,Chapter 01:P rofessional Nursing
l l l
Harding: Lewis’sMedical-Surgical Nursing, 12thEdition
l l bj l l
MULTIPLECHOICE l
1. The nurse completes an admission database and explains that the plan of care and discharge goals
l l l l l l l l l l l l l l l l
willbe developed with the patient‗s input. The patient asks, ―How is t his different fromwhat the p
l l l l l l l l l l l l l l l l l
hysician does?‖ Which response would the nurse provide?
l l l l l l l
a. ―Theroleo f the nurse is to a dminister medications and other treatments prescribed by y
l l l l l l l l l l l l l l
our physician.‖ l
b. ―Inaddition to caringf or y ouw hile you ares ick,t he nurses w illhelp you plant o maint
l l bj l l l l bj l l l l l l l l l
ain your health.‖ l l
c. ―Thenurse‗sjob ist o collect informationa ndc ommunicate a ny problems t hat occ
l l l l l l l l l l l l
ur to the physician.‖ l l l
d. ―Nursesperformmany of t hesame p rocedures as the physician,but nursesare with l l l l l l l l l l bj l l
the patients for a longer time than the physician.‖
l l l l l l l l l
ANS: B l
The American Nurses Association (ANA) definition of nursing describes the role of nurses in promoting h
l l l l l l l l l l l l l l l
ealth. The other responses describe dependent and collaborative functions of the nursing role but do not
l l l l l l l l l l l l l l l l
accurately describe the nurse‗s unique role in the health care system.
l l l l l l l l l l
DIF: CognitiveLevel:Analyze(Analysis) l l l
TOP: Nursing Process:Implementation bj l MSC: NCLEX:SafeandEffective CareEnvironment l l l l bj l
2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
l l l l l l l l l l l l
a. ―Patient care is based on clinical judgment, experience, and traditions.‖ l l l l l l l l l
b. ―Data areanalyzed later to show that the patient outcomes are consistently met.‖
l l l l l l l l l l l l
c. ―Research fromall published articles are used as a guide for planning patient care.‖ l l l l l l l l l l l l l
d. ―Recommendationsare based o n research,c linicalexpertise,a nd patient pre l l l l l l l l l
ferences.‖
ANS: D l
Evidence-based practice (EBP) is the use of the best research- l l l l l l l l l
based evidence combined with clinician expertise and consideration of patient preferences. Clinic
l l l l l l l l l l l
al judgment based on the nurse‗s clinical experience is part of EBP, but clinical decisi on making s
l l l l l l l l l l l l l l l l l
hould also incorporate current research and research-
l l l l l l
based guidelines. Evaluation of patient outcomes is important, but data analysis is not require
l l l l l l l l l l l l l
d to use EBP. All published articles do not provide research evidence; interventions should b
l l l l l l l l l l l l l l
ebased on credible research, preferably randomized controlled studies with a large number of subjects.
l l l l l l l l l l l l l l
DIF: Cognitive Level: Understand (Comprehension) l l l
TOP:Nursing Process:P lanning MSC: NCLEX: Safe and Effective Care Environment
l bj l l l l l l l l
3. Whichstatement by the nurse providesa clear explanation of the nursing process?
l l l l l l l l l l l l
a. ―Thenursing process is aresearch method o f diagnosing t he patient‗s health care prob
l l l l l l l l l l l l l
lems.‖
b. ―Thenursing process is used primarily to e xplain nursing interventions t o o ther heal
l l l l l l l l l l l l
th care professionals.‖ l l
c. ―The nursing process is a problem-solving tool used to identify a nd manage the
l l l l l l l l l l l l
, patients‗ health care needs.‖ l l l
d. ―Thenursing process is based on nursing t heory t hat incorporatest he bio
l l l l l l l l l l l
psychosocial nature of humans.‖ l l l
ANS: C l
The nursing process is a problem-
l l l l l
solving approach to the identification and treatment of patients‗ problems. Nursing process does n
l l l l l l l l l l l l l
ot require research methods for diagnosis. The primary use of the nursing process is in patient care, n
l l l l l l l l l l l l l l l l l
ot to establish nursing theory or explain nursing interventions to other health ca re professionals.
