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TEST BANK FOR Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume 12th Edition by Mariann M. Harding, Jeffrey Kwong, Debra Hagler & Courtney Reinisch , ISBN: 9780323789615 |Chapter 1-69| Guide A+

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Lewis Medical-Surgical Nursing: Assessment and Management of Clinical Problems 12th Edition By Harding & Kwong Test Bank Stuvia Is Available For Download After Purchase. In Case You Encounter Any Difficulties With The Download, Please Feel Free To Reach Out To Me. I Will Promptly Send It To You Through Google Doc or Email. Thank You. The Test Bank for Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems 12th Edition by Harding & Kwong is your go-to study aid. This resource offers a robust selection of practice questions tailored to mirror exam challenges, enhancing your understanding of Medical-Surgical Nursing. With insights from Harding Medical-Surgical Nursing and Kwong Nursing Test Bank, you'll gain a comprehensive grasp of clinical problems. The Clinical Problems Test Bank provides targeted practice to strengthen your exam readiness. Dive into the Lewis’s Medical-Surgical Nursing materials to reinforce your knowledge. The Nursing Assessment Study Guide sections are particularly useful for mastering key concepts. This test bank supports you through Harding Clinical Management techniques and Kwong Medical-Surgical Essentials, helping you excel in your studies with confidence. 1. 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 asks, “How is this different from what the physician does?” Which response would the nurse provide? a. “The role of the nurse is to administer medications and other treatments prescribed by your physician.” b. “In addition to caring for you while you are sick, the nurses will help you plan to maintain your health.” c. “The nurse‘s job is to collect information and communicate any problems that occur to the physician.” d. “Nurses perform many of the same procedures as the physician, but nurses are with the patients for a longer time than the physician.” ANS: B The American Nurses Association (ANA) definition of nursing describes the role of nurses in promoting health. The other responses describe dependent and collaborative functions of the nursing role but do not accurately describe the nurse‘s unique role in the health care system. DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)? a. “Patient care is based on clinical judgment, experience, and traditions.” b. “Data are analyzed later to show that the patient outcomes are consistently met.” c. “Research from all published articles are used as a guide for planning patient care.” d. “Recommendations are based on research, clinical expertise, and patient preferences.” ANS: D Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician expertise and consideration of patient preferences. Clinical judgment based on the nurse‘s clinical experience is part of EBP, but clinical decision making should also incorporate current research and research-based guidelines. Evaluation of patient outcomes is important, but data analysis is not required to use EBP. All published articles do not provide research evidence; interventions should be based on credible research, preferably randomized controlled studies with a large number of subjects. DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 3. Which statement by the nurse provides a clear explanation of the nursing process? a. “The nursing process is a research method of diagnosing the patient‘s health care problems.” b. “The nursing process is used primarily to explain nursing interventions to other health care professionals.” c. “The nursing process is a problem-solving tool used to identify and manage the patients‘ health care needs.” d. “The nursing process is based on nursing theory that incorporates the biopsychosocial nature of humans.” ANS: C The nursing process is a problem-solving approach to the identification and treatment of patients‘ problems. Nursing process does not require research methods for diagnosis. The primary use of the nursing process is in patient care, not to establish nursing theory or explain nursing interventions to other health care professionals. DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 4. A patient admitted to the hospital for surgery tells the nurse, “I do not feel comfortable leaving my children with my parents.” Which action would the nurse take next? a. Reassure the patient that these feelings are common for parents. b. Have the patient call the children to ensure that they are doing well. c. Gather information on the patient‘s concerns about the child care arrangements. d. Call the patient‘s parents to determine whether adequate child care is being provided. ANS: C Because a complete assessment is necessary in order to identify a problem and choose an appropriate intervention, the nurse‘s first action should be to obtain more information. The other actions may be appropriate, but more assessment is needed before the best intervention can be chosen. DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis. Which expected outcome would the nurse select for this patient? a. Patient has a balanced intake and output. b. Patient‘s bedding is kept clean and free of moisture. c. Patient understands the need for increased fluid intake. d. Patient‘s skin remains cool and dry throughout hospitalization. ANS: A Balanced intake and output gives measurable data showing resolution of the problem of deficient fluid volume. The other statements would not indicate that the problem of hypovolemia was resolved. DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 6. Which statement describes the purpose of the evaluation phase of the nursing process? a. To document the nursing care plan in the progress notes of the health record b. To determine if interventions have been effective in meeting patient outcomes c. To decide whether the patient‘s health problems have been completely resolved d. To establish if the patient agrees that the nursing care provided was satisfactory ANS: B 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 the evaluation phase. DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 7. Which statement describes 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 to diagnose patient strengths and 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 diagnose patient strengths and problems. The other responses are examples of the planning, intervention, and evaluation phases of the nursing process. DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 8. When developing the plan of care, which components would the nurse include in the clinical problem statement? a. The problem and the suggested patient goals or outcomes b. The problem, its causes, and the signs and symptoms of the problem c. The problem with the possible etiology and the planned interventions d. The problem, its pathophysiology, and the expected outcome ANS: B When writing clinical problems or nursing diagnoses, the subjective as well as objective data to support the problem‘s existence should be included. Goals, outcomes, and interventions are not included in the problem statement. DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)? a. Instruct the patient about the need to alternate activity and rest. b. Monitor level of shortness of breath or fatigue after ambulation. 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 AP education includes accurate vital sign measurement. Assessment and patient teaching require registered nurse education and scope of practice and cannot be delegated. DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 10. A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one assistive personnel (AP), and one licensed practical/vocational nurse (LPN/VN). Which assignment, if delegated by the nurse, would be outside that individual‘s scope of practice? a. Check for the presence of bowel sounds by AP b. Administration of oral medications by LPN/VN c. Insulin administration by float RN from the pediatric unit d. Measurement of a patient‘s urinary catheter output by AP ANS: A Assessment requires RN education and scope of practice so it cannot be delegated to an LPN/VN or AP. The other assignments made by the RN are appropriate for the role of the team member. DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 11. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/VN)? a. Complete the initial admission assessment and plan of care. b. Measure bedside blood glucose before administering insulin. c. Document teaching completed before a diagnostic procedure. d. Instruct a patient about low-fat, reduced sodium dietary restrictions. ANS: B The education and scope of practice of the LPN/LVN include activities such as obtaining glucose testing using a finger stick and administering insulin. Patient teaching and the initial assessment and development of the plan of care are nursing actions that require registered nurse education and scope of practice. DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 12. A nurse is assigned as a case manager for a hospitalized patient who has a spinal cord injury. Which activity can the patient expect the nurse in this role to perform? a. Care for the patient during hospitalization for the injuries. b. Assist the patient with home care activities during recovery. c. Coordinate the services the patient receives in the hospital and at home. d. Determine what medical care the patient needs for optimal rehabilitation. ANS: C The role of the case manager is to coordinate the patient‘s care through multiple settings and levels of care to allow the maximal patient benefit at the least cost. The case manager does not provide direct care in the acute or home setting. The case manager coordinates and advocates for care. The HCP determines what medical care is needed. DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 13. The nurse is caring for an older adult patient who needs continued nursing care and physical therapy to improve mobility after surgery to repair a fractured hip. The nurse would help to arrange for transfer of the patient to which type of facility? a. A skilled care facility b. A transitional care facility c. A residential care facility d. An intermediate care facility ANS: B Transitional care settings are appropriate for patients who need continued rehabilitation before discharge to home or to long-term care settings. The patient is no longer in need of the more continuous assessment and care given in acute care settings. There is no indication that the patient will need the permanent and ongoing medical and nursing services available in intermediate or skilled care. The patient is not yet independent enough to transfer to a residential care facility.

