, 3
Chapter 01: Professional Nursing
vz vz vz
Harding: Lewis’s Medical-Surgical Nursing, 12th
vz vz vz vz
MULTIPLE CHOICE v z
1. The nurse completes an admission database and explains that the plan of care a
v z v z v z v z v z v z v z v z v z v z v z v z v z
nd discharge goals will be developed with the patient‗s input. The patient asks,
vz v z v z v z v z v z v z v z v z v z v z v z v
z―How is this different from what the physician does?‖ Which response would
v z v z v z v z v z v z v z v z v z v z v z
the nurse provide?
v z v z vz
a. ―The role of the nurse is to administer medications and other
vz vz vz vz vz vz v z vz v z vz
treatments prescribed by your physician.‖
v z v z v z v z v z
b. ―In addition to caring for you while you are sick, the nurses wil
v z v z v z vz v z v z v z v z vz v z v z v z
l help you plan to maintain your health.‖
v z vz v z v z v z v z v z
c. ―The nurse‗s job is to collect information and communicate any
vz vz vz vz vz vz vz vz vz v
problems that occur to the physician.‖
z v z v z v z v z v z
d. ―Nurses perform many of the same procedures as the physician,
v z v z vz v z vz vz v z v z vz v z
but nurses are with the patients for a longer time than the
vz v z v z v z v z v z v z v z v z v z v z v
physician.‖
z
ANS: v z B
The American Nurses Association (ANA) definition of nursing describes the role
v z v z v z v z v z v z v z v z v z v z v z
of nurses in promoting health. The other responses describe dependent and
vz v z v z v z v z v z v z v z v z v z vz
collaborative functions of the nursing role but do not accurately describe the nurs
v z v z v z v z v z v z v z v z v z vz v z v z
e‗s unique role in the health care system.
vz v z v z v z v z v z v z
DIF: v z v z Cognitive Level: Analyze (Analysis) v z v z v z
TOP: Nursing Process: Implementation MSC:
v z v z vzvz NCLEX: Safe and Effective Care Environment
v z v z v z v z v z
2. Which statement by the nurse accurately describes the use of evidence-
v z v z vz v z v z v z v z v z v z v z
based practice (EBP)? v z v z
a. ―Patient care is based on clinical judgment, experience, and traditions.‖
vz vz vz vz v z vz vz vz vz
b. ―Data are analyzed later to show that the patient outcomes are consistently met.‖
v z v z v z v z v z v z v z v z v z v z v z v z
c. ―Research from all published articles are used as a guide for planning patient care.‖
v z v z v z v z v z v z v z v z v z v z v z vz v z
d. ―Recommendations are based on research, clinical expertise vz vz vz vz vz vz
, and patient preferences.‖
vz v z v z
ANS: v z D
Evidence-based practice (EBP) is the use of the best research- v z v z v z v z v z v z v z v z v z
based evidence combined with clinician expertise and consideration of patient pr
v z vz v z v z v z v z v z v z v z v z
eferences. Clinical judgment based on the nurse‗s clinical experience is part of
v z vz v z v z v z v z v z v z v z v z v z v
zEBP, but clinical decision making should also incorporate current research and
v z v z vz v z v z v z v z v z v z v z v
zresearch-
based guidelines. Evaluation of patient outcomes is important, but data analysis
vz v z v z v z v z v z v z v z v z v z v
zis not required to use EBP. All published articles do not provide research evi
v z vz v z v z v z v z v z v z v z v z v z v z v z
dence; interventions should be based on credible research, preferably randomized
vz v z v z v z v z v z v z v z v z v
zcontrolled studies with a large number of subjects.
vz v z v z v z v z v z v z
DIF: Cognitive Level: Understand (Comprehension) v z v z v z
TOP: Nursing Process: Planning MSC:
vz vz vz v z
NCLEX: Safe and Effective Care Environment
v z v z v z v z v z
3. Which statement by the nurse provides a clear explanation of the nursing process?
v z v z v z v z v z v z v z v z v z v z v z v z
a. ―The nursing process is a research method of diagnosing the patient‗
vz vz vz vz vz vz vz vz vz vz
s health care problems.‖
vz v z v z
b. ―The nursing process is used primarily to explain nursing
vz vz vz vz vz vz vz vz v
interventions to other health care professionals.‖
z v z v z v z v z v z
c. ―The nursing process is a problem-solving tool used to identify and manage the
vz v z v z v z v z v z v z v z v z v z v z v z
, 4
patients‗ health care needs.‖ vz v z v z
d. ―The nursing process is based on nursing theory that
vz vz vz vz vz vz vz vz vz
incorporates the biopsychosocial nature of human v z v z v z v z v z
s.‖
ANS: v z C
The nursing process is a problem-
v z v z v z v z v z
solving approach to the identification and treatment of patients‗ problems. Nursi
v z v z v z v z v z v z vz v z v z v z
ng process does not require research methods for diagnosis. The primary use o
v z v z v z v z v z v z v z vz v z v z v z v z
f the nursing process is in patient care, not to establish nursing theory or expl
v z v z v z v z v z v z v z v z v z v z vz v z v z v z
ain nursing interventions to other health care professionals.