l l l l l l l l l l l l l l
DIF: Cognitive Level: Understand (Comprehension) l l l
TOP:NursingP rocess:Evaluation MSC: NCLEX: Safe and Effective Care Environment
l l l l l l l l l l
4. Apatientadmitted to the h ospitalf or s urgerytells the n urse,―I do n ot feelcomfortable leavi
l l l l l l l l l l bj l bj l l l
ng my children with my parents.‖ Which action would the nurse take next?
l l l l l l l l l l l l
a. Reassure the patient that these feelings are common for parents. l l l l l l l l l
b. Havethe patient call the children to ensure that they are doing well.
l bj l l l l l l l l l l
c. Gather information on the patient‗s concerns about the child care arrangements.
l l l l l l l l l l
d. Callthe patient‗s parents to determine whether adequate child care is being prov
l l l l l l l l l l l l
ided.
ANS: C l
Because a complete assessment is necessary in order to identify a problem and choose an ap propriate i
l l l l l l l l l l l l l l l l l
ntervention, the nurse‗s first action should be to obtain more information. The oth er actions may b
l l l l l l l l l l l l l l l l
e appropriate, but more assessment is needed before the best intervention can b e chosen.
l l l l l l l l l l l l l l
DIF: CognitiveLevel:Analyze (Analysis) l l l
TOP: Nursing Process:Assessment bj l MSC: NCLEX:P sychosocialIntegrity l l l
5. A patient with a bacterial infection is hypovolemic due t o a fever and excessive diaphoresis. Whic
l l l l l l l l l l l l l l l
h expected outcome would the nurse select for this patient?
l l l l l l l l l
a. Patient has a balanced intake and output. l l l l l l
b. Patient‗sbedding is kept clean and free of moisture. l l l l l l l l
c. Patient understands the need for increased fluid intake. l l l l l l l
d. Patient‗s skin remains cool and dry throughout hospitalization. l l l l l l l
ANS: A l
Balanced intake and output gives measurable data showing resolution of the problem of deficie nt flui
l l l l l l l l l l l l l l l
d volume. The other statements would not indicate that the problem of hypovolemia was resolved.
l l l l l l l l l l l l l l
DIF: Cognitive Level: Apply (Application) l l l
TOP:Nursing Process:P lanning MSC: NCLEX: Physiological Integrity l bj l l l l l
6. Which statement describes the purpose of the evaluation phase of the nursing process?
l l l l l l l l l l l l
a. Todocument the nursing care plan in the progress notes of the health record
l l l l l l l l l l l l l
b. To determine if interventions have been effective in meeting patient outcomes
l l l l l l l l l l
c. To decide whether the patient‗s health problems have been completely resolved
l l l l l l l l l l
d. Toestablish if the patient agrees that the nursing care provided was satisfactory
l l l l l l l l l l l l
ANS: B l
, Evaluation consists of determining whether the desired patient outcomes have been met and whethe
l l l l l l l l l l l l l
r the nursing interventions were appropriate. The other responses do not describe the evaluation pha
l l l l l l l l l l l l l l
se.
DIF: Cognitive Level: Understand (Comprehension)
l l l l l
TOP:NursingP rocess:Evaluation MSC: NCLEX: Safe and Effective Care Environment
l l l l l l l l l l
7. Which statement describes the purpose of the assessment phase of the nursing process?
l l l l l l l l l l l l
a. To teach interventions that relieve health problems
l l l l l l
b. Tousepatient data to evaluate patient care o utcomes
l l l l l l l l
c. Toobtain data to diagnose patient strengths and problems
l l l l l l l l
d. To help the patient identify realistic outcomes for health problems
l l l l l l l l l
ANS: C l
During the assessment phase, the nurse gathers information about the patient to diagnose patie nt stre
l l l l l l l l l l bj l l l l
ngths and problems. The other responses are examples of the planning, intervention, a nd evaluati
l l l l l l l l l l l l l l
on phases of the nursing process.