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,Chapter 01: Professional Nursing
ki ki ki




Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
ki ki ki ki ki




MULTIPLE CHOICE ki




1. The nurse completes an admission database and explains that the plan of care and discharge
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



goals will be developed with the patient‗s input. The patient asks, ―How is this different from
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



what the physician does?‖ Which response would the nurse provide?
ki ki ki ki ki ki ki ki ki ki



a. ―The role of the nurse is to administer medications and other treatments prescribed by
ki ki ki ki ki ki ki ki ki ki ki ki ki



your physician.‖
ki ki



b. ―In addition to caring for you while you are sick, the nurses will help you plan to
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



maintain your health.‖
ki ki ki



c. ―The nurse‗s job is to collect information and communicate anyproblems that
ki ki ki ki ki ki ki ki ki ki ki



occur to the physician.‖
ki ki ki ki



d. ―Nurses perform many of the same procedures as the physician, but nurses are
ki ki ki ki ki ki ki ki ki ki ki ki



with the patients for a longer time than the physician.‖
ki ki ki ki ki ki ki ki ki ki




ANS: B ki



The American Nurses Association (ANA) definition of nursing describes the role of nurses in
ki ki ki ki ki ki ki ki ki ki ki ki ki



promoting health. The other responses describe dependent and collaborative functions of the
ki ki ki ki ki ki ki ki ki ki ki ki



nursing role but do not accurately describe the nurse‗s unique role in the health care system.
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki




DIF: k i Cognitive Level: Analyze (Analysis)
k i ki ki ki



TOP: k i Nursing Process: Implementation ki ki k i k i k i MSC: NCLEX: Safe and Effective Care Environmentk i ki ki ki ki ki




