,Chapter 01: Professional Nursing Practice
ss ss ss ss
Lewis: Medical-Surgical Nursing, 10th Edition
ss ss ss ss ss
MULTIPLE CHOICE ss
1. The nurse completes an admission database and explains that the plan of care and discharge
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
goals will be developed with the patient‘s input. The patient states, ―How is this different from
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
what the doctor does?‖ Which response would be most appropriate for the nurse to make?
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
a. ―The role of the nurse is to administer medications and other treatments prescribed
ss ss ss ss ss ss ss ss ss ss ss ss
by your doctor.‖
ss ss ss
b. ―The nurse‘s job is to help the doctor by collecting information and
ss ss ss ss ss ss ss ss ss ss ss
communicating any problems that occur.‖
ss ss ss ss ss
c. ―Nurses perform many of the same procedures as the doctor, but nurses are with
ss ss ss ss ss ss ss ss ss ss ss ss ss
the patients for a longer time thadoctor.‖
ss ss ss ss ss ss ss
d. ―In addition to caring for you while you are sick, the nurses will assist you to
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
develop an individualized plan to maintain your health.‖
ss ss ss ss ss ss ss ss
ANS: s s D
This response is consistent with the American Nurses Association (ANA) definition of nursing,
ss ss ss ss ss ss ss ss ss ss ss ss
which describes the role of nurses in promoting health. The other responses describe some of the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
dependent and collaborative functions of the nursing role but do not accurately describe the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
nurse‘s role in the health care system.
ss ss ss ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 3 ss ss ss s s s s
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
s s ss ss s s ss ss ss ss ss
2. The nurse describes to a student nurse how to use evidence-based practice guidelines when
ss ss ss ss ss ss ss ss ss ss ss ss ss
ss caring for patients. Which statement, if made by the nurse, would be the most accurate?
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
a. ―Inferences from clinical research studies are used as a guide.‖ ss ss ss ss ss ss ss ss ss
b. ―Patient care is based on clinical judgment, experience, and traditions.‖
ss ss ss ss ss ss ss ss ss
c. ―Data are evaluated to show that the patient outcomes are consistently met.‖
ss ss ss ss ss ss ss ss ss ss ss
d. ―Recommendations are based on research, clinical expertise, and patient ss ss ss ss ss ss ss ss
preferences.‖
ss
ANS: s s D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with ss ss ss ss ss ss ss ss ss ss ss ss
clinician expertise. Clinical judgment based on the nurse‘s clinical experience is part of EBP, but
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
clinical decision making should also incorporate current research and research-based guidelines.
ss ss ss ss ss ss ss ss ss ss ss
Evaluation of patient outcomes is important, but interventions should be based on research from
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
randomized control studies with a large number of subjects.
ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Remember (knowledge) REF: 15 ss ss ss s s s s
TOP: Nursing Process: Planning s MSC: NCLEX: Safe and Effective Care Environment
s ss ss s s ss ss ss ss ss
3. The nurse teaches a student nurse about how to apply the nursing process when providing patient
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
care. Which statement, if made by the student nurse, indicates that teaching was successful?
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
a. ―The nursing process is a scientific-based method of diagnosing the patient‘s
ss ss ss ss ss ss ss ss ss ss
, health care problems.‖ ss ss
b. ―The nursing process is a problem-solving tool used to identify and treat patients‘
ss ss ss ss ss ss ss ss ss ss ss ss
health care needs.‖
ss ss ss
c. ―The nursing process is used primarily to explain nursing interventions to other
ss ss ss ss ss ss ss ss ss ss ss
health care professionals.‖
ss ss ss
d. ―The nursing process is based on nursing theory that incorporates the
ss ss ss ss ss ss ss ss ss ss
biopsychosocial nature of humans.‖
ss ss ss ss
ANS: s s B
The nursing process is a problem-solving approach to the identification and treatment of patients‘
ss ss ss ss ss ss ss ss ss ss ss ss ss
problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
process is in patient care, not to establish nursing theory or explain nursing interventions to
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
other health care professionals.
ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 5 ss ss ss s s s s
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
s s ss ss s s ss ss ss ss ss
4. A patient has been admitted to the hospital for surgery and tells the nurse, ―I do not feel
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
comfortable leaving my children with my parents.‖ Which action should the nurse take next?