l l l l l
DIF: CognitiveLevel:Understand(Comprehension) l l l
TOP: Nursing Process:Assessment MSC: NCLEX:Safeand EffectiveCare Environment bj l l l l l l bj
8. When developing the plan of care, which components would the nurse include in the clinical proble
l l l l l l l l l l l l l l l
mstatement?
l
a. Theproblemand the suggested patient goals or outcomes
l l l l l l l l
b. Theproblem, its causes, and the signs and symptoms of t he problem
l l l l l l l l l l l
c. The problem with the possible etiology and the planned interventions
l l l l l l l l l
d. The problem, its pathophysiology, and the expected outcome
l l l l l l l
ANS: B l
When writing clinical problems or nursing diagnoses, the subjective as well as objective data to su
l l l l l l l l l l l l l l l
pport the problem‗s existence should be included. Goals, outcomes,and interventions are not include
l l l l l l l l l l l l l
d in the problem statement.
l l l l
DIF: Cognitive Level: Understand (Comprehension) l l l
TOP:NursingP rocess:Diagnosis MSC: NCLEX: Safe and Effective Care Environment
l l l l l l l l l l
9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
l l l l l l l l l l l l
a. Instruct the patient about the need to alternate activityand rest.
l l l l l l l l l l
b. Monitor level of s hortness of breath or fatigue after ambulation.
l l l l l l l l l
c. Obtain the patient‗s blood pressure and pulse rate after ambulation.
l l l l l l l l l
d. Determine whether the patient is ready to increase the activity level. l l l l l l l l l l
ANS: C l
AP education includes accurate vitalsign measurement. Assessment and patient teaching requi re re
l l l l l l l l l bj l l l
gistered nurse education and scope of practice and cannot be delegated.
l l l l l l l l l l
DIF: Cognitive Level: Apply (Application)
l l l l l
TOP:Nursing Process:P lanning MSC: NCLEX: Safe and Effective Care Environment
l bj l l l l l l l l
l l l
Harding: Lewis’sMedical-Surgical Nursing, 12thEdition
l l bj l l
MULTIPLECHOICE l
1. The nurse completes an admission database and explains that the plan of care and discharge goals
l l l l l l l l l l l l l l l l
willbe developed with the patient‗s input. The patient asks, ―How is t his different fromwhat the p
l l l l l l l l l l l l l l l l l
hysician does?‖ Which response would the nurse provide?
l l l l l l l
a. ―Theroleo f the nurse is to a dminister medications and other treatments prescribed by y
l l l l l l l l l l l l l l
our physician.‖ l
b. ―Inaddition to caringf or y ouw hile you ares ick,t he nurses w illhelp you plant o maint
l l bj l l l l bj l l l l l l l l l
ain your health.‖ l l
c. ―Thenurse‗sjob ist o collect informationa ndc ommunicate a ny problems t hat occ
l l l l l l l l l l l l
ur to the physician.‖ l l l
d. ―Nursesperformmany of t hesame p rocedures as the physician,but nursesare with l l l l l l l l l l bj l l
the patients for a longer time than the physician.‖
l l l l l l l l l
ANS: B l
The American Nurses Association (ANA) definition of nursing describes the role of nurses in promoting h
l l l l l l l l l l l l l l l
ealth. The other responses describe dependent and collaborative functions of the nursing role but do not
l l l l l l l l l l l l l l l l
accurately describe the nurse‗s unique role in the health care system.