2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
ki ki ki ki ki ki ki ki ki ki ki ki



a. ―Patient care is based on clinical judgment, experience, and traditions.‖
ki ki ki ki ki ki ki ki ki



b. ―Data are analyzed later to show that the patient outcomes are consistently met.‖
ki ki ki ki ki ki ki ki ki ki ki ki



c. ―Research from all published articles are used as a guide for planning patient care.‖
ki ki ki ki ki ki ki ki ki ki ki ki ki



d. ―Recommendations are based on research, clinical expertise, and patient ki ki ki ki ki ki ki ki



preferences.‖
ki




ANS: D ki



Evidence-based practice (EBP) is the use of the best research-based evidence combined with ki ki ki ki ki ki ki ki ki ki ki ki



clinician expertise and consideration of patient preferences. Clinical judgment based on the
ki ki ki ki ki ki ki ki ki ki ki ki



nurse‗s clinical experience is part of EBP, but clinical decision making should also
ki ki ki ki ki ki ki ki ki ki ki ki ki



incorporate current research and research-based guidelines. Evaluation of patient outcomes is
ki ki ki ki ki ki ki ki ki ki ki



important, but data analysis is not required to use EBP. All published articles do not provide
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



research evidence; interventions should be based on credible research, preferably randomized
ki ki ki ki ki ki ki ki ki ki ki



controlled studies with a large number of subjects.
ki ki ki ki ki ki ki ki




DIF: Cognitive Level: Understand (Comprehension) ki ki ki TOP: Nursing Process: Planning ki ki ki



MSC: NCLEX: Safe and Effective Care Environment
ki k i ki ki ki ki ki




3. Which statement by the nurse provides a clear explanation of the nursing process?
ki ki ki ki ki ki ki ki ki ki ki ki



a. ―The nursing process is a research method of diagnosing the patient‗s health care
ki ki ki ki ki ki ki ki ki ki ki ki



problems.‖
ki



b. ―The nursing process is used primarily to explain nursing interventions to other
ki ki ki ki ki ki ki ki ki ki ki



health care professionals.‖
ki ki ki



c. ―The nursing process is a problem-solving tool used to identify and manage the
ki ki ki ki ki ki ki ki ki ki ki ki

, patients‗ health care needs.‖ ki ki ki



d. ―The nursing process is based on nursing theorythat incorporates the
ki ki ki ki ki ki ki ki ki ki



biopsychosocial nature of humans.‖
ki ki ki ki




ANS: C ki



The nursing process is a problem-solving approach to the identification and treatment of
ki ki ki ki ki ki ki ki ki ki ki ki



patients‗ problems. Nursing process does not require research methods for diagnosis. The
ki ki ki ki ki ki ki ki ki ki ki ki



primary use of the nursing process is in patient care, not to establish nursing theory or explain
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



nursing interventions to other health care professionals.
ki ki ki ki ki ki ki




DIF: Cognitive Level: Understand (Comprehension) ki ki ki TOP: Nursing Process: Evaluation ki ki ki



MSC: NCLEX: Safe and Effective Care Environment
ki k i ki ki ki ki ki




4. A patient admitted to the hospital for surgery tells the nurse, ―I do not feel comfortable
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



leaving my children with my parents.‖ Which action would the nurse take next?
ki ki ki ki ki ki ki ki ki ki ki ki ki



a. Reassure the patient that these feelings are common for parents. ki ki ki ki ki ki ki ki ki



b. Have the patient call the children to ensure that they are doing well.
ki ki ki ki ki ki ki ki ki ki ki ki



c. Gather information on the patient‗s concerns about the child care arrangements.
ki ki ki ki ki ki ki ki ki ki



d. Call the patient‗s parents to determine whether adequate child care is being
ki ki ki ki ki ki ki ki ki ki ki



provided.
ki




ANS: C ki



Because a complete assessment is necessary in order to identify a problem and choose an
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



appropriate intervention, the nurse‗s first action should be to obtain more information. The
ki ki ki ki ki ki ki ki ki ki ki ki ki



other actions may be appropriate, but more assessment is needed before the best intervention
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



can be chosen.
ki ki ki




DIF: Cognitive Level: Analyze (Analysis) ki ki ki



TOP: Nursing Process: Assessment
k i MSC: NCLEX: Psychosocial Integrity ki ki k i ki ki




5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis.
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



Which expected outcome would the nurse select for this patient?
ki ki ki ki ki ki ki ki ki ki



a. Patient has a balanced intake and output. ki ki ki ki ki ki



b. Patient‗s bedding is kept clean and free of moisture. ki ki ki ki ki ki ki ki



c. Patient understands the need for increased fluid intake.
ki ki ki ki ki ki ki



d. Patient‗s skin remains cool and dry throughout hospitalization. ki ki ki ki ki ki ki




