,Chapter 01: Professional Nursing Practice
x x x x
Ignatavicius Medical-Surgical Nursing, 10th
x x x x
Edition
x x
MULTIPLE xCHOICE
1. The xnurse xcompletes xan xadmission xdatabase xand xexplains xthat xthe xplan xof xcare xand
xdischarge xgoals xwill xbe xdeveloped xwith xthe xpatient’s xinput. xThe xpatient xstates, x“How xis
xthis xdifferent xfromxwhat xthe xdoctor xdoes?” xWhich xresponse xwould xbe xmost xappropriate xfor
xthe xnurse xto xmake?
a. “The xrole xof xthe xnurse xis xto xadminister xmedications xand xother xtreatments
xprescribedx by xyour xdoctor.”
b. “The xnurse’s xjob xis xto xhelp xthe xdoctor xby xcollecting xinformation
xandxcommunicating xany xproblems xthat xoccur.”
c. “Nurses xperform xmany xof xthe xsame xprocedures xas xthe xdoctor, xbut xnurses xare
xwithxthe xpatients xfor xa xlonger xtime xthan xthe xdoctor.”
d. “In xaddition xto xcaring xfor xyou xwhile xyou xare xsick, xthe xnurses xwill xassist
develop xan xindividualized xplan xto xmaintain xyour xhealth.”
xyou xtox
ANS: x D
This xresponse xis xconsistent xwith xthe xAmerican xNurses xAssociation x(ANA) xdefinition xof
xnursing, xwhich xdescribes xthe xrole xof xnurses xin xpromoting xhealth. xThe xother xresponses
xdescribexsome xof xthe xdependent xand xcollaborative xfunctions xof xthe xnursing xrole xbut xdo
xnot xaccurately xdescribe xthe xnurse’s xrole xin xthe xhealth xcare xsystem.
DIF: Cognitive xLevel: xUnderstand x(comprehension) REF: x 3
TOP: x Nursing xProcess: xImplementation MSC: x NCLEX: xSafe xand xEffective xCare xEnvironment
2. The xnurse xdescribes xto xa xstudent xnurse xhow xto xuse xevidence-based xpractice xguidelines
xwhenxcaring xfor xpatients. xWhich xstatement, xif xmade xby xthe xnurse, xwould xbe xthe x most
xaccurate?
a. “Inferences xfrom xclinical xresearch xstudies xare xused xas xa xguide.”
b. “Patient xcare xis xbased xon xclinical xjudgment, xexperience, xand xtraditions.”
c. “Data xare xevaluated xto xshow xthat xthe xpatient xoutcomes xare xconsistently xmet.”
d. “Recommendations xare xbased xon xresearch, xclinical xexpertise, xand
preferences.”
xpatientx
ANS: x D
Evidence-based xpractice x(EBP) xis xthe xuse xof xthe xbest xresearch-based xevidence xcombined
xwithxclinician xexpertise. xClinical xjudgment xbased xon xthe xnurse’s xclinical xexperience xis
xpart xof xEBP,x
but xclinical xdecision xmaking xshould xalso xincorporate xcurrent xresearch xand
xresearch-based xguidelines. xEvaluation xof xpatient xoutcomes xis ximportant, xbut xinterventions
xshould xbe xbased xonxresearch xfrom xrandomized xcontrol xstudies xwith xa xlarge xnumber xof
xsubjects.
DIF: Cognitive xLevel: xRemember x(knowledge) REF: x 15
TOP: x Nursing xProcess: xPlanning MSC: x NCLEX: xSafe xand xEffective xCare xEnvironment
3. The xnurse xteaches xa xstudent xnurse xabout xhow xto xapply xthe xnursing xprocess xwhen
xprovidingxpatient xcare. xWhich xstatement, xif xmade xby xthe xstudent xnurse, xindicates xthat
xteaching xwas xsuccessful?
a. “The xnursing xprocess xis xa xscientific-based xmethod xof xdiagnosing xthe
xpatient’sx
health xcare xproblems.”
b. “The xnursing xprocess xis xa xproblem-solving xtool x used xto xidentify xand xtreat xpatients’
, health xcare xneeds.”
c. “The xnursing xprocess xis xused xprimarily xto xexplain xnursing xinterventions xto
x otherxhealth xcare xprofessionals.”
d. “The xnursing xprocess xis xbased xon xnursing xtheory xthat xincorporates
x thexbiopsychosocial xnature xof xhumans.”
