Test Bank for Lewis\'s Medical-Surgical Nursing, 12th
cc cc cc cc cc cc
Edition by Mariann M. Harding, Jeffrey Kwong, Debra
cc cc cc cc cc cc cc cc cc
Hagler Chapter 1-69
cc cc cc
,Chapter 01: Professional Nursing
cc cc cc
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
cc cc cc cc cc
MULTIPLE CHOICE cc
1. The nurse completes an admission database and explains that the plan of care and
cc cc cc cc cc cc cc cc cc cc cc cc cc
discharge goals will be developed with the patient‗s input. The patient asks, ―How is this
cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc
different from what the physician does?‖ Which response would the nurse provide?
cc cc cc cc cc cc cc cc cc cc cc cc
a. ―The role of the nurse is to administer medications and other treatments prescribed
cc cc cc cc cc cc cc cc cc cc cc cc
by your physician.‖
cc cc cc
b. ―In addition to caring for you while you are sick, the nurses will help you plan to
cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc
maintain your health.‖
cc cc cc
c. ―The nurse‗s job is to collect information and communicate any problems that
cc cc cc cc cc cc cc cc cc cc cc
occur to the physician.‖
cc cc cc cc
d. ―Nurses perform many of the same procedures as the physician, but nurses are
cc cc cc cc cc cc cc cc cc cc cc cc
with the patients for a longer time than the physician.‖
cc cc cc cc cc cc cc cc cc cc
ANS: B cc
The American Nurses Association (ANA) definition of nursing describes the role of nurses in
cc cc cc cc cc cc cc cc cc cc cc cc cc
promoting health. The other responses describe dependent and collaborative functions of
cc cc cc cc cc cc cc cc cc cc cc
the nursing role but do not accurately describe the nurse‗s unique role in the health care
cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc
system.
cc
DIF: c c c c Cognitive Level: Analyze (Analysis) cc cc cc
TOP: c c Nursing Process: Implementation cc cc c c c c c c MSC: NCLEX: Safe and Effective Care Environment
c c cc cc cc cc cc
2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
cc cc cc cc cc cc cc cc cc cc cc cc
a. ―Patient care is based on clinical judgment, experience, and traditions.‖
cc cc cc cc cc cc cc cc cc
b. ―Data are analyzed later to show that the patient outcomes are consistently met.‖
cc cc cc cc cc cc cc cc cc cc cc cc
c. ―Research from all published articles are used as a guide for planning patient care.‖
cc cc cc cc cc cc cc cc cc cc cc cc cc
d. ―Recommendations are based on research, clinical expertise, and patient cc cc cc cc cc cc cc cc
preferences.‖
cc
ANS: D cc
Evidence-based practice (EBP) is the use of the best research-based evidence combined with
cc cc cc cc cc cc cc cc cc cc cc cc
clinician expertise and consideration of patient preferences. Clinical judgment based on the
cc cc cc cc cc cc cc cc cc cc cc cc
nurse‗s clinical experience is part of EBP, but clinical decision making should also
cc cc cc cc cc cc cc cc cc cc cc cc cc
incorporate current research and research-based guidelines. Evaluation of patient outcomes is
cc cc cc cc cc cc cc cc cc cc cc
important, but data analysis is not required to use EBP. All published articles do not
cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc
provide research evidence; interventions should be based on credible research, preferably
cc cc cc cc cc cc cc cc cc cc cc
randomized controlled studies with a large number of subjects.
