Test Bank for Lewis\'s Medical-Surgical Nursing, 12th
.6t .6t .6t .6t .6t .6t
Edition by Mariann M. Harding, Jeffrey Kwong, Debra
.6t .6t .6t .6t .6t .6t .6t .6t .6t
Hagler Chapter 1-69 .6t .6t .6t
,Chapter 01: Professional Nursing
.6t .6t .6t
Harding: Lewis’sMedical-Surgical Nursing, 12th Edition
.6t .6t .6t .6t .6t
MULTIPLECHOICE .6t
1. The nurse completes an admission database and explains that the plan of care and discharge
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
goals will be developed with the patient‘s input. The patient asks, “How is this different from what
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
the physician does?” Which response would the nurse provide?
.6t .6t .6t .6t .6t .6t .6t .6t .6t
a. “Theroleofthenurseistoadministermedications and othertreatmentsprescribed by
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
your physician.”
.6t .6t
b. “Inaddition tocaringfor youwhile you aresick, thenurses will help youplanto
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
maintain your health.”
.6t .6t .6t
c. “Thenurse‘sjobisto collectinformationand communicateanyproblemsthat .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
occur to the physician.”
.6t .6t .6t .6t
d. “Nursesperformmanyof thesameprocedures as thephysician,but nurses are with .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
the patients for a longer time than the physician.”
.6t .6t .6t .6t .6t .6t .6t .6t .6t
ANS: B .6t
The American Nurses Association (ANA) definition of nursing describes the role of nurses in
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
promoting health. The other responses describe dependent and collaborative functions of the
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
nursing role but do not accurately describe the nurse‘s unique role in the health care system.
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
DIF: . 6 t . 6 tCognitiveLevel: Analyze (Analysis) .6t .6t .6t
TOP: . 6 t NursingProcess: Implementation .6t .6t . 6 t . 6 t . 6 t MSC: NCLEX: Safe and Effective Care Environment . 6 t .6t .6t .6t .6t .6t
2. Which statement bythe nurse accurately describes the use of evidence-based practice (EBP)?
.6t .6t .6t .6t .6t .6t . 6t .6t .6t .6t .6t .6t
a. “Patientcareisbasedon clinical judgment,experience,and traditions.” .6t .6t .6t .6t .6t .6t .6t .6t .6t
b. “Data areanalyzed laterto show that thepatient outcomes areconsistently met.” .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
c. “Researchfrom allpublishedarticles areused as aguide forplanningpatientcare.” .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
d. “Recommendations are based on research, clinical expertise, and patient .6t .6t .6t .6t .6t .6t .6t .6t
.6t preferences.”
ANS: D .6t
Evidence-based practice (EBP) is the use of the best research-based evidence combined with .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
clinician expertise and consideration of patient preferences. Clinical judgment based on the
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
nurse‘s clinical experience is part of EBP, but clinical decision making should also
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
incorporate current research and research-based guidelines. Evaluation ofpatient outcomes is
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
important, but data analysis is not required to use EBP. All published articles do not provide
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
research evidence; interventions should bebased on credible research, preferablyrandomized
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
controlled studies with a large number of subjects.
.6t .6t .6t .6t .6t .6t .6t .6t
DIF: Cognitive Level: Understand (Comprehension) .6t .6t .6t TOP: NursingProcess: Planning . 6t .6t .6t
MSC: NCLEX: Safe and Effective Care Environment
.6t . 6 t .6t .6t .6t .6t .6t
3. Which statement bythe nurse provides a clear explanation of the nursing process?
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
a. “Thenursingprocessisa researchmethodofdiagnosingthepatient‘shealthcare .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
problems.”
.6t
b. “Thenursingprocessisusedprimarilyto explainnursinginterventions to other
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
health care professionals.”
.6t .6t .6t
c. “Thenursing process is a problem-solvingtool usedto identifyand manage the
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
, patients‘ health careneeds.” .6t .6t .6t
d. “Thenursingprocessisbasedonnursingtheorythatincorporatesthe .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
.6t biopsychosocial nature of humans.” .6t .6t .6t
ANS: C .6t
The nursing process is a problem-solving approach to the identification and treatment of
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
patients‘ problems. Nursing process does not require research methods for diagnosis. The
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
primaryuse of thenursing process is in patient care, not to establish nursing theoryor explain
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
nursing interventions to other health care professionals.