ANS: x B
The xnursing xprocess xis xa xproblem-solving xapproach xto xthe xidentification xand xtreatment xof
xpatients’ xproblems. xDiagnosis xis xonly xone xphase xof xthe xnursing xprocess. xThe xprimary xuse
xof xthex
nursing xprocess xis xin xpatient xcare, xnot xto xestablish xnursing xtheory xor xexplain
xnursing xinterventions xto xother xhealth xcare xprofessionals.
DIF: Cognitive xLevel: xUnderstand x(comprehension) REF: x 5
TOP: x Nursing xProcess: xImplementation MSC: x NCLEX: xSafe xand xEffective xCare xEnvironment
4. A xpatient xhas xbeen xadmitted xto xthe xhospital xfor xsurgery xand xtells xthe xnurse, x“I xdo xnot
feel xcomfortable xleaving xmy xchildren xwith xmy xparents.” xWhich xaction xshould xthe xnurse
x
take xnext?
x
a. Reassure xthe xpatient xthat xthese xfeelings xare xcommon xfor xparents.
b. Have xthe xpatient xcall xthe xchildren xto xensure xthat xthey xare xdoing xwell.
c. Gather xmore xdata xabout xthe xpatient’s xfeelings xabout xthe xchild-care xarrangements.
d. Call xthe xpatient’s xparents xto xdetermine xwhether xadequate xchild xcare xis
xbeingx
provided.
ANS: x C
Because xa xcomplete xassessment xis xnecessary xin xorder xto xidentify xa xproblem xand xchoose
xan xappropriate xintervention, xthe xnurse’s xfirst xaction xshould xbe xto xobtain xmore
xinformation. xThe xother xactions xmay xbe xappropriate, xbut xmore xassessment xis xneeded
xbefore xthe xbest xinterventionx
can xbe xchosen.
DIF: Cognitive xLevel: xApply x(application) REF: 6
OBJ: x x x Special xQuestions: xPrioritization TOP: x Nursing xProcess:
xAssessmentx MSC: x NCLEX: xPsychosocial xIntegrity
5. A xpatient xwho xis xparalyzed xon xthe xleft xside xof xthe xbody xafter xa xstroke xdevelops xa
x pressure xulcerxon xthe xleft xhip. xWhich xnursing xdiagnosis xis x most xappropriate?
a. Impaired xphysical xmobility xrelated xto xleft-sided xparalysis
b. Risk xfor ximpaired xtissue xintegrity xrelated xto xleft-sided xweakness
c. Impaired xskin xintegrity xrelated xto xaltered xcirculation xand xpressure
d. Ineffective xtissue xperfusion xrelated xto xinability xto xmove xindependently
ANS: x C
The xpatient’s xmajor xproblem xis xthe ximpaired xskin xintegrity xas xdemonstrated xby xthe
xpresence xof xa xpressure xulcer. xThe xnurse xis xable xto xtreat xthe xcause xof xaltered xcirculation
xand xpressure xby xfrequently xrepositioning xthe xpatient. xAlthough xleft-sided xweakness xis xa
xproblem xfor xthe xpatient,xthe xnurse xcannot xtreat xthe xweakness. xThe x“risk xfor” xdiagnosis xis
xnot xappropriate xfor xthis xpatient,xwho xalready xhas ximpaired xtissue xintegrity. xThe xpatient
xdoes xhave xineffective xtissue xperfusion, xbut xthe ximpaired xskin xintegrity xdiagnosis xindicates
xmore xclearly xwhat xthe xhealth xproblem xis.