cc cc cc cc cc cc cc cc cc
DIF: Cognitive Level: Understand (Comprehension) cc cc cc TOP: Nursing Process: Planning cc cc cc
MSC: NCLEX: Safe and Effective Care Environment
cc c c cc cc cc cc cc
3. Which statement by the nurse provides a clear explanation of the nursing process?
cc cc cc cc cc cc cc cc cc cc cc cc
a. ―The nursing process is a research method of diagnosing the patient‗s health care
cc cc cc cc cc cc cc cc cc cc cc cc
problems.‖
cc
b. ―The nursing process is used primarily to explain nursing interventions to other
cc cc cc cc cc cc cc cc cc cc cc
health care professionals.‖
cc cc cc
c. ―The nursing process is a problem-solving tool used to identify and manage the
cc cc cc cc cc cc cc cc cc cc cc cc
, patients‗ health care needs.‖ cc cc cc
d. ―The nursing process is based on nursing theory that incorporates the
cc cc cc cc cc cc cc cc cc cc
biopsychosocial nature of humans.‖
cc cc cc cc
ANS: C cc
The nursing process is a problem-solving approach to the identification and treatment of
cc cc cc cc cc cc cc cc cc cc cc cc
patients‗ problems. Nursing process does not require research methods for diagnosis. The
cc cc cc cc cc cc cc cc cc cc cc cc
primary use of the nursing process is in patient care, not to establish nursing theory or explain
cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc
nursing interventions to other health care professionals.
cc cc cc cc cc cc cc
DIF: Cognitive Level: Understand (Comprehension) cc cc cc TOP: Nursing Process: Evaluation cc cc cc
MSC: NCLEX: Safe and Effective Care Environment
cc c c cc cc cc cc cc
4. A patient admitted to the hospital for surgery tells the nurse, ―I do not feel comfortable
cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc
leaving my children with my parents.‖ Which action would the nurse take next?
cc cc cc cc cc cc cc cc cc cc cc cc cc
a. Reassure the patient that these feelings are common for parents.cc cc cc cc cc cc cc cc cc
b. Have the patient call the children to ensure that they are doing well.
cc cc cc cc cc cc cc cc cc cc cc cc
c. Gather information on the patient‗s concerns about the child care arrangements.
cc cc cc cc cc cc cc cc cc cc
d. Call the patient‗s parents to determine whether adequate child care is being
cc cc cc cc cc cc cc cc cc cc cc
provided.
cc
ANS: C cc
Because a complete assessment is necessary in order to identify a problem and choose an
cc cc cc cc cc cc cc cc cc cc cc cc cc cc
appropriate intervention, the nurse‗s first action should be to obtain more information. The
cc cc cc cc cc cc cc cc cc cc cc cc cc
other actions may be appropriate, but more assessment is needed before the best intervention
cc cc cc cc cc cc cc cc cc cc cc cc cc cc
can be chosen.
cc cc cc
DIF: Cognitive Level: Analyze (Analysis) cc cc cc
TOP: Nursing Process: Assessment
c c MSC: NCLEX: Psychosocial Integrity cc cc cc cc cc
5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis.
cc cc cc cc cc cc cc cc cc cc cc cc cc cc
Which expected outcome would the nurse select for this patient?
cc cc cc cc cc cc cc cc cc cc
a. Patient has a balanced intake and output. cc cc cc cc cc cc
b. Patient‗s bedding is kept clean and free of moisture. cc cc cc cc cc cc cc cc
c. Patient understands the need for increased fluid intake.
cc cc cc cc cc cc cc
d. Patient‗s skin remains cool and dry throughout hospitalization.
cc cc cc cc cc cc cc
ANS: A cc
Balanced intake and output gives measurable data showing resolution of the problem of
cc cc cc cc cc cc cc cc cc cc cc cc
deficient fluid volume. The other statements would not indicate that the problem of
cc cc cc cc cc cc cc cc cc cc cc cc cc
hypovolemia was resolved.
cc cc cc
DIF: Cognitive Level: Apply (Application) cc cc cc TOP: Nursing Process: Planning cc cc cc
MSC: NCLEX: Physiological Integrity
cc c c cc cc
6. Which statement describes the purpose of the evaluation phase of the nursing process?
cc cc cc cc cc cc cc cc cc cc cc cc
a. To document the nursing care plan in the progress notes of the health record
cc cc cc cc cc cc cc cc cc cc cc cc cc
b. To determine if interventions have been effective in meeting patient outcomes
cc cc cc cc cc cc cc cc cc cc
c. To decide whether the patient‗s health problems have been completely resolved
cc cc cc cc cc cc cc cc cc cc
d. To establish if the patient agrees that the nursing care provided was satisfactory
cc cc cc cc cc cc cc cc cc cc cc cc
ANS: B cc
, Evaluation consists of determining whether the desired patient outcomes have been met
cc cc cc cc cc cc cc cc cc cc cc
and whether the nursing interventions were appropriate. The other responses do not
cc cc cc cc cc cc cc cc cc cc cc cc
describe the evaluation phase.