l l l l l l l l l l
DIF: CognitiveLevel:Analyze(Analysis) l l l
TOP: Nursing Process:Implementation bj l MSC: NCLEX:SafeandEffective CareEnvironment l l l l bj l
2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
l l l l l l l l l l l l
a. ―Patient care is based on clinical judgment, experience, and traditions.‖ l l l l l l l l l
b. ―Data areanalyzed later to show that the patient outcomes are consistently met.‖
l l l l l l l l l l l l
c. ―Research fromall published articles are used as a guide for planning patient care.‖ l l l l l l l l l l l l l
d. ―Recommendationsare based o n research,c linicalexpertise,a nd patient pre l l l l l l l l l
ferences.‖
ANS: D l
Evidence-based practice (EBP) is the use of the best research- l l l l l l l l l
based evidence combined with clinician expertise and consideration of patient preferences. Clinic
l l l l l l l l l l l
al judgment based on the nurse‗s clinical experience is part of EBP, but clinical decisi on making s
l l l l l l l l l l l l l l l l l
hould also incorporate current research and research-
l l l l l l
based guidelines. Evaluation of patient outcomes is important, but data analysis is not require
l l l l l l l l l l l l l
d to use EBP. All published articles do not provide research evidence; interventions should b
l l l l l l l l l l l l l l
ebased on credible research, preferably randomized controlled studies with a large number of subjects.
l l l l l l l l l l l l l l
DIF: Cognitive Level: Understand (Comprehension) l l l
TOP:Nursing Process:P lanning MSC: NCLEX: Safe and Effective Care Environment
l bj l l l l l l l l
3. Whichstatement by the nurse providesa clear explanation of the nursing process?
l l l l l l l l l l l l
a. ―Thenursing process is aresearch method o f diagnosing t he patient‗s health care prob
l l l l l l l l l l l l l
lems.‖
b. ―Thenursing process is used primarily to e xplain nursing interventions t o o ther heal
l l l l l l l l l l l l
th care professionals.‖ l l
c. ―The nursing process is a problem-solving tool used to identify a nd manage the
l l l l l l l l l l l l
, patients‗ health care needs.‖ l l l
d. ―Thenursing process is based on nursing t heory t hat incorporatest he bio
l l l l l l l l l l l
psychosocial nature of humans.‖ l l l
ANS: C l
The nursing process is a problem-
l l l l l
solving approach to the identification and treatment of patients‗ problems. Nursing process does n
l l l l l l l l l l l l l
ot require research methods for diagnosis. The primary use of the nursing process is in patient care, n
l l l l l l l l l l l l l l l l l
ot to establish nursing theory or explain nursing interventions to other health ca re professionals.
l l l l l l l l l l l l l l
DIF: Cognitive Level: Understand (Comprehension) l l l
TOP:NursingP rocess:Evaluation MSC: NCLEX: Safe and Effective Care Environment
l l l l l l l l l l
4. Apatientadmitted to the h ospitalf or s urgerytells the n urse,―I do n ot feelcomfortable leavi
l l l l l l l l l l bj l bj l l l
ng my children with my parents.‖ Which action would the nurse take next?
l l l l l l l l l l l l
a. Reassure the patient that these feelings are common for parents. l l l l l l l l l
b. Havethe patient call the children to ensure that they are doing well.
l bj l l l l l l l l l l
c. Gather information on the patient‗s concerns about the child care arrangements.
l l l l l l l l l l
d. Callthe patient‗s parents to determine whether adequate child care is being prov
l l l l l l l l l l l l
ided.
ANS: C l
Because a complete assessment is necessary in order to identify a problem and choose an ap propriate i
l l l l l l l l l l l l l l l l l
ntervention, the nurse‗s first action should be to obtain more information. The oth er actions may b
l l l l l l l l l l l l l l l l
e appropriate, but more assessment is needed before the best intervention can b e chosen.
l l l l l l l l l l l l l l
DIF: CognitiveLevel:Analyze (Analysis) l l l
TOP: Nursing Process:Assessment bj l MSC: NCLEX:P sychosocialIntegrity l l l
5. A patient with a bacterial infection is hypovolemic due t o a fever and excessive diaphoresis. Whic
l l l l l l l l l l l l l l l
h expected outcome would the nurse select for this patient?
l l l l l l l l l
a. Patient has a balanced intake and output. l l l l l l
b. Patient‗sbedding is kept clean and free of moisture. l l l l l l l l
c. Patient understands the need for increased fluid intake. l l l l l l l
d. Patient‗s skin remains cool and dry throughout hospitalization. l l l l l l l
ANS: A l
Balanced intake and output gives measurable data showing resolution of the problem of deficie nt flui
l l l l l l l l l l l l l l l
d volume. The other statements would not indicate that the problem of hypovolemia was resolved.