ANS: A ki



Balanced intake and output gives measurable data showing resolution of the problem of
ki ki ki ki ki ki ki ki ki ki ki ki



deficient fluid volume. The other statements would not indicate that the problem of
ki ki ki ki ki ki ki ki ki ki ki ki ki



hypovolemia was resolved.
ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki TOP: Nursing Process: Planning ki ki ki



MSC: NCLEX: Physiological Integrity
ki k i ki ki




6. Which statement describes the purpose of the evaluation phase of the nursing process?
ki ki ki ki ki ki ki ki ki ki ki ki



a. To document the nursing care plan in the progress notes of the health record
ki ki ki ki ki ki ki ki ki ki ki ki ki



b. To determine if interventions have been effective in meeting patient outcomes
ki ki ki ki ki ki ki ki ki ki



c. To decide whether the patient‗s health problems have been completely resolved
ki ki ki ki ki ki ki ki ki ki



d. To establish if the patient agrees that the nursing care provided was satisfactory
ki ki ki ki ki ki ki ki ki ki ki ki




ANS: B ki

, Evaluation consists of determining whether the desired patient outcomes have been met and
ki ki ki ki ki ki ki ki ki ki ki ki



whether the nursing interventions were appropriate. The other responses do not describe the
ki ki ki ki ki ki ki ki ki ki ki ki ki



evaluation phase.
ki ki




DIF: Cognitive Level: Understand (Comprehension)
k i ki ki ki TOP: Nursing Process: Evaluation
ki ki ki



MSC: NCLEX: Safe and Effective Care Environment
ki k i ki ki ki ki ki




7. Which statement describes the purpose of the assessment phase of the nursing process?
ki ki ki ki ki ki ki ki ki ki ki ki



a. To teach interventions that relieve health problems
ki ki ki ki ki ki



b. To use patient data to evaluate patient care outcomes
ki ki ki ki ki ki ki ki



c. To obtain data to diagnose patient strengths and problems
ki ki ki ki ki ki ki ki



d. To help the patient identify realistic outcomes for health problems
ki ki ki ki ki ki ki ki ki




ANS: C ki



During the assessment phase, the nurse gathers information about the patient to diagnose
ki ki ki ki ki ki ki ki ki ki ki ki



patient strengths and problems. The other responses are examples of the planning,
ki ki ki ki ki ki ki ki ki ki ki ki



intervention, and evaluation phases of the nursing process.
ki ki ki ki ki ki ki ki




DIF: Cognitive Level: Understand (Comprehension) ki ki ki



TOP: Nursing Process: Assessment
k i MSC: NCLEX: Safe and Effective Care Environment
ki ki k i ki ki ki ki ki




8. When developing the plan of care, which components would the nurse include in the clinical
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



problem statement?
ki ki



a. The problem and the suggested patient goals or outcomes
ki ki ki ki ki ki ki ki



b. The problem, its causes, and the signs and symptoms of the problem
ki ki ki ki ki ki ki ki ki ki ki



c. The problem with the possible etiology and the planned interventions
ki ki ki ki ki ki ki ki ki



d. The problem, its pathophysiology, and the expected outcome
ki ki ki ki ki ki ki




ANS: B ki



When writing clinical problems or nursing diagnoses, the subjective as well as objective data
ki ki ki ki ki ki ki ki ki ki ki ki ki



to support the problem‗s existence should be included. Goals, outcomes, and interventions are
ki ki ki ki ki ki ki ki ki ki ki ki ki



not included in the problem statement.
ki ki ki ki ki ki




DIF: Cognitive Level: Understand (Comprehension) ki ki ki TOP: Nursing Process: Diagnosis
ki ki ki



MSC: NCLEX: Safe and Effective Care Environment
ki k i ki ki ki ki ki




9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
ki ki ki ki ki ki ki ki ki ki ki ki



a. Instruct the patient about the need to alternate activity and rest.
ki ki ki ki ki ki ki ki ki ki



b. Monitor level of shortness of breath or fatigue after ambulation.
ki ki ki ki ki ki ki ki ki



c. Obtain the patient‗s blood pressure and pulse rate after ambulation.
ki ki ki ki ki ki ki ki ki



d. Determine whether the patient is ready to increase the activity level. ki ki ki ki ki ki ki ki ki ki




ANS: C ki



AP education includes accurate vital sign measurement. Assessment and patient teaching
ki ki ki ki ki ki ki ki ki ki



require registered nurse education and scope of practice and cannot be delegated.
ki ki ki ki ki ki ki ki ki ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki TOP: Nursing Process: Planningki ki ki