v z v z v z v z v z v z v z
DIF: Cognitive Level: Understand (Comprehension)
v z v z v z
TOP: Nursing Process: Evaluation MSC:
vz vz vz v z
NCLEX: Safe and Effective Care Environment
v z v z v z v z v z
4. A patient admitted to the hospital for surgery tells the nurse, ―I
v z v z v z v z v z v z v z v z v z v z v z v z
do not feel comfortable leaving my children with my parents.‖ Wh
v z vz v z v z v z v z v z v z v z v z
ich action would the nurse take next?
v z vz v z v z v z v z
a. Reassure the patient that these feelings are common for parents.
v z v z v z v z v z v z v z v z v z
b. Have the patient call the children to ensure that they are doing well.
v z v z v z v z v z v z v z v z v z v z v z v z
c. Gather information on the patient‗s concerns about the child care arrangements.
vz v z v z v z v z v z v z v z v z v z
d. Call the patient‗s parents to determine whether adequate c
v z v z v z v z vz v z v z v z
hild care is being provided. vz v z v z v z
ANS: v z C
Because a complete assessment is necessary in order to identify a proble
v z v z v z v z v z v z v z v z v z v z v z
m and choose an appropriate intervention, the nurse‗s first action should be to
v z vz v z v z v z v z v z v z v z v z v z v z
obtain more information. The other actions may be appropriate, but more asse
v z v z vz v z v z v z v z v z v z v z v z v z
ssment is needed before the best intervention can be chosen.
v z v z vz v z v z v z v z v z v z
DIF: Cognitive Level: Analyze (Analysis) vz v z v z
TOP: Nursing Process: Assessment MSC: v z v z v z NCLEX: Psychosocial Integrity v z v z
5. A patient with a bacterial infection is hypovolemic due to a feve
v z v z v z v z v z v z v z v z v z v z v z
r and excessive diaphoresis. Which expected outcome would the n
v z vz v z v z v z v z v z v z v z
urse select for this patient?
v z vz v z v z
a. Patient has a balanced intake and output.v z v z v z v z v z v z
b. Patient‗s bedding is kept clean and free of moisture.
v z v z v z v z v z v z v z v z
c. Patient understands the need for increased fluid intake.
v z v z v z v z v z v z v z
d. Patient‗s skin remains cool and dry throughout hospitalization.
v z v z v z v z v z vz v z
ANS: v z A
Balanced intake and output gives measurable data showing resolution of the pro
v z v z v z v z v z v z v z v z v z v z v z
blem of deficient fluid volume. The other statements would not indicate that th
vz v z v z v z v z v z v z v z v z v z v z v z
e problem of hypovolemia was resolved.
v z v z v z v z v z
DIF: Cognitive Level: Apply (Application) v z v z v z
TOP: Nursing Process: Planning MSC:
vz vz vz v z
NCLEX: Physiological Integrity v z v z
6. Which v z statement describes the purpose of the evaluation phase of the nursing process?
v z v z v z v z v z v z v z v z v z v z v z
a. To v z document the nursing care plan in the progress notes of the health record
v z v z v z v z v z v z v z v z v z v z v z v z
b. To v z determine if interventions have been effective in meeting patient outcomes
v z v z v z v z v z v z v z v z v z
c. To v z decide whether the patient‗s health problems have been completely resolved
v z v z v z v z v z v z v z v z v z
d. To v z establish if the patient agrees that the nursing care provided was satisfactory
v z v z v z v z v z v z v z v z v z v z v z
ANS: v z B
, 5
Evaluation consists of determining whether the desired patient outcomes have
v z v z v z v z v z v z v z v z v z v z
been met and whether the nursing interventions were appropriate. The other resp
vz v z v z v z v z v z v z v z v z v z v z
onses do not describe the evaluation phase.