cc cc cc cc
DIF: Cognitive Level: Understand (Comprehension)
c c cc cc cc TOP: Nursing Process: Evaluation
cc cc cc
MSC: NCLEX: Safe and Effective Care Environment
cc c c cc cc cc cc cc
7. Which statement describes the purpose of the assessment phase of the nursing process?
cc cc cc cc cc cc cc cc cc cc cc cc
a. To teach interventions that relieve health problems
cc cc cc cc cc cc
b. To use patient data to evaluate patient care outcomes
cc cc cc cc cc cc cc cc
c. To obtain data to diagnose patient strengths and problems
cc cc cc cc cc cc cc cc
d. To help the patient identify realistic outcomes for health problems
cc cc cc cc cc cc cc cc cc
ANS: C cc
During the assessment phase, the nurse gathers information about the patient to diagnose
cc cc cc cc cc cc cc cc cc cc cc cc
patient strengths and problems. The other responses are examples of the planning,
cc cc cc cc cc cc cc cc cc cc cc cc
intervention, and evaluation phases of the nursing process.
cc cc cc cc cc cc cc cc
DIF: Cognitive Level: Understand (Comprehension) cc cc cc
TOP: Nursing Process: Assessment
c c MSC: NCLEX: Safe and Effective Care Environment
cc cc c c cc cc cc cc cc
8. When developing the plan of care, which components would the nurse include in the clinical
cc cc cc cc cc cc cc cc cc cc cc cc cc cc
cc problem statement? cc
a. The problem and the suggested patient goals or outcomes
cc cc cc cc cc cc cc cc
b. The problem, its causes, and the signs and symptoms of the problem
cc cc cc cc cc cc cc cc cc cc cc
c. The problem with the possible etiology and the planned interventions
cc cc cc cc cc cc cc cc cc
d. The problem, its pathophysiology, and the expected outcome
cc cc cc cc cc cc cc
ANS: B cc
When writing clinical problems or nursing diagnoses, the subjective as well as objective
cc cc cc cc cc cc cc cc cc cc cc cc
data to support the problem‗s existence should be included. Goals, outcomes, and
cc cc cc cc cc cc cc cc cc cc cc cc
interventions are not included in the problem statement.
cc cc cc cc cc cc cc cc
DIF: Cognitive Level: Understand (Comprehension) cc cc cc TOP: Nursing Process: Diagnosis
cc cc cc
MSC: NCLEX: Safe and Effective Care Environment
cc c c cc cc cc cc cc
9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
cc cc cc cc cc cc cc cc cc cc cc cc
a. Instruct the patient about the need to alternate activity and rest.
cc cc cc cc cc cc cc cc cc cc
b. Monitor level of shortness of breath or fatigue after ambulation.
cc cc cc cc cc cc cc cc cc
c. Obtain the patient‗s blood pressure and pulse rate after ambulation.
cc cc cc cc cc cc cc cc cc
d. Determine whether the patient is ready to increase the activity level.cc cc cc cc cc cc cc cc cc cc
ANS: C cc
AP education includes accurate vital sign measurement. Assessment and patient teaching
cc cc cc cc cc cc cc cc cc cc
require registered nurse education and scope of practice and cannot be delegated.