MSC: NCLEX: Safe and Effective Care Environment
ki k i ki ki ki ki ki

,10. A nurse is caring for a group of patients on the medical-surgical unit with the help of one float
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



registered nurse (RN), one assistive personnel (AP), and one licensed practical/vocational
ki ki ki ki ki ki ki ki ki ki ki



nurse (LPN/VN). Which assignment, if delegated by the nurse, would be outside that
ki ki ki ki ki ki ki ki ki ki ki ki ki



individual‗s scope of practice?
ki ki ki ki



a. Check for the presence of bowel sounds by AP ki ki ki ki ki ki ki ki



b. Administration of oral medications by LPN/VN ki ki ki ki ki



c. Insulin administration by float RN from the pediatric unit ki ki ki ki ki ki ki ki



d. Measurement of a patient‗s urinary catheter output by AP ki ki ki ki ki ki ki ki




ANS: A ki



Assessment requires RN education and scope of practice so it cannot be delegated to an
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



LPN/VN or AP. The other assignments made by the RN are appropriate for the role of the team
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



member.
ki




DIF: Cognitive Level: Apply (Application) ki ki ki TOP: Nursing Process: Planning ki ki ki



MSC: NCLEX: Safe and Effective Care Environment
ki k i ki ki ki ki ki




11. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse
ki ki ki ki ki ki ki ki ki ki ki ki ki



(LPN/VN)?
ki



a. Complete the initial admission assessment and plan of care. ki ki ki ki ki ki ki ki



b. Measure bedside blood glucose before administering insulin. ki ki ki ki ki ki



c. Document teaching completed before a diagnostic procedure. ki ki ki ki ki ki



d. Instruct a patient about low-fat, reduced sodium dietary restrictions.
ki ki ki ki ki ki ki ki




ANS: B ki



The education and scope of practice of the LPN/LVN include activities such as obtaining
ki ki ki ki ki ki ki ki ki ki ki ki ki



glucose testing using a finger stick and administering insulin. Patient teaching and the initial
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



assessment and development of the plan of care are nursing actions that require registered
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



nurse education and scope of practice.
ki ki ki ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki TOP: Nursing Process: Planning ki ki ki



MSC: NCLEX: Safe and Effective Care Environment
ki k i ki ki ki ki ki




12. A nurse is assigned as a case manager for a hospitalized patient who has a spinal cord injury.
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



Which activity can the patient expect the nurse in this role to perform?
ki ki ki ki ki ki ki ki ki ki ki ki ki



a. Care for the patient during hospitalization for the injuries.
ki ki ki ki ki ki ki ki



b. Assist the patient with home care activities during recovery.
ki ki ki ki ki ki ki ki



c. Coordinate the services the patient receives in the hospital and at home. ki ki ki ki ki ki ki ki ki ki ki



d. Determine what medical care the patient needs for optimal rehabilitation. ki ki ki ki ki ki ki ki ki




ANS: C ki



The role of the case manager is to coordinate the patient‗s care through multiple settings and
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



levels of care to allow the maximal patient benefit at the least cost. The case manager does not
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



provide direct care in the acute or home setting. The case manager coordinates and advocates
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



for care. The HCP determines what medical care is needed.
ki ki ki ki ki ki ki ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki



TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
k i ki ki k i ki ki ki ki ki




13. The nurse is caring for an older adult patient who needs continued nursing care and physical
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



therapy to improve mobility after surgery to repair a fractured hip. The nurse would help
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



to arrange for transfer of the patient to which type of facility?
ki ki ki ki ki ki ki ki ki ki ki ki

, a. A skilled care facility
ki ki ki



b. A transitional care facility
ki ki ki



c. A residential care facility
ki ki ki



d. An intermediate care facility
ki ki ki




ANS: B ki



Transitional care settings are appropriate for patients who need continued rehabilitation before
ki ki ki ki ki ki ki ki ki ki ki



discharge to home or to long-term care settings. The patient is no longer in need of the more
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



continuous assessment and care given in acute care settings. There is no indication that the
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



patient will need the permanent and ongoing medical and nursing services available in
ki ki ki ki ki ki ki ki ki ki ki ki ki



intermediate or skilled care. The patient is not yet independent enough to transfer to a
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



residential care facility.
ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki TOP: Nursing Process: Planning ki ki ki



MSC: NCLEX: Safe and Effective Care Environment
ki k i ki ki ki ki ki




14. A home care nurse is planning care for a patient who has just been diagnosed with type 2
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



diabetes. Which task is appropriate for the nurse to delegate to the home health aide?
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



a. Assist the patient to choose appropriate foods. ki ki ki ki ki ki



b. Help the patient with a daily bath and oral care.
ki ki ki ki ki ki ki ki ki



c. Check the patient‗s feet for signs of breakdown. ki ki ki ki ki ki ki



d. Teach the patient how to monitor blood glucose. ki ki ki ki ki ki ki




ANS: B ki



Assisting with patient hygiene is included in home health-aide education and scope of
ki ki ki ki ki ki ki ki ki ki ki ki



practice. Assessment of the patient and instructing the patient in new skills, such as diet and
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



blood glucose monitoring, are complex skills that are included in registered nurse education
ki ki ki ki ki ki ki ki ki ki ki ki ki



and scope of practice.
ki ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki



TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
k i ki ki k i ki ki ki ki ki




15. The nurse is providing education to nursing staff on quality care initiatives. Which statement
ki ki ki ki ki ki ki ki ki ki ki ki ki



is an accurate description of the impact of health care financing on quality care?
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



a. ―If a patient develops a catheter-related infection, the hospital receives additional
ki ki ki ki ki ki ki ki ki ki



funding.‖ ki



b. ―Payment for patient care is primarilybased on clinical outcomes and patient ki ki ki ki ki ki ki ki ki ki ki



satisfaction.‖
ki



c. ―Hospitals are reimbursed for all costs incurred if care is documented ki ki ki ki ki ki ki ki ki ki



electronically.‖
ki



d. ―Because hospitals are accountable for overall care, it is not nursing‗s ki ki ki ki ki ki ki ki ki ki



responsibility to monitor care delivered by others.‖
ki ki ki ki ki ki ki




ANS: B ki



Payment for health care services programs reimburses hospitals for their performance on
ki ki ki ki ki ki ki ki ki ki ki



overall quality-of-care measures. These measures include clinical outcomes and patient
ki ki ki ki ki ki ki ki ki ki



satisfaction. Nurses are responsible for coordinating complex aspects of patient care,
ki ki ki ki ki ki ki ki ki ki ki



including the care delivered by others, and identifying issues that are associated with poor
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



quality care. Payment for care can be withheld if something happens to the patient that is
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



considered preventable (e.g., acquiring a catheter-related urinary tract infection).
ki ki ki ki ki ki ki ki ki

, DIF: Cognitive Level: Apply (Application) ki ki ki



TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
k i ki ki k i ki ki ki ki ki




16. The nurse documenting the patient‗s progress in the electronic health record is demonstrating
ki ki ki ki ki ki ki ki ki ki ki ki



ki competency in which area? ki ki ki



a. Patient-centered care ki



b. Evidence-based practice ki



c. Quality improvement ki



d. Informatics and technology ki ki




ANS: D ki



The nurse is displaying competency in informatics and technology. Using a computerized
ki ki ki ki ki ki ki ki ki ki ki



information system to document patient needs and progress and communicate vital
ki ki ki ki ki ki ki ki ki ki ki



information about the patient with the interprofessional care team members provides evidence
ki ki ki ki ki ki ki ki ki ki ki ki



that nursing practice standards related to the nursing process have been maintained during the
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



care of the patient.
ki ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki



TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
k i ki ki k i ki ki ki ki ki




MULTIPLE RESPONSE ki




1. Which information will the nurse consider when deciding what nursing actions to delegate to a
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



licensed practical/vocational nurse (LPN/VN) who is working on a medical-surgical unit?
ki ki ki ki ki ki ki ki ki ki ki



(Select all that apply.)
ki ki ki ki



a. Agency policies ki



b. Stability of the patients ki ki ki



c. State nurse practice act ki ki ki



d. LPN/VN teaching abilities ki ki



e. Experience of the LPN/VN ki ki ki




ANS: A, B, C, E ki ki ki ki



The nurse should assess the experience of LPN/VNs when delegating. In addition, state nurse
ki ki ki ki ki ki ki ki ki ki ki ki ki



practice acts and agency policies must be considered. In general, while the LPN/VN scope of
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



practice includes caring for patients who are stable, registered nurses should provide most of
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



the care for unstable patients. Because the LPN/VN scope of practice does not include patient
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



education, this will not be part of the delegation process.
ki ki ki ki ki ki ki ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki TOP: Nursing Process: Planningki ki ki



MSC: NCLEX: Safe and Effective Care Environment
ki k i ki ki ki ki ki




2. Which actions by the nurse administering medications are consistent with promoting safe
ki ki ki ki ki ki ki ki ki ki ki



delivery of patient care? (Select all that apply.)
ki ki ki ki ki ki ki ki



a. Discards a medication that is not labeled. ki ki ki ki ki ki



b. Uses hand sanitizer before preparing a medication.
ki ki ki ki ki ki



c. Identifies the patient by the room number on the door. ki ki ki ki ki ki ki ki ki



d. Checks laboratory test results before administering a diuretic.
ki ki ki ki ki ki ki



e. Gives the patient a list of current medications upon discharge.
ki ki ki ki ki ki ki ki ki




ANS: A, B, D, E ki ki ki ki

, National Patient Safety Goals have been established to promote safe delivery of care. The
ki ki ki ki ki ki ki ki ki ki ki ki ki



nurse should use at least 2 reliable ways to identify the patient such as asking the patient‗s full
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



name and date of birth before medication administration. Other actions that improve patient
ki ki ki ki ki ki ki ki ki ki ki ki ki



safety include performing hand hygiene, disposing of unlabeled medications, completing
ki ki ki ki ki ki ki ki ki ki



appropriate assessments before administering medications, and giving a list of the current
ki ki ki ki ki ki ki ki ki ki ki ki



medicines to the patient and caregiver before discharge.
ki ki ki ki ki ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki



TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
k i ki ki k i ki ki ki ki ki




3. Which actions by a nurse would demonstrate an aspect of nursing clinical judgment? (Select
ki ki ki ki ki ki ki ki ki ki ki ki ki



ki all that apply.)
ki ki



a. Identifying priority problems ki ki



b. Noticing a change in patient status ki ki ki ki ki



c. Memorizing the steps of a procedure ki ki ki ki ki



d. Assessing data about a patient situation ki ki ki ki ki



e. Generating possible solutions to a patient problem ki ki ki ki ki ki



f. Making decisions based on the implications of a patient‗s situation
ki ki ki ki ki ki ki ki ki




ANS: A, B, D, E, Fki ki ki ki ki



Clinical judgment is evident when the nurse assesses data or situations, notices a change in a
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



patient‗s status, identifies priority problems, generates the best possible solutions, and makes
ki ki ki ki ki ki ki ki ki ki ki ki



decisions about patient care based on analysis of the situation. Clinical judgment is not
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



memorizing a list of facts or the steps of a procedure.
ki ki ki ki ki ki ki ki ki ki ki




DIF: Cognitive Level: Understand (Comprehension) ki ki ki



TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
k i ki ki k i ki ki ki ki ki




Chapter 02: Social Determinants of Health
ki ki ki ki ki



Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
ki ki ki ki ki




MULTIPLE CHOICE ki




1. Which data from the patient‗s health history would be the nurse‗s focus for patient teaching?
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



a. Family history ki



b. Age and gender ki ki



c. Dietary fat intake ki ki



d. Race and ethnicity ki ki




ANS: C ki



Behaviors are strongly linked to many health care problems. The patient‗s fat intake is a
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



behavior that the patient can change. The other information will be useful as the nurse
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



develops an individualized plan for improving the patient‗s health but will not be the focus of
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



patient teaching for behavior change.
ki ki ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki TOP: Nursing Process: Planning ki ki ki



MSC: NCLEX: Health Promotion and Maintenance
ki k i ki ki ki ki

,2. The nurse works in a clinic located in a community where many of the residents are Hispanic.
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



Which strategy, if implemented by the nurse, would decrease health care disparities and
ki ki ki ki ki ki ki ki ki ki ki ki ki



promote health equity for this community?
ki ki ki ki ki ki



a. Improve public transportation to the clinic. ki ki ki ki ki



b. Update equipment and supplies at the clinic. ki ki ki ki ki ki



c. Teach clinic staff about cultural health beliefs.ki ki ki ki ki ki



d. Obtain low-cost medications for clinic patients. ki ki ki ki ki




ANS: C ki



Health care disparities are caused by stereotyping, biases, and prejudice of health care
ki ki ki ki ki ki ki ki ki ki ki ki



providers. The nurse can decrease these through staff education. The other strategies may also
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



be addressed by the nurse but will not directly impact health disparities.
ki ki ki ki ki ki ki ki ki ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki TOP: Nursing Process: Planning ki ki ki



MSC: NCLEX: Health Promotion and Maintenance
ki k i ki ki ki ki




3. Which information would the nurse collect as a measure of community health?
ki ki ki ki ki ki ki ki ki ki ki



a. Air pollution levels ki ki



b. Number of healthy food stores ki ki ki ki



c. Most common causes of death ki ki ki ki



d. Education level of the individuals ki ki ki ki




ANS: C ki



Health status measures of a community include birth and death rates, life expectancy, access
ki ki ki ki ki ki ki ki ki ki ki ki ki



to care, and morbidity and mortality rates related to disease and injury. Although air pollution,
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



access to health food stores, and education level are factors that affect a community‗s health
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



status, they are not health measures.
ki ki ki ki ki ki




DIF: Cognitive Level: Understand (Comprehension) ki ki ki



TOP: Nursing Process: Assessment
k i MSC: NCLEX: Health Promotion and Maintenance ki ki k i ki ki ki ki




4. The nurse is caring for a patient who has traditional Native American beliefs about health and
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



illness. Which action by the nurse would demonstrate cultural competence?
ki ki ki ki ki ki ki ki ki ki



a. Explain the hospital schedule for meal times, care, and family visits.
ki ki ki ki ki ki ki ki ki ki



b. Ask the patient whether it is important that a cultural healer is contacted.
ki ki ki ki ki ki ki ki ki ki ki ki



c. Avoid asking health questions unless the patient initiates the conversation.
ki ki ki ki ki ki ki ki ki



d. Obtain information about the patient‗s cultural beliefs from a family member.
ki ki ki ki ki ki ki ki ki ki