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
a. Reassure the patient that these feelings are common for parents. ss ss ss ss ss ss ss ss ss
b. Have the patient call the children to ensure that they are doing well.
ss ss ss ss ss ss ss ss ss ss ss ss
c. Gather more data about the patient‘s feelings about the child-care arrangements.
ss ss ss ss ss ss ss ss ss ss
d. Call the patient‘s parents to determine whether adequate child care is being
ss ss ss ss ss ss ss ss ss ss ss
provided.
ss
ANS: s s C
Because a complete assessment is necessary in order to identify a problem and choose an
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
appropriate intervention, the nurse‘s first action should be to obtain more information. The other
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
actions may be appropriate, but more assessment is needed before the best intervention can be
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
chosen.
ss
DIF: Cognitive Level: Apply (application) REF: 6 ss ss ss
OBJ: Special Questions: Prioritization TOP: Nursing Process:
s s ss ss s s ss
Assessment MSC: NCLEX: Psychosocial Integrity
ss ss s s ss ss
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the left hip. Which nursing diagnosis is most appropriate?
ss ss ss ss ss ss ss ss ss
a. Impaired physical mobility related to left-sided paralysis ss ss ss ss ss ss
b. Risk for impaired tissue integrity related to left-sided weakness
ss ss ss ss ss ss ss ss
c. Impaired skin integrity related to altered circulation and pressure ss ss ss ss ss ss ss ss
d. Ineffective tissue perfusion related to inability to move independently ss ss ss ss ss ss ss ss
ANS: s s C
The patient‘s major problem is the impaired skin integrity as demonstrated by the presence of a
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
frequently repositioning the patient. Although left-sided weakness is a problem for the patient,
ss ss ss ss ss ss ss ss ss ss ss ss ss
the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate for this patient,
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the impaired skin integrity diagnosis indicates more clearly what the health problem is.
ss ss ss ss ss ss ss ss ss ss ss ss ss
, DIF: Cognitive Level: Apply (application) REF: 7 ss ss ss
TOP: Nursing Process: Diagnosis
s s MSC: NCLEX: Physiological Integrity ss ss s s ss ss
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this patient?
ss ss ss ss ss ss ss ss ss ss ss ss ss
a. Patient has a balanced intake and output. ss ss ss ss ss ss
b. Patient‘s bedding is changed when it becomes damp. ss ss ss ss ss ss ss
c. Patient understands the need for increased fluid intake. ss ss ss ss ss ss ss
d. Patient‘s skin remains cool and dry throughout hospitalization. ss ss ss ss ss ss ss
ANS: s s A
This statement gives measurable data showing resolution of the problem of deficient fluid
ss ss ss ss ss ss ss ss ss ss ss ss
volume that was identified in the nursing diagnosis statement. The other statements would not
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
indicate that the problem of deficient fluid volume was resolved.
ss ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Apply (application) REF: 7 ss ss ss
TOP: Nursing Process: Planning
s s MSC: NCLEX: Physiological Integrity ss ss s s ss ss
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the evaluation phase of the nursing process?
ss ss ss ss ss ss ss
a. To determine if interventions have been effective in meeting patient outcomes
ss ss ss ss ss ss ss ss ss ss
b. To document the nursing care plan in the progress notes of the medical record
ss ss ss ss ss ss ss ss ss ss ss ss ss
c. To decide whether the patient‘s health problems have been completely resolved
ss ss ss ss ss ss ss ss ss ss
d. To establish if the patient agrees that the nursing care provided was satisfactory
ss ss ss ss ss ss ss ss ss ss ss ss
ANS: s s A
Evaluation consists of determining whether the desired patient outcomes have been met and
ss ss ss ss ss ss ss ss ss ss ss ss
whether the nursing interventions were appropriate. The other responses do not describe the
ss ss ss ss ss ss ss ss ss ss ss ss ss
evaluation phase.
ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 5 ss ss ss
TOP: Nursing Process: Evaluation
s s MSC: NCLEX: Safe and Effective Care Environment ss ss s s ss ss ss ss ss
8. The nurse interviews a patient while completing the health history and physical examination.
ss ss ss ss ss ss ss ss ss ss ss ss
What is the purpose of the assessment phase of the nursing process?
ss ss ss ss ss ss ss ss ss ss ss ss
a. To teach interventions that relieve health problems
ss ss ss ss ss ss
b. To use patient data to evaluate patient care outcomes
ss ss ss ss ss ss ss ss
c. To obtain data with which to diagnose patient problems
ss ss ss ss ss ss ss ss
d. To help the patient identify realistic outcomes for health problems
ss ss ss ss ss ss ss ss ss
ANS: s s C
During the assessment phase, the nurse gathers information about the patient to diagnose patient
ss ss ss ss ss ss ss ss ss ss ss ss ss
problems. The other responses are examples of the planning, intervention, and evaluation phases
ss ss ss ss ss ss ss ss ss ss ss ss ss
of the nursing process.
ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 5 ss ss ss
TOP: Nursing Process: Assessment
s s MSC: NCLEX: Safe and Effective Care Environment ss ss s s ss ss ss ss ss
ss ss ss ss
Lewis: Medical-Surgical Nursing, 10th Edition
ss ss ss ss ss
MULTIPLE CHOICE ss
1. The nurse completes an admission database and explains that the plan of care and discharge
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
goals will be developed with the patient‘s input. The patient states, ―How is this different from
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
what the doctor does?‖ Which response would be most appropriate for the nurse to make?
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
a. ―The role of the nurse is to administer medications and other treatments prescribed
ss ss ss ss ss ss ss ss ss ss ss ss
by your doctor.‖
ss ss ss
b. ―The nurse‘s job is to help the doctor by collecting information and
ss ss ss ss ss ss ss ss ss ss ss
communicating any problems that occur.‖
ss ss ss ss ss
c. ―Nurses perform many of the same procedures as the doctor, but nurses are with
ss ss ss ss ss ss ss ss ss ss ss ss ss
the patients for a longer time thadoctor.‖
ss ss ss ss ss ss ss
d. ―In addition to caring for you while you are sick, the nurses will assist you to
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
develop an individualized plan to maintain your health.‖
ss ss ss ss ss ss ss ss
ANS: s s D
This response is consistent with the American Nurses Association (ANA) definition of nursing,
ss ss ss ss ss ss ss ss ss ss ss ss
which describes the role of nurses in promoting health. The other responses describe some of the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
dependent and collaborative functions of the nursing role but do not accurately describe the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
nurse‘s role in the health care system.
ss ss ss ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 3 ss ss ss s s s s
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
s s ss ss s s ss ss ss ss ss
2. The nurse describes to a student nurse how to use evidence-based practice guidelines when
ss ss ss ss ss ss ss ss ss ss ss ss ss
ss caring for patients. Which statement, if made by the nurse, would be the most accurate?
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
a. ―Inferences from clinical research studies are used as a guide.‖ ss ss ss ss ss ss ss ss ss
b. ―Patient care is based on clinical judgment, experience, and traditions.‖
ss ss ss ss ss ss ss ss ss
c. ―Data are evaluated to show that the patient outcomes are consistently met.‖
ss ss ss ss ss ss ss ss ss ss ss
d. ―Recommendations are based on research, clinical expertise, and patient ss ss ss ss ss ss ss ss
preferences.‖
ss
ANS: s s D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with ss ss ss ss ss ss ss ss ss ss ss ss
clinician expertise. Clinical judgment based on the nurse‘s clinical experience is part of EBP, but
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
clinical decision making should also incorporate current research and research-based guidelines.
ss ss ss ss ss ss ss ss ss ss ss
Evaluation of patient outcomes is important, but interventions should be based on research from
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
randomized control studies with a large number of subjects.
ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Remember (knowledge) REF: 15 ss ss ss s s s s
TOP: Nursing Process: Planning s MSC: NCLEX: Safe and Effective Care Environment
s ss ss s s ss ss ss ss ss
3. The nurse teaches a student nurse about how to apply the nursing process when providing patient
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
care. Which statement, if made by the student nurse, indicates that teaching was successful?
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
a. ―The nursing process is a scientific-based method of diagnosing the patient‘s
ss ss ss ss ss ss ss ss ss ss
, health care problems.‖ ss ss
b. ―The nursing process is a problem-solving tool used to identify and treat patients‘
ss ss ss ss ss ss ss ss ss ss ss ss
health care needs.‖
ss ss ss
c. ―The nursing process is used primarily to explain nursing interventions to other
ss ss ss ss ss ss ss ss ss ss ss
health care professionals.‖
ss ss ss
d. ―The nursing process is based on nursing theory that incorporates the
ss ss ss ss ss ss ss ss ss ss
biopsychosocial nature of humans.‖
ss ss ss ss
ANS: s s B
The nursing process is a problem-solving approach to the identification and treatment of patients‘
ss ss ss ss ss ss ss ss ss ss ss ss ss
problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
process is in patient care, not to establish nursing theory or explain nursing interventions to
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
other health care professionals.
ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 5 ss ss ss s s s s
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
s s ss ss s s ss ss ss ss ss
4. A patient has been admitted to the hospital for surgery and tells the nurse, ―I do not feel
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
comfortable leaving my children with my parents.‖ Which action should the nurse take next?