DIF: Cognitive xLevel: xApply x(application) REF: 7
TOP: x Nursing xProcess: xDiagnosis MSC: x NCLEX: xPhysiological xIntegrity
, 6. A xpatient xwith xa xbacterial xinfection xhas xa xnursing xdiagnosis xof xdeficient xfluid xvolume
xrelated xtoxexcessive xdiaphoresis. xWhich xoutcome xwould xthe xnurse xrecognize xas
xappropriate xfor xthis xpatient?
a. Patient xhas xa xbalanced xintake xand xoutput.
b. Patient’s xbedding xis xchanged xwhen xit xbecomes xdamp.
c. Patient xunderstands xthe xneed xfor xincreased xfluid xintake.
d. Patient’s xskin xremains xcool xand xdry xthroughout xhospitalization.
ANS: x A
This xstatement xgives xmeasurable xdata xshowing xresolution xof xthe xproblem xof xdeficient
xfluid xvolume xthat xwas xidentified xin xthe xnursing xdiagnosis xstatement. xThe xother xstatements
xwould xnotxindicate xthat xthe xproblem xof xdeficient xfluid xvolume xwas xresolved.
DIF: Cognitive xLevel: xApply x(application) REF: 7
TOP: x Nursing xProcess: xPlanning MSC: x NCLEX: xPhysiological xIntegrity
7. A xnurse xasks xthe xpatient xif xpain xwas xrelieved xafter xreceiving xmedication. xWhat xis xthe
x purposexof xthe xevaluation xphase xof xthe xnursing xprocess?
a. To xdetermine xif xinterventions xhave xbeen xeffective xin xmeeting xpatient xoutcomes
b. To xdocument xthe xnursing xcare xplan xin xthe xprogress xnotes xof xthe xmedical xrecord
c. To xdecide xwhether xthe xpatient’s xhealth xproblems xhave xbeen xcompletely xresolved
d. To xestablish xif xthe xpatient xagrees xthat xthe xnursing xcare xprovided xwas xsatisfactory
ANS: x A
Evaluation xconsists xof xdetermining xwhether xthe xdesired xpatient xoutcomes xhave xbeen
xmet xand xwhether xthe xnursing xinterventions xwere xappropriate. xThe xother xresponses xdo
xnot xdescribe xthex
evaluation xphase.
DIF: x x x Cognitive xLevel: xUnderstand x(comprehension) REF: x 5
TOP: x Nursing xProcess: xEvaluation MSC: x NCLEX: xSafe xand xEffective xCare xEnvironment
8. The xnurse xinterviews xa xpatient xwhile xcompleting xthe xhealth xhistory xand xphysical
x examination.xWhat xis xthe xpurpose xof xthe xassessment xphase xof xthe xnursing xprocess?
a. To xteach xinterventions xthat xrelieve xhealth xproblems
b. To xuse xpatient xdata xto xevaluate xpatient xcare xoutcomes
c. To xobtain xdata xwith xwhich xto xdiagnose xpatient xproblems
d. To xhelp xthe xpatient xidentify xrealistic xoutcomes xfor xhealth xproblems
ANS: x C
During xthe xassessment xphase, xthe xnurse xgathers xinformation xabout xthe xpatient xto
xdiagnosexpatient xproblems. xThe xother xresponses x are xexamples xof xthe xplanning,
xintervention, xand xevaluation xphases xof xthe xnursing xprocess.
DIF: x x x Cognitive xLevel: xUnderstand x(comprehension) REF: x 5
TOP: x Nursing xProcess: xAssessment MSC: x NCLEX: xSafe xand xEffective xCare xEnvironment
9. Which xnursing xdiagnosis xstatement xis xwritten xcorrectly?
a. Altered xtissue xperfusion xrelated xto xheart xfailure
b. Risk xfor ximpaired xtissue xintegrity xrelated xto xsacral xredness
c. Ineffective xcoping xrelated xto xresponse xto xbiopsy xtest xresults
d. Altered xurinary xelimination xrelated xto xurinary xtract xinfection
x x x x
Ignatavicius Medical-Surgical Nursing, 10th
x x x x
Edition
x x
MULTIPLE xCHOICE
1. The xnurse xcompletes xan xadmission xdatabase xand xexplains xthat xthe xplan xof xcare xand
xdischarge xgoals xwill xbe xdeveloped xwith xthe xpatient’s xinput. xThe xpatient xstates, x“How xis
xthis xdifferent xfromxwhat xthe xdoctor xdoes?” xWhich xresponse xwould xbe xmost xappropriate xfor
xthe xnurse xto xmake?