cc cc cc cc cc cc cc cc cc cc cc cc
DIF: Cognitive Level: Apply (Application) cc cc cc TOP: Nursing Process: Planning
cc cc cc
MSC: NCLEX: Safe and Effective Care Environment
cc c c cc cc cc cc cc
cc cc cc cc cc cc
Edition by Mariann M. Harding, Jeffrey Kwong, Debra
cc cc cc cc cc cc cc cc cc
Hagler Chapter 1-69
cc cc cc
,Chapter 01: Professional Nursing
cc cc cc
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
cc cc cc cc cc
MULTIPLE CHOICE cc
1. The nurse completes an admission database and explains that the plan of care and
cc cc cc cc cc cc cc cc cc cc cc cc cc
discharge goals will be developed with the patient‗s input. The patient asks, ―How is this
cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc
different from what the physician does?‖ Which response would the nurse provide?
cc cc cc cc cc cc cc cc cc cc cc cc
a. ―The role of the nurse is to administer medications and other treatments prescribed
cc cc cc cc cc cc cc cc cc cc cc cc
by your physician.‖
cc cc cc
b. ―In addition to caring for you while you are sick, the nurses will help you plan to
cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc
maintain your health.‖
cc cc cc
c. ―The nurse‗s job is to collect information and communicate any problems that
cc cc cc cc cc cc cc cc cc cc cc
occur to the physician.‖
cc cc cc cc
d. ―Nurses perform many of the same procedures as the physician, but nurses are
cc cc cc cc cc cc cc cc cc cc cc cc
with the patients for a longer time than the physician.‖
cc cc cc cc cc cc cc cc cc cc
ANS: B cc
The American Nurses Association (ANA) definition of nursing describes the role of nurses in
cc cc cc cc cc cc cc cc cc cc cc cc cc
promoting health. The other responses describe dependent and collaborative functions of
cc cc cc cc cc cc cc cc cc cc cc
the nursing role but do not accurately describe the nurse‗s unique role in the health care
cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc
system.
cc
DIF: c c c c Cognitive Level: Analyze (Analysis) cc cc cc
TOP: c c Nursing Process: Implementation cc cc c c c c c c MSC: NCLEX: Safe and Effective Care Environment
c c cc cc cc cc cc
2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
cc cc cc cc cc cc cc cc cc cc cc cc
a. ―Patient care is based on clinical judgment, experience, and traditions.‖
cc cc cc cc cc cc cc cc cc
b. ―Data are analyzed later to show that the patient outcomes are consistently met.‖
cc cc cc cc cc cc cc cc cc cc cc cc
c. ―Research from all published articles are used as a guide for planning patient care.‖
cc cc cc cc cc cc cc cc cc cc cc cc cc
d. ―Recommendations are based on research, clinical expertise, and patient cc cc cc cc cc cc cc cc
preferences.‖
cc
ANS: D cc
Evidence-based practice (EBP) is the use of the best research-based evidence combined with
cc cc cc cc cc cc cc cc cc cc cc cc
clinician expertise and consideration of patient preferences. Clinical judgment based on the
cc cc cc cc cc cc cc cc cc cc cc cc
nurse‗s clinical experience is part of EBP, but clinical decision making should also
cc cc cc cc cc cc cc cc cc cc cc cc cc
incorporate current research and research-based guidelines. Evaluation of patient outcomes is
cc cc cc cc cc cc cc cc cc cc cc
important, but data analysis is not required to use EBP. All published articles do not
cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc
provide research evidence; interventions should be based on credible research, preferably
cc cc cc cc cc cc cc cc cc cc cc
randomized controlled studies with a large number of subjects.
cc cc cc cc cc cc cc cc cc
DIF: Cognitive Level: Understand (Comprehension) cc cc cc TOP: Nursing Process: Planning cc cc cc