l l l l l l l l l l l l l l
DIF: Cognitive Level: Apply (Application) l l l
TOP:Nursing Process:P lanning MSC: NCLEX: Physiological Integrity l bj l l l l l
6. Which statement describes the purpose of the evaluation phase of the nursing process?
l l l l l l l l l l l l
a. Todocument the nursing care plan in the progress notes of the health record
l l l l l l l l l l l l l
b. To determine if interventions have been effective in meeting patient outcomes
l l l l l l l l l l
c. To decide whether the patient‗s health problems have been completely resolved
l l l l l l l l l l
d. Toestablish if the patient agrees that the nursing care provided was satisfactory
l l l l l l l l l l l l
ANS: B l
, Evaluation consists of determining whether the desired patient outcomes have been met and whethe
l l l l l l l l l l l l l
r the nursing interventions were appropriate. The other responses do not describe the evaluation pha
l l l l l l l l l l l l l l
se.
DIF: Cognitive Level: Understand (Comprehension)
l l l l l
TOP:NursingP rocess:Evaluation MSC: NCLEX: Safe and Effective Care Environment
l l l l l l l l l l
7. Which statement describes the purpose of the assessment phase of the nursing process?
l l l l l l l l l l l l
a. To teach interventions that relieve health problems
l l l l l l
b. Tousepatient data to evaluate patient care o utcomes
l l l l l l l l
c. Toobtain data to diagnose patient strengths and problems
l l l l l l l l
d. To help the patient identify realistic outcomes for health problems
l l l l l l l l l
ANS: C l
During the assessment phase, the nurse gathers information about the patient to diagnose patie nt stre
l l l l l l l l l l bj l l l l
ngths and problems. The other responses are examples of the planning, intervention, a nd evaluati
l l l l l l l l l l l l l l
on phases of the nursing process.
l l l l l
DIF: CognitiveLevel:Understand(Comprehension) l l l
TOP: Nursing Process:Assessment MSC: NCLEX:Safeand EffectiveCare Environment bj l l l l l l bj
8. When developing the plan of care, which components would the nurse include in the clinical proble
l l l l l l l l l l l l l l l
mstatement?
l
a. Theproblemand the suggested patient goals or outcomes
l l l l l l l l
b. Theproblem, its causes, and the signs and symptoms of t he problem
l l l l l l l l l l l
c. The problem with the possible etiology and the planned interventions
l l l l l l l l l
d. The problem, its pathophysiology, and the expected outcome
l l l l l l l
ANS: B l
When writing clinical problems or nursing diagnoses, the subjective as well as objective data to su
l l l l l l l l l l l l l l l
pport the problem‗s existence should be included. Goals, outcomes,and interventions are not include
l l l l l l l l l l l l l
d in the problem statement.
l l l l
DIF: Cognitive Level: Understand (Comprehension) l l l
TOP:NursingP rocess:Diagnosis MSC: NCLEX: Safe and Effective Care Environment
l l l l l l l l l l
9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
l l l l l l l l l l l l
a. Instruct the patient about the need to alternate activityand rest.
l l l l l l l l l l
b. Monitor level of s hortness of breath or fatigue after ambulation.
l l l l l l l l l
c. Obtain the patient‗s blood pressure and pulse rate after ambulation.
l l l l l l l l l
d. Determine whether the patient is ready to increase the activity level. l l l l l l l l l l
ANS: C l
AP education includes accurate vitalsign measurement. Assessment and patient teaching requi re re
l l l l l l l l l bj l l l
gistered nurse education and scope of practice and cannot be delegated.
l l l l l l l l l l
DIF: Cognitive Level: Apply (Application)
l l l l l
TOP:Nursing Process:P lanning MSC: NCLEX: Safe and Effective Care Environment
l bj l l l l l l l l