.6t .6t .6t .6t .6t .6t .6t
DIF: Cognitive Level: Understand (Comprehension) .6t .6t .6t TOP: NursingProcess: Evaluation . 6t .6t .6t
MSC: NCLEX: Safe and Effective Care Environment
.6t . 6 t .6t .6t .6t .6t .6t
4. Apatientadmittedto thehospitalforsurgerytellsthe nurse, “Ido not feel comfortable
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
leaving my children with my parents.” Which action would the nurse take next?
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
a. Reassurethe patient that thesefeelings are common for parents. .6t .6t .6t .6t .6t .6t .6t .6t .6t
b. Have the patient call the children to ensure that they are doing well. .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
c. Gatherinformation on the patient‘s concerns about the child care arrangements. .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
d. Call the patient‘s parents to determine whether adequate child careis being
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
provided. .6t
ANS: C .6t
Because a complete assessment is necessary in order to identify a problem and choose an
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
appropriate intervention, the nurse‘s first action should be to obtain more information. The
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
otheractions maybe appropriate, but more assessment is needed before the best intervention can
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
be chosen.
.6t .6t
DIF: Cognitive Level: Analyze (Analysis) .6t .6t .6t
TOP: NursingProcess: Assessment. MSC: NCLEX:Psychosocial Integrity
6 t .6t .6t . 6 t .6t .6t
5. A patient with a bacterial infection is hypovolemic dueto a fever and excessive diaphoresis.
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
Which expected outcome would the nurse select for this patient?
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
a. Patient has abalanced intake and output. .6t .6t .6t .6t .6t .6t
b. Patient‘s bedding is kept clean and free of moisture. .6t .6t .6t .6t .6t .6t .6t .6t
c. Patient understands the need forincreased fluid intake. .6t .6t .6t .6t .6t .6t .6t
d. Patient‘sskin remains cool and drythroughout hospitalization. .6t .6t .6t .6t .6t .6t .6t
ANS: A .6t
Balanced intake and output gives measurable data showingresolution ofthe problem of deficient
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
fluid volume. The other statements would not indicate that the problem of hypovolemia was
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
resolved.
.6t
DIF: Cognitive Level: Apply (Application) .6t .6t .6t TOP: NursingProcess: Planning . 6t .6t .6t
MSC: NCLEX: Physiological Integrity
.6t . 6 t .6t .6t
6. Which statement describes the purpose of the evaluation phase of the nursing process?
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
a. To document the nursing care plan in the progress notes of the health record
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
b. To determine if interventions have been effective in meetingpatient outcomes
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
c. To decide whether the patient‘s health problems have been completely resolved
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
d. To establish if the patient agrees that the nursing care provided was satisfactory
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
ANS: B .6t
, Evaluation consists of determining whether the desired patient outcomes have been met and .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
whether the nursing interventions were appropriate. The other responses do not describe the
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
evaluation phase.
.6t .6t
DIF: Cognitive Level: Understand (Comprehension)
. 6 t .6t .6t .6t TOP: Nursing Process: Evaluation . 6t .6t .6t
MSC: NCLEX: Safe and Effective Care Environment
.6t . 6 t .6t .6t .6t .6t .6t
7. Whichstatement describes the purpose of the assessment phase of the nursing process?
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
a. To teach interventions that relieve health problems
.6t .6t .6t .6t .6t .6t
b. To use patient data to evaluate patient care outcomes
.6t .6t .6t .6t .6t .6t .6t .6t
c. To obtain data to diagnose patient strengths and problems
.6t .6t .6t .6t .6t .6t .6t .6t
d. To help the patient identifyrealistic outcomes for health problems
.6t .6t .6t .6t .6t .6t .6t .6t .6t
ANS: C .6t
During the assessment phase, the nurse gathers information about the patient to diagnose patient
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
strengths and problems. The other responses are examples of the planning, intervention, and
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
evaluation phases of the nursing process.