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
a. Reassure the patient that these feelings are common for parents. ss ss ss ss ss ss ss ss ss
b. Have the patient call the children to ensure that they are doing well.
ss ss ss ss ss ss ss ss ss ss ss ss
c. Gather more data about the patient‘s feelings about the child-care arrangements.
ss ss ss ss ss ss ss ss ss ss
d. Call the patient‘s parents to determine whether adequate child care is being
ss ss ss ss ss ss ss ss ss ss ss
provided.
ss
ANS: s s C
Because a complete assessment is necessary in order to identify a problem and choose an
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
appropriate intervention, the nurse‘s first action should be to obtain more information. The other
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
actions may be appropriate, but more assessment is needed before the best intervention can be
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
chosen.
ss
DIF: Cognitive Level: Apply (application) REF: 6 ss ss ss
OBJ: Special Questions: Prioritization TOP: Nursing Process:
s s ss ss s s ss
Assessment MSC: NCLEX: Psychosocial Integrity
ss ss s s ss ss
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the left hip. Which nursing diagnosis is most appropriate?
ss ss ss ss ss ss ss ss ss
a. Impaired physical mobility related to left-sided paralysis ss ss ss ss ss ss
b. Risk for impaired tissue integrity related to left-sided weakness
ss ss ss ss ss ss ss ss
c. Impaired skin integrity related to altered circulation and pressure ss ss ss ss ss ss ss ss
d. Ineffective tissue perfusion related to inability to move independently ss ss ss ss ss ss ss ss
ANS: s s C
The patient‘s major problem is the impaired skin integrity as demonstrated by the presence of a
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
frequently repositioning the patient. Although left-sided weakness is a problem for the patient,
ss ss ss ss ss ss ss ss ss ss ss ss ss
the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate for this patient,
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the impaired skin integrity diagnosis indicates more clearly what the health problem is.
ss ss ss ss ss ss ss ss ss ss ss ss ss
, DIF: Cognitive Level: Apply (application) REF: 7 ss ss ss
TOP: Nursing Process: Diagnosis
s s MSC: NCLEX: Physiological Integrity ss ss s s ss ss
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this patient?
ss ss ss ss ss ss ss ss ss ss ss ss ss
a. Patient has a balanced intake and output. ss ss ss ss ss ss
b. Patient‘s bedding is changed when it becomes damp. ss ss ss ss ss ss ss
c. Patient understands the need for increased fluid intake. ss ss ss ss ss ss ss
d. Patient‘s skin remains cool and dry throughout hospitalization. ss ss ss ss ss ss ss
ANS: s s A
This statement gives measurable data showing resolution of the problem of deficient fluid
ss ss ss ss ss ss ss ss ss ss ss ss
volume that was identified in the nursing diagnosis statement. The other statements would not
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
indicate that the problem of deficient fluid volume was resolved.
ss ss ss ss ss ss ss ss ss ss
DIF: Cognitive Level: Apply (application) REF: 7 ss ss ss
TOP: Nursing Process: Planning
s s MSC: NCLEX: Physiological Integrity ss ss s s ss ss
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the evaluation phase of the nursing process?
ss ss ss ss ss ss ss
a. To determine if interventions have been effective in meeting patient outcomes
ss ss ss ss ss ss ss ss ss ss
b. To document the nursing care plan in the progress notes of the medical record
ss ss ss ss ss ss ss ss ss ss ss ss ss
c. To decide whether the patient‘s health problems have been completely resolved
ss ss ss ss ss ss ss ss ss ss
d. To establish if the patient agrees that the nursing care provided was satisfactory
ss ss ss ss ss ss ss ss ss ss ss ss
ANS: s s A
Evaluation consists of determining whether the desired patient outcomes have been met and
ss ss ss ss ss ss ss ss ss ss ss ss
whether the nursing interventions were appropriate. The other responses do not describe the
ss ss ss ss ss ss ss ss ss ss ss ss ss
evaluation phase.
ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 5 ss ss ss
TOP: Nursing Process: Evaluation
s s MSC: NCLEX: Safe and Effective Care Environment ss ss s s ss ss ss ss ss
8. The nurse interviews a patient while completing the health history and physical examination.
ss ss ss ss ss ss ss ss ss ss ss ss
What is the purpose of the assessment phase of the nursing process?
ss ss ss ss ss ss ss ss ss ss ss ss
a. To teach interventions that relieve health problems
ss ss ss ss ss ss
b. To use patient data to evaluate patient care outcomes
ss ss ss ss ss ss ss ss
c. To obtain data with which to diagnose patient problems
ss ss ss ss ss ss ss ss
d. To help the patient identify realistic outcomes for health problems
ss ss ss ss ss ss ss ss ss
ANS: s s C
During the assessment phase, the nurse gathers information about the patient to diagnose patient
ss ss ss ss ss ss ss ss ss ss ss ss ss
problems. The other responses are examples of the planning, intervention, and evaluation phases
ss ss ss ss ss ss ss ss ss ss ss ss ss
of the nursing process.
ss ss ss ss
DIF: Cognitive Level: Understand (comprehension) REF: 5 ss ss ss
TOP: Nursing Process: Assessment
s s MSC: NCLEX: Safe and Effective Care Environment ss ss s s ss ss ss ss ss