MSC: NCLEX: Safe and Effective Care Environment
cc c c cc cc cc cc cc
3. Which statement by the nurse provides a clear explanation of the nursing process?
cc cc cc cc cc cc cc cc cc cc cc cc
a. ―The nursing process is a research method of diagnosing the patient‗s health care
cc cc cc cc cc cc cc cc cc cc cc cc
problems.‖
cc
b. ―The nursing process is used primarily to explain nursing interventions to other
cc cc cc cc cc cc cc cc cc cc cc
health care professionals.‖
cc cc cc
c. ―The nursing process is a problem-solving tool used to identify and manage the
cc cc cc cc cc cc cc cc cc cc cc cc
, patients‗ health care needs.‖ cc cc cc
d. ―The nursing process is based on nursing theory that incorporates the
cc cc cc cc cc cc cc cc cc cc
biopsychosocial nature of humans.‖
cc cc cc cc
ANS: C cc
The nursing process is a problem-solving approach to the identification and treatment of
cc cc cc cc cc cc cc cc cc cc cc cc
patients‗ problems. Nursing process does not require research methods for diagnosis. The
cc cc cc cc cc cc cc cc cc cc cc cc
primary use of the nursing process is in patient care, not to establish nursing theory or explain
cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc
nursing interventions to other health care professionals.
cc cc cc cc cc cc cc
DIF: Cognitive Level: Understand (Comprehension) cc cc cc TOP: Nursing Process: Evaluation cc cc cc
MSC: NCLEX: Safe and Effective Care Environment
cc c c cc cc cc cc cc
4. A patient admitted to the hospital for surgery tells the nurse, ―I do not feel comfortable
cc cc cc cc cc cc cc cc cc cc cc cc cc cc cc
leaving my children with my parents.‖ Which action would the nurse take next?
cc cc cc cc cc cc cc cc cc cc cc cc cc
a. Reassure the patient that these feelings are common for parents.cc cc cc cc cc cc cc cc cc
b. Have the patient call the children to ensure that they are doing well.
cc cc cc cc cc cc cc cc cc cc cc cc
c. Gather information on the patient‗s concerns about the child care arrangements.
cc cc cc cc cc cc cc cc cc cc
d. Call the patient‗s parents to determine whether adequate child care is being
cc cc cc cc cc cc cc cc cc cc cc
provided.
cc
ANS: C cc
Because a complete assessment is necessary in order to identify a problem and choose an
cc cc cc cc cc cc cc cc cc cc cc cc cc cc
appropriate intervention, the nurse‗s first action should be to obtain more information. The
cc cc cc cc cc cc cc cc cc cc cc cc cc
other actions may be appropriate, but more assessment is needed before the best intervention
cc cc cc cc cc cc cc cc cc cc cc cc cc cc
can be chosen.
cc cc cc
DIF: Cognitive Level: Analyze (Analysis) cc cc cc
TOP: Nursing Process: Assessment
c c MSC: NCLEX: Psychosocial Integrity cc cc cc cc cc
5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis.
cc cc cc cc cc cc cc cc cc cc cc cc cc cc
Which expected outcome would the nurse select for this patient?
cc cc cc cc cc cc cc cc cc cc
a. Patient has a balanced intake and output. cc cc cc cc cc cc
b. Patient‗s bedding is kept clean and free of moisture. cc cc cc cc cc cc cc cc
c. Patient understands the need for increased fluid intake.
cc cc cc cc cc cc cc
d. Patient‗s skin remains cool and dry throughout hospitalization.
cc cc cc cc cc cc cc
ANS: A cc
Balanced intake and output gives measurable data showing resolution of the problem of
cc cc cc cc cc cc cc cc cc cc cc cc
deficient fluid volume. The other statements would not indicate that the problem of
cc cc cc cc cc cc cc cc cc cc cc cc cc
hypovolemia was resolved.
cc cc cc
DIF: Cognitive Level: Apply (Application) cc cc cc TOP: Nursing Process: Planning cc cc cc
MSC: NCLEX: Physiological Integrity
cc c c cc cc
6. Which statement describes the purpose of the evaluation phase of the nursing process?
cc cc cc cc cc cc cc cc cc cc cc cc
a. To document the nursing care plan in the progress notes of the health record
cc cc cc cc cc cc cc cc cc cc cc cc cc
b. To determine if interventions have been effective in meeting patient outcomes
cc cc cc cc cc cc cc cc cc cc
c. To decide whether the patient‗s health problems have been completely resolved
cc cc cc cc cc cc cc cc cc cc
d. To establish if the patient agrees that the nursing care provided was satisfactory
cc cc cc cc cc cc cc cc cc cc cc cc
ANS: B cc
, Evaluation consists of determining whether the desired patient outcomes have been met
cc cc cc cc cc cc cc cc cc cc cc
and whether the nursing interventions were appropriate. The other responses do not
cc cc cc cc cc cc cc cc cc cc cc cc
describe the evaluation phase.