v z vz v z v z v z v z
DIF: Cognitive Level: Understand (Comprehension)
v z v z v z TOP: Nursing
Process: Evaluation MSC: vz v z
NCLEX: Safe and Effective Care Environment
v z v z v z v z v z
7. Which v z statement describes the purpose of the assessment phase of the nursing process?
v z v z v z v z v z v z v z v z v z v z v z
a. To v z teach interventions that relieve health problems
v z v z v z v z v z
b. To v z use patient data to evaluate patient care outcomes
v z v z v z v z v z v z v z
c. To v z obtain data to diagnose patient strengths and problems
v z v z v z v z v z v z v z
d. To v z help the patient identify realistic outcomes for health problems
v z v z v z v z v z v z v z v z
ANS: v z C
During the assessment phase, the nurse gathers information about the patient to
v z v z v z v z v z v z v z v z v z v z v z v
zdiagnose patient strengths and problems. The other responses are examples of t
v z v z v z v z v z v z v z v z v z v z v z
he planning, intervention, and evaluation phases of the nursing process.
vz v z v z v z v z v z v z v z v z
DIF: Cognitive Level: Understand (Comprehension) v z v z vz
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
v z v z v z v z v z v z v z v z
8. When developing the plan of care, which components would the nurse i
v z v z v z v z v z v z v z v z v z v z v z
nclude in the clinical problem statement?
vz v z v z v z v z
a. The problem and the suggested patient goals or outcomes
v z v z v z v z v z v z v z v z
b. The problem, its causes, and the signs and symptoms of the problem
v z v z v z v z v z v z v z v z v z v z v z
c. The problem with the possible etiology and the planned interventions
v z v z v z v z v z v z v z v z v z
d. The problem, its pathophysiology, and the expected outcome
v z v z v z v z v z v z v z
ANS: v z B
When writing clinical problems or nursing diagnoses, the subjective as well
v z v z v z v z v z v z v z v z v z v z
v as objective data to support the problem‗s existence should be included.
z vz v z v z v z v z v z v z v z v z v z v
zGoals, outcomes, and interventions are not included in the problem statement.
vz v z v z v z v z v z v z v z v z v z
DIF: Cognitive Level: Understand (Comprehension)
v z v z v z
TOP: Nursing Process: Diagnosis MSC:
vz vz vz v z
NCLEX: Safe and Effective Care Environment
v z v z v z v z v z
9. Which patient care task would the nurse delegate to experienced assistive personnel (A
v z v z v z v z v z v z v z v z v z v z v z v z
P)?
a. Instruct the patient about the need to alternate activity and rest.
v z v z v z v z v z v z v z v z v z v z
b. Monitor level of shortness of breath or fatigue after ambulation.
v z v z v z v z v z v z v z v z v z
c. Obtain the patient‗s blood pressure and pulse rate after ambulation.
v z v z v z v z v z v z v z v z v z
d. Determine whether the patient is ready to increase the activity level.
v z v z v z v z v z v z v z v z v z v z
ANS: v z C
AP education includes accurate vital sign measurement. Assessment and patient t
v z v z v z v z v z v z v z v z v z vz
eaching require registered nurse education and scope of practice and cannot be
v z v z v z v z v z v z v z v z v z v z v z vz
delegated.
DIF: Cognitive Level: Apply (Application) v z v z v z
TOP: Nursing Process: Planning MSC:
vz vz vz v z
NCLEX: Safe and Effective Care Environment
v z v z v z v z v z
Chapter 01: Professional Nursing
vz vz vz
Harding: Lewis’s Medical-Surgical Nursing, 12th
vz vz vz vz
MULTIPLE CHOICE v z
1. The nurse completes an admission database and explains that the plan of care a
v z v z v z v z v z v z v z v z v z v z v z v z v z
nd discharge goals will be developed with the patient‗s input. The patient asks,
vz v z v z v z v z v z v z v z v z v z v z v z v
z―How is this different from what the physician does?‖ Which response would
v z v z v z v z v z v z v z v z v z v z v z
the nurse provide?
v z v z vz
a. ―The role of the nurse is to administer medications and other
vz vz vz vz vz vz v z vz v z vz
treatments prescribed by your physician.‖
v z v z v z v z v z
b. ―In addition to caring for you while you are sick, the nurses wil
v z v z v z vz v z v z v z v z vz v z v z v z
l help you plan to maintain your health.‖
v z vz v z v z v z v z v z
c. ―The nurse‗s job is to collect information and communicate any
vz vz vz vz vz vz vz vz vz v
problems that occur to the physician.‖
z v z v z v z v z v z
d. ―Nurses perform many of the same procedures as the physician,
v z v z vz v z vz vz v z v z vz v z
but nurses are with the patients for a longer time than the
vz v z v z v z v z v z v z v z v z v z v z v
physician.‖
z
ANS: v z B
The American Nurses Association (ANA) definition of nursing describes the role
v z v z v z v z v z v z v z v z v z v z v z
of nurses in promoting health. The other responses describe dependent and
vz v z v z v z v z v z v z v z v z v z vz
collaborative functions of the nursing role but do not accurately describe the nurs
v z v z v z v z v z v z v z v z v z vz v z v z
e‗s unique role in the health care system.