.6t .6t .6t .6t .6t .6t
DIF: Cognitive Level: Understand (Comprehension) .6t .6t .6t
TOP: NursingProcess: Assessment
. MSC: NCLEX: Safeand Effective Care Environment
6 t .6t .6t . 6 t .6t .6t .6t .6t .6t
8. When developingthe plan of care, which components would the nurseinclude in theclinical
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
problem statement?
.6t .6t
a. Theproblem and the suggested patient goals or outcomes
.6t .6t .6t .6t .6t .6t .6t .6t
b. Theproblem, its causes, and the signs and symptoms of the problem
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
c. Theproblem with the possible etiologyand the planned interventions
.6t .6t .6t .6t .6t .6t .6t .6t .6t
d. Theproblem, its pathophysiology, and the expected outcome
.6t .6t .6t .6t .6t .6t .6t
ANS: B .6t
When writing clinical problems or nursing diagnoses, the subjective as well as objective data
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
to support the problem‘s existence should be included. Goals, outcomes, and interventions are
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
not included in the problem statement.
.6t .6t .6t .6t .6t .6t
DIF: Cognitive Level: Understand (Comprehension) .6t .6t .6t TOP: NursingProcess: Diagnosis . 6t .6t .6t
MSC: NCLEX: Safe and Effective Care Environment
.6t . 6 t .6t .6t .6t .6t .6t
9. Which patient care task would the nursedelegate to experienced assistive personnel (AP)?
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
a. Instruct the patient about the need to alternate activityand rest. .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
b. Monitor level of shortness of breath or fatigue after ambulation. .6t .6t .6t .6t .6t .6t .6t .6t .6t
c. Obtainthe patient‘s blood pressure and pulse rate after ambulation. .6t .6t .6t .6t .6t .6t .6t .6t .6t
d. Determine whether the patient is readyto increase the activitylevel. .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
ANS: C .6t
AP educationincludes accurate vital sign measurement.Assessment and patient teaching require
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
registered nurse education and scope of practice and cannot be delegated.
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
DIF: Cognitive Level: Apply (Application) .6t .6t .6t TOP: NursingProcess: Planning . 6t .6t .6t
MSC: NCLEX: Safe and Effective Care Environment
.6t . 6 t .6t .6t .6t .6t .6t
.6t .6t .6t .6t .6t .6t
Edition by Mariann M. Harding, Jeffrey Kwong, Debra
.6t .6t .6t .6t .6t .6t .6t .6t .6t
Hagler Chapter 1-69 .6t .6t .6t
,Chapter 01: Professional Nursing
.6t .6t .6t
Harding: Lewis’sMedical-Surgical Nursing, 12th Edition
.6t .6t .6t .6t .6t
MULTIPLECHOICE .6t
1. The nurse completes an admission database and explains that the plan of care and discharge
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
goals will be developed with the patient‘s input. The patient asks, “How is this different from what
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
the physician does?” Which response would the nurse provide?
.6t .6t .6t .6t .6t .6t .6t .6t .6t
a. “Theroleofthenurseistoadministermedications and othertreatmentsprescribed by
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
your physician.”
.6t .6t
b. “Inaddition tocaringfor youwhile you aresick, thenurses will help youplanto
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
maintain your health.”
.6t .6t .6t
c. “Thenurse‘sjobisto collectinformationand communicateanyproblemsthat .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
occur to the physician.”
.6t .6t .6t .6t
d. “Nursesperformmanyof thesameprocedures as thephysician,but nurses are with .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
the patients for a longer time than the physician.”
.6t .6t .6t .6t .6t .6t .6t .6t .6t
ANS: B .6t
The American Nurses Association (ANA) definition of nursing describes the role of nurses in
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
promoting health. The other responses describe dependent and collaborative functions of the
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
nursing role but do not accurately describe the nurse‘s unique role in the health care system.