a. “The xrole xof xthe xnurse xis xto xadminister xmedications xand xother xtreatments
xprescribedx by xyour xdoctor.”
b. “The xnurse’s xjob xis xto xhelp xthe xdoctor xby xcollecting xinformation
xandxcommunicating xany xproblems xthat xoccur.”
c. “Nurses xperform xmany xof xthe xsame xprocedures xas xthe xdoctor, xbut xnurses xare
xwithxthe xpatients xfor xa xlonger xtime xthan xthe xdoctor.”
d. “In xaddition xto xcaring xfor xyou xwhile xyou xare xsick, xthe xnurses xwill xassist
develop xan xindividualized xplan xto xmaintain xyour xhealth.”
xyou xtox
ANS: x D
This xresponse xis xconsistent xwith xthe xAmerican xNurses xAssociation x(ANA) xdefinition xof
xnursing, xwhich xdescribes xthe xrole xof xnurses xin xpromoting xhealth. xThe xother xresponses
xdescribexsome xof xthe xdependent xand xcollaborative xfunctions xof xthe xnursing xrole xbut xdo
xnot xaccurately xdescribe xthe xnurse’s xrole xin xthe xhealth xcare xsystem.
DIF: Cognitive xLevel: xUnderstand x(comprehension) REF: x 3
TOP: x Nursing xProcess: xImplementation MSC: x NCLEX: xSafe xand xEffective xCare xEnvironment
2. The xnurse xdescribes xto xa xstudent xnurse xhow xto xuse xevidence-based xpractice xguidelines
xwhenxcaring xfor xpatients. xWhich xstatement, xif xmade xby xthe xnurse, xwould xbe xthe x most
xaccurate?
a. “Inferences xfrom xclinical xresearch xstudies xare xused xas xa xguide.”
b. “Patient xcare xis xbased xon xclinical xjudgment, xexperience, xand xtraditions.”
c. “Data xare xevaluated xto xshow xthat xthe xpatient xoutcomes xare xconsistently xmet.”
d. “Recommendations xare xbased xon xresearch, xclinical xexpertise, xand
preferences.”
xpatientx
ANS: x D
Evidence-based xpractice x(EBP) xis xthe xuse xof xthe xbest xresearch-based xevidence xcombined
xwithxclinician xexpertise. xClinical xjudgment xbased xon xthe xnurse’s xclinical xexperience xis
xpart xof xEBP,x
but xclinical xdecision xmaking xshould xalso xincorporate xcurrent xresearch xand
xresearch-based xguidelines. xEvaluation xof xpatient xoutcomes xis ximportant, xbut xinterventions
xshould xbe xbased xonxresearch xfrom xrandomized xcontrol xstudies xwith xa xlarge xnumber xof
xsubjects.
DIF: Cognitive xLevel: xRemember x(knowledge) REF: x 15
TOP: x Nursing xProcess: xPlanning MSC: x NCLEX: xSafe xand xEffective xCare xEnvironment
3. The xnurse xteaches xa xstudent xnurse xabout xhow xto xapply xthe xnursing xprocess xwhen
xprovidingxpatient xcare. xWhich xstatement, xif xmade xby xthe xstudent xnurse, xindicates xthat
xteaching xwas xsuccessful?
a. “The xnursing xprocess xis xa xscientific-based xmethod xof xdiagnosing xthe
xpatient’sx
health xcare xproblems.”
b. “The xnursing xprocess xis xa xproblem-solving xtool x used xto xidentify xand xtreat xpatients’
, health xcare xneeds.”
c. “The xnursing xprocess xis xused xprimarily xto xexplain xnursing xinterventions xto
x otherxhealth xcare xprofessionals.”
d. “The xnursing xprocess xis xbased xon xnursing xtheory xthat xincorporates
x thexbiopsychosocial xnature xof xhumans.”