ANS: B ki



Because the patient has traditional health care beliefs, it is appropriate for the nurse to ask
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



whether the patient would like a visit by cultural healer. There is no cultural reason for the
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



nurse to avoid asking the patient questions because these questions are necessary to obtain
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



health information. The patient (rather than the family) should be consulted first about
ki ki ki ki ki ki ki ki ki ki ki ki ki



personal cultural beliefs. The hospital routines for meals, care, and visits should be adapted to
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



the patient‗s preferences rather than expecting the patient to adapt to the hospital schedule.
ki ki ki ki ki ki ki ki ki ki ki ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki



TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
k i ki ki k i ki ki




5. The nurse is caring for a patient being admitted to the hospital who is Asian. Which action
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



would be respectful for the nurse to take when interviewing this patient?
ki ki ki ki ki ki ki ki ki ki ki ki



a. Avoid any eye contact with the patient. ki ki ki ki ki ki

, b. Look directly at the patient when interacting. ki ki ki ki ki ki



c. Observe and follow the patient‗s use of eye contact. ki ki ki ki ki ki ki ki



d. Ask a family member about the patient‗s cultural beliefs.
ki ki ki ki ki ki ki ki




ANS: C ki



Observation of the patient‗s use of eye contact will be most useful in determining the best way
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



to communicate effectively with the patient. Looking directly at the patient or avoiding eye
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



contact may be appropriate, depending on the patient‗s individual cultural beliefs. The nurse
ki ki ki ki ki ki ki ki ki ki ki ki ki



should assess the patient, rather than asking family members about the patient‗s beliefs.
ki ki ki ki ki ki ki ki ki ki ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki



TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
k i ki ki k i ki ki




6. The nurse is caring for a patient who speaks a different language. If an interpreter or
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



interpretation phone service is not available, which action would the nurse take?
ki ki ki ki ki ki ki ki ki ki ki ki



a. Talk slowly so that each word is clearly heard.
ki ki ki ki ki ki ki ki



b. Use gestures or pictures to demonstrate meaning.
ki ki ki ki ki ki



c. Speak loudly in close proximity to the patient‗s ears. ki ki ki ki ki ki ki ki



d. Repeat important words so that the patient will recognize them. ki ki ki ki ki ki ki ki ki




ANS: B ki



The use of gestures or pictures will enable some information to be communicated to the patient.
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



The other actions will not improve communication with the patient.
ki ki ki ki ki ki ki ki ki ki




DIF: Cognitive Level: Understand (Comprehension) ki ki ki



TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
k i ki ki k i ki ki




7. Which action would the nurse include in the plan of care for a hospitalized patient who uses
ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki ki



ki culturally based treatments? ki ki



a. Encourage the use of additional diagnostic procedures. ki ki ki ki ki ki



b. Teach the patient that folk remedies will interfere with prescribed orders.
ki ki ki ki ki ki ki ki ki ki



c. Ask the patient to discontinue the cultural treatments during hospitalization.
ki ki ki ki ki ki ki ki ki



d. Coordinate the use of requested treatments with prescribed medical therapies. ki ki ki ki ki ki ki ki ki




ANS: D ki



Many culturally based therapies can be accommodated along with the use of Western
ki ki ki ki ki ki ki ki ki ki ki ki



treatments and medications. The nurse should attempt to use both traditional folk treatments
ki ki ki ki ki ki ki ki ki ki ki ki ki



and the ordered Western therapies when possible. Some culturally based treatments can be
ki ki ki ki ki ki ki ki ki ki ki ki ki



effective in treating ―Western‖ diseases. Not all folk remedies interfere with Western
ki ki ki ki ki ki ki ki ki ki ki ki



therapies. It may be appropriate for the patient to continue some culturally based treatments
ki ki ki ki ki ki ki ki ki ki ki ki ki ki



while he or she is hospitalized.
ki ki ki ki ki ki




DIF: Cognitive Level: Apply (Application) ki ki ki TOP: Nursing Process: Planning ki ki ki



MSC: NCLEX: Psychosocial Integrity
ki k i ki ki




8. The nurse is caring for a newly admitted patient. Which intervention is considered appropriate
ki ki ki ki ki ki ki ki ki ki ki ki ki



across most cultures?
ki ki ki



a. Maintain a personal space of at least 2 ft when assessing the patient. ki ki ki ki ki ki ki ki ki ki ki ki



b. Insist that family members provide most of the patient‗s personal care.
ki ki ki ki ki ki ki ki ki ki



c. Ask permission before touching a patient during the physical assessment.
ki ki ki ki ki ki ki ki ki



d. Consider the patient‗s ethnicity as the most important factor in planning care. ki ki ki ki ki ki ki ki ki ki ki

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