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
DIF: . 6 t . 6 tCognitiveLevel: Analyze (Analysis) .6t .6t .6t
TOP: . 6 t NursingProcess: Implementation .6t .6t . 6 t . 6 t . 6 t MSC: NCLEX: Safe and Effective Care Environment . 6 t .6t .6t .6t .6t .6t
2. Which statement bythe nurse accurately describes the use of evidence-based practice (EBP)?
.6t .6t .6t .6t .6t .6t . 6t .6t .6t .6t .6t .6t
a. “Patientcareisbasedon clinical judgment,experience,and traditions.” .6t .6t .6t .6t .6t .6t .6t .6t .6t
b. “Data areanalyzed laterto show that thepatient outcomes areconsistently met.” .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
c. “Researchfrom allpublishedarticles areused as aguide forplanningpatientcare.” .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
d. “Recommendations are based on research, clinical expertise, and patient .6t .6t .6t .6t .6t .6t .6t .6t
.6t preferences.”
ANS: D .6t
Evidence-based practice (EBP) is the use of the best research-based evidence combined with .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
clinician expertise and consideration of patient preferences. Clinical judgment based on the
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
nurse‘s clinical experience is part of EBP, but clinical decision making should also
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
incorporate current research and research-based guidelines. Evaluation ofpatient outcomes is
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
important, but data analysis is not required to use EBP. All published articles do not provide
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
research evidence; interventions should bebased on credible research, preferablyrandomized
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
controlled studies with a large number of subjects.
.6t .6t .6t .6t .6t .6t .6t .6t
DIF: Cognitive Level: Understand (Comprehension) .6t .6t .6t TOP: NursingProcess: Planning . 6t .6t .6t
MSC: NCLEX: Safe and Effective Care Environment
.6t . 6 t .6t .6t .6t .6t .6t
3. Which statement bythe nurse provides a clear explanation of the nursing process?
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
a. “Thenursingprocessisa researchmethodofdiagnosingthepatient‘shealthcare .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
problems.”
.6t
b. “Thenursingprocessisusedprimarilyto explainnursinginterventions to other
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
health care professionals.”
.6t .6t .6t
c. “Thenursing process is a problem-solvingtool usedto identifyand manage the
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
, patients‘ health careneeds.” .6t .6t .6t
d. “Thenursingprocessisbasedonnursingtheorythatincorporatesthe .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
.6t biopsychosocial nature of humans.” .6t .6t .6t
ANS: C .6t
The nursing process is a problem-solving approach to the identification and treatment of
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
patients‘ problems. Nursing process does not require research methods for diagnosis. The
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
primaryuse of thenursing process is in patient care, not to establish nursing theoryor explain
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
nursing interventions to other health care professionals.
.6t .6t .6t .6t .6t .6t .6t
DIF: Cognitive Level: Understand (Comprehension) .6t .6t .6t TOP: NursingProcess: Evaluation . 6t .6t .6t
MSC: NCLEX: Safe and Effective Care Environment
.6t . 6 t .6t .6t .6t .6t .6t
4. Apatientadmittedto thehospitalforsurgerytellsthe nurse, “Ido not feel comfortable
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
leaving my children with my parents.” Which action would the nurse take next?
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
a. Reassurethe patient that thesefeelings are common for parents. .6t .6t .6t .6t .6t .6t .6t .6t .6t
b. Have the patient call the children to ensure that they are doing well. .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
c. Gatherinformation on the patient‘s concerns about the child care arrangements. .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
d. Call the patient‘s parents to determine whether adequate child careis being
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
provided. .6t
ANS: C .6t
Because a complete assessment is necessary in order to identify a problem and choose an
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
appropriate intervention, the nurse‘s first action should be to obtain more information. The
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
otheractions maybe appropriate, but more assessment is needed before the best intervention can
.6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
be chosen.
.6t .6t
DIF: Cognitive Level: Analyze (Analysis) .6t .6t .6t
TOP: NursingProcess: Assessment. MSC: NCLEX:Psychosocial Integrity
6 t .6t .6t . 6 t .6t .6t
5. A patient with a bacterial infection is hypovolemic dueto a fever and excessive diaphoresis.
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Which expected outcome would the nurse select for this patient?