ANS: x B
The xnursing xprocess xis xa xproblem-solving xapproach xto xthe xidentification xand xtreatment xof
xpatients’ xproblems. xDiagnosis xis xonly xone xphase xof xthe xnursing xprocess. xThe xprimary xuse
xof xthex
nursing xprocess xis xin xpatient xcare, xnot xto xestablish xnursing xtheory xor xexplain
xnursing xinterventions xto xother xhealth xcare xprofessionals.
DIF: Cognitive xLevel: xUnderstand x(comprehension) REF: x 5
TOP: x Nursing xProcess: xImplementation MSC: x NCLEX: xSafe xand xEffective xCare xEnvironment
4. A xpatient xhas xbeen xadmitted xto xthe xhospital xfor xsurgery xand xtells xthe xnurse, x“I xdo xnot
feel xcomfortable xleaving xmy xchildren xwith xmy xparents.” xWhich xaction xshould xthe xnurse
x
take xnext?
x
a. Reassure xthe xpatient xthat xthese xfeelings xare xcommon xfor xparents.
b. Have xthe xpatient xcall xthe xchildren xto xensure xthat xthey xare xdoing xwell.
c. Gather xmore xdata xabout xthe xpatient’s xfeelings xabout xthe xchild-care xarrangements.
d. Call xthe xpatient’s xparents xto xdetermine xwhether xadequate xchild xcare xis
xbeingx
provided.
ANS: x C
Because xa xcomplete xassessment xis xnecessary xin xorder xto xidentify xa xproblem xand xchoose
xan xappropriate xintervention, xthe xnurse’s xfirst xaction xshould xbe xto xobtain xmore
xinformation. xThe xother xactions xmay xbe xappropriate, xbut xmore xassessment xis xneeded
xbefore xthe xbest xinterventionx
can xbe xchosen.
DIF: Cognitive xLevel: xApply x(application) REF: 6
OBJ: x x x Special xQuestions: xPrioritization TOP: x Nursing xProcess:
xAssessmentx MSC: x NCLEX: xPsychosocial xIntegrity
5. A xpatient xwho xis xparalyzed xon xthe xleft xside xof xthe xbody xafter xa xstroke xdevelops xa
x pressure xulcerxon xthe xleft xhip. xWhich xnursing xdiagnosis xis x most xappropriate?
a. Impaired xphysical xmobility xrelated xto xleft-sided xparalysis
b. Risk xfor ximpaired xtissue xintegrity xrelated xto xleft-sided xweakness
c. Impaired xskin xintegrity xrelated xto xaltered xcirculation xand xpressure
d. Ineffective xtissue xperfusion xrelated xto xinability xto xmove xindependently
ANS: x C
The xpatient’s xmajor xproblem xis xthe ximpaired xskin xintegrity xas xdemonstrated xby xthe
xpresence xof xa xpressure xulcer. xThe xnurse xis xable xto xtreat xthe xcause xof xaltered xcirculation
xand xpressure xby xfrequently xrepositioning xthe xpatient. xAlthough xleft-sided xweakness xis xa
xproblem xfor xthe xpatient,xthe xnurse xcannot xtreat xthe xweakness. xThe x“risk xfor” xdiagnosis xis
xnot xappropriate xfor xthis xpatient,xwho xalready xhas ximpaired xtissue xintegrity. xThe xpatient
xdoes xhave xineffective xtissue xperfusion, xbut xthe ximpaired xskin xintegrity xdiagnosis xindicates
xmore xclearly xwhat xthe xhealth xproblem xis.
