role of the nurse is to administer medications and other treatments
prescribedby your doctor.”
b. “The nurse’s job is to help the doctor by collecting information and
communicating any problems that occur.”
c. “Nurses perform many of the same procedures as the doctor, but nurses are
withthe 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 describesome
of the dependent and collaborative functions of the nursing role but do not accurately
describe the nurse’s role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
• The nurse describes to a student nurse how to use evidence-based practice guidelines
whencaring 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
patientpreferences.”
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with
NURSING MISC Medical Surgical Nursing 10th Edition
Lewis Test-Bank Questions and Answers best Rated A+
guaranteed success Latest update 2022/2023