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a. Patient has abalanced intake and output. .6t .6t .6t .6t .6t .6t
b. Patient‘s bedding is kept clean and free of moisture. .6t .6t .6t .6t .6t .6t .6t .6t
c. Patient understands the need forincreased fluid intake. .6t .6t .6t .6t .6t .6t .6t
d. Patient‘sskin remains cool and drythroughout hospitalization. .6t .6t .6t .6t .6t .6t .6t
ANS: A .6t
Balanced intake and output gives measurable data showingresolution ofthe problem of deficient
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fluid volume. The other statements would not indicate that the problem of hypovolemia was
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resolved.
.6t
DIF: Cognitive Level: Apply (Application) .6t .6t .6t TOP: NursingProcess: Planning . 6t .6t .6t
MSC: NCLEX: Physiological Integrity
.6t . 6 t .6t .6t
6. Which statement describes the purpose of the evaluation phase of the nursing process?
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a. To document the nursing care plan in the progress notes of the health record
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b. To determine if interventions have been effective in meetingpatient outcomes
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c. To decide whether the patient‘s health problems have been completely resolved
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d. To establish if the patient agrees that the nursing care provided was satisfactory
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ANS: B .6t
, Evaluation consists of determining whether the desired patient outcomes have been met and .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
whether the nursing interventions were appropriate. The other responses do not describe the
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evaluation phase.
.6t .6t
DIF: Cognitive Level: Understand (Comprehension)
. 6 t .6t .6t .6t TOP: Nursing Process: Evaluation . 6t .6t .6t
MSC: NCLEX: Safe and Effective Care Environment
.6t . 6 t .6t .6t .6t .6t .6t
7. Whichstatement describes the purpose of the assessment phase of the nursing process?
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a. To teach interventions that relieve health problems
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b. To use patient data to evaluate patient care outcomes
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c. To obtain data to diagnose patient strengths and problems
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d. To help the patient identifyrealistic outcomes for health problems
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ANS: C .6t
During the assessment phase, the nurse gathers information about the patient to diagnose patient
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strengths and problems. The other responses are examples of the planning, intervention, and
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evaluation phases of the nursing process.
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DIF: Cognitive Level: Understand (Comprehension) .6t .6t .6t
TOP: NursingProcess: Assessment
. MSC: NCLEX: Safeand Effective Care Environment
6 t .6t .6t . 6 t .6t .6t .6t .6t .6t
8. When developingthe plan of care, which components would the nurseinclude in theclinical
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problem statement?
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a. Theproblem and the suggested patient goals or outcomes
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b. Theproblem, its causes, and the signs and symptoms of the problem
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c. Theproblem with the possible etiologyand the planned interventions
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d. Theproblem, its pathophysiology, and the expected outcome
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ANS: B .6t
When writing clinical problems or nursing diagnoses, the subjective as well as objective data
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to support the problem‘s existence should be included. Goals, outcomes, and interventions are
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not included in the problem statement.
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DIF: Cognitive Level: Understand (Comprehension) .6t .6t .6t TOP: NursingProcess: Diagnosis . 6t .6t .6t
MSC: NCLEX: Safe and Effective Care Environment
.6t . 6 t .6t .6t .6t .6t .6t
9. Which patient care task would the nursedelegate to experienced assistive personnel (AP)?
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a. Instruct the patient about the need to alternate activityand rest. .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
b. Monitor level of shortness of breath or fatigue after ambulation. .6t .6t .6t .6t .6t .6t .6t .6t .6t
c. Obtainthe patient‘s blood pressure and pulse rate after ambulation. .6t .6t .6t .6t .6t .6t .6t .6t .6t
d. Determine whether the patient is readyto increase the activitylevel. .6t .6t .6t .6t .6t .6t .6t .6t .6t .6t
ANS: C .6t
AP educationincludes accurate vital sign measurement.Assessment and patient teaching require
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registered nurse education and scope of practice and cannot be delegated.
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DIF: Cognitive Level: Apply (Application) .6t .6t .6t TOP: NursingProcess: Planning . 6t .6t .6t
MSC: NCLEX: Safe and Effective Care Environment
.6t . 6 t .6t .6t .6t .6t .6t