DIF: Cognitive xLevel: xApply x(application) REF: 7
TOP: x Nursing xProcess: xDiagnosis MSC: x NCLEX: xPhysiological xIntegrity
, 6. A xpatient xwith xa xbacterial xinfection xhas xa xnursing xdiagnosis xof xdeficient xfluid xvolume
xrelated xtoxexcessive xdiaphoresis. xWhich xoutcome xwould xthe xnurse xrecognize xas
xappropriate xfor xthis xpatient?
a. Patient xhas xa xbalanced xintake xand xoutput.
b. Patient’s xbedding xis xchanged xwhen xit xbecomes xdamp.
c. Patient xunderstands xthe xneed xfor xincreased xfluid xintake.
d. Patient’s xskin xremains xcool xand xdry xthroughout xhospitalization.
ANS: x A
This xstatement xgives xmeasurable xdata xshowing xresolution xof xthe xproblem xof xdeficient
xfluid xvolume xthat xwas xidentified xin xthe xnursing xdiagnosis xstatement. xThe xother xstatements
xwould xnotxindicate xthat xthe xproblem xof xdeficient xfluid xvolume xwas xresolved.
DIF: Cognitive xLevel: xApply x(application) REF: 7
TOP: x Nursing xProcess: xPlanning MSC: x NCLEX: xPhysiological xIntegrity
7. A xnurse xasks xthe xpatient xif xpain xwas xrelieved xafter xreceiving xmedication. xWhat xis xthe
x purposexof xthe xevaluation xphase xof xthe xnursing xprocess?
a. To xdetermine xif xinterventions xhave xbeen xeffective xin xmeeting xpatient xoutcomes
b. To xdocument xthe xnursing xcare xplan xin xthe xprogress xnotes xof xthe xmedical xrecord
c. To xdecide xwhether xthe xpatient’s xhealth xproblems xhave xbeen xcompletely xresolved
d. To xestablish xif xthe xpatient xagrees xthat xthe xnursing xcare xprovided xwas xsatisfactory
ANS: x A
Evaluation xconsists xof xdetermining xwhether xthe xdesired xpatient xoutcomes xhave xbeen
xmet xand xwhether xthe xnursing xinterventions xwere xappropriate. xThe xother xresponses xdo
xnot xdescribe xthex
evaluation xphase.
DIF: x x x Cognitive xLevel: xUnderstand x(comprehension) REF: x 5
TOP: x Nursing xProcess: xEvaluation MSC: x NCLEX: xSafe xand xEffective xCare xEnvironment
8. The xnurse xinterviews xa xpatient xwhile xcompleting xthe xhealth xhistory xand xphysical
x examination.xWhat xis xthe xpurpose xof xthe xassessment xphase xof xthe xnursing xprocess?
a. To xteach xinterventions xthat xrelieve xhealth xproblems
b. To xuse xpatient xdata xto xevaluate xpatient xcare xoutcomes
c. To xobtain xdata xwith xwhich xto xdiagnose xpatient xproblems
d. To xhelp xthe xpatient xidentify xrealistic xoutcomes xfor xhealth xproblems
ANS: x C
During xthe xassessment xphase, xthe xnurse xgathers xinformation xabout xthe xpatient xto
xdiagnosexpatient xproblems. xThe xother xresponses x are xexamples xof xthe xplanning,
xintervention, xand xevaluation xphases xof xthe xnursing xprocess.
DIF: x x x Cognitive xLevel: xUnderstand x(comprehension) REF: x 5
TOP: x Nursing xProcess: xAssessment MSC: x NCLEX: xSafe xand xEffective xCare xEnvironment
9. Which xnursing xdiagnosis xstatement xis xwritten xcorrectly?
a. Altered xtissue xperfusion xrelated xto xheart xfailure
b. Risk xfor ximpaired xtissue xintegrity xrelated xto xsacral xredness
c. Ineffective xcoping xrelated xto xresponse xto xbiopsy xtest xresults
d. Altered xurinary xelimination xrelated xto xurinary xtract xinfection