cc cc cc cc
DIF: Cognitive Level: Understand (Comprehension)
c c cc cc cc TOP: Nursing Process: Evaluation
cc cc cc
MSC: NCLEX: Safe and Effective Care Environment
cc c c cc cc cc cc cc
7. Which statement describes the purpose of the assessment phase of the nursing process?
cc cc cc cc cc cc cc cc cc cc cc cc
a. To teach interventions that relieve health problems
cc cc cc cc cc cc
b. To use patient data to evaluate patient care outcomes
cc cc cc cc cc cc cc cc
c. To obtain data to diagnose patient strengths and problems
cc cc cc cc cc cc cc cc
d. To help the patient identify realistic outcomes for health problems
cc cc cc cc cc cc cc cc cc
ANS: C cc
During the assessment phase, the nurse gathers information about the patient to diagnose
cc cc cc cc cc cc cc cc cc cc cc cc
patient strengths and problems. The other responses are examples of the planning,
cc cc cc cc cc cc cc cc cc cc cc cc
intervention, and evaluation phases of the nursing process.
cc cc cc cc cc cc cc cc
DIF: Cognitive Level: Understand (Comprehension) cc cc cc
TOP: Nursing Process: Assessment
c c MSC: NCLEX: Safe and Effective Care Environment
cc cc c c cc cc cc cc cc
8. When developing the plan of care, which components would the nurse include in the clinical
cc cc cc cc cc cc cc cc cc cc cc cc cc cc
cc problem statement? cc
a. The problem and the suggested patient goals or outcomes
cc cc cc cc cc cc cc cc
b. The problem, its causes, and the signs and symptoms of the problem
cc cc cc cc cc cc cc cc cc cc cc
c. The problem with the possible etiology and the planned interventions
cc cc cc cc cc cc cc cc cc
d. The problem, its pathophysiology, and the expected outcome
cc cc cc cc cc cc cc
ANS: B cc
When writing clinical problems or nursing diagnoses, the subjective as well as objective
cc cc cc cc cc cc cc cc cc cc cc cc
data to support the problem‗s existence should be included. Goals, outcomes, and
cc cc cc cc cc cc cc cc cc cc cc cc
interventions are not included in the problem statement.
cc cc cc cc cc cc cc cc
DIF: Cognitive Level: Understand (Comprehension) cc cc cc TOP: Nursing Process: Diagnosis
cc cc cc
MSC: NCLEX: Safe and Effective Care Environment
cc c c cc cc cc cc cc
9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
cc cc cc cc cc cc cc cc cc cc cc cc
a. Instruct the patient about the need to alternate activity and rest.
cc cc cc cc cc cc cc cc cc cc
b. Monitor level of shortness of breath or fatigue after ambulation.
cc cc cc cc cc cc cc cc cc
c. Obtain the patient‗s blood pressure and pulse rate after ambulation.
cc cc cc cc cc cc cc cc cc
d. Determine whether the patient is ready to increase the activity level.cc cc cc cc cc cc cc cc cc cc
ANS: C cc
AP education includes accurate vital sign measurement. Assessment and patient teaching
cc cc cc cc cc cc cc cc cc cc
require registered nurse education and scope of practice and cannot be delegated.
cc cc cc cc cc cc cc cc cc cc cc cc
DIF: Cognitive Level: Apply (Application) cc cc cc TOP: Nursing Process: Planning
cc cc cc
MSC: NCLEX: Safe and Effective Care Environment
cc c c cc cc cc cc cc