vz v z v z v z v z v z v z
DIF: v z v z Cognitive Level: Analyze (Analysis) v z v z v z
TOP: Nursing Process: Implementation MSC:
v z v z vzvz NCLEX: Safe and Effective Care Environment
v z v z v z v z v z
2. Which statement by the nurse accurately describes the use of evidence-
v z v z vz v z v z v z v z v z v z v z
based practice (EBP)? v z v z
a. ―Patient care is based on clinical judgment, experience, and traditions.‖
vz vz vz vz v z vz vz vz vz
b. ―Data are analyzed later to show that the patient outcomes are consistently met.‖
v z v z v z v z v z v z v z v z v z v z v z v z
c. ―Research from all published articles are used as a guide for planning patient care.‖
v z v z v z v z v z v z v z v z v z v z v z vz v z
d. ―Recommendations are based on research, clinical expertise vz vz vz vz vz vz
, and patient preferences.‖
vz v z v z
ANS: v z D
Evidence-based practice (EBP) is the use of the best research- v z v z v z v z v z v z v z v z v z
based evidence combined with clinician expertise and consideration of patient pr
v z vz v z v z v z v z v z v z v z v z
eferences. Clinical judgment based on the nurse‗s clinical experience is part of
v z vz v z v z v z v z v z v z v z v z v z v
zEBP, but clinical decision making should also incorporate current research and
v z v z vz v z v z v z v z v z v z v z v
zresearch-
based guidelines. Evaluation of patient outcomes is important, but data analysis
vz v z v z v z v z v z v z v z v z v z v
zis not required to use EBP. All published articles do not provide research evi
v z vz v z v z v z v z v z v z v z v z v z v z v z
dence; interventions should be based on credible research, preferably randomized
vz v z v z v z v z v z v z v z v z v
zcontrolled studies with a large number of subjects.
vz v z v z v z v z v z v z
DIF: Cognitive Level: Understand (Comprehension) v z v z v z
TOP: Nursing Process: Planning MSC:
vz vz vz v z
NCLEX: Safe and Effective Care Environment
v z v z v z v z v z
3. Which statement by the nurse provides a clear explanation of the nursing process?
v z v z v z v z v z v z v z v z v z v z v z v z
a. ―The nursing process is a research method of diagnosing the patient‗
vz vz vz vz vz vz vz vz vz vz
s health care problems.‖
vz v z v z
b. ―The nursing process is used primarily to explain nursing
vz vz vz vz vz vz vz vz v
interventions to other health care professionals.‖
z v z v z v z v z v z
c. ―The nursing process is a problem-solving tool used to identify and manage the
vz v z v z v z v z v z v z v z v z v z v z v z
, 4
patients‗ health care needs.‖ vz v z v z
d. ―The nursing process is based on nursing theory that
vz vz vz vz vz vz vz vz vz
incorporates the biopsychosocial nature of human v z v z v z v z v z
s.‖
ANS: v z C
The nursing process is a problem-
v z v z v z v z v z
solving approach to the identification and treatment of patients‗ problems. Nursi
v z v z v z v z v z v z vz v z v z v z
ng process does not require research methods for diagnosis. The primary use o
v z v z v z v z v z v z v z vz v z v z v z v z
f the nursing process is in patient care, not to establish nursing theory or expl
v z v z v z v z v z v z v z v z v z v z vz v z v z v z
ain nursing interventions to other health care professionals.
v z v z v z v z v z v z v z
DIF: Cognitive Level: Understand (Comprehension)
v z v z v z
TOP: Nursing Process: Evaluation MSC:
vz vz vz v z
NCLEX: Safe and Effective Care Environment
v z v z v z v z v z
4. A patient admitted to the hospital for surgery tells the nurse, ―I
v z v z v z v z v z v z v z v z v z v z v z v z
do not feel comfortable leaving my children with my parents.‖ Wh
v z vz v z v z v z v z v z v z v z v z
ich action would the nurse take next?
v z vz v z v z v z v z
a. Reassure the patient that these feelings are common for parents.
v z v z v z v z v z v z v z v z v z
b. Have the patient call the children to ensure that they are doing well.
v z v z v z v z v z v z v z v z v z v z v z v z
c. Gather information on the patient‗s concerns about the child care arrangements.
vz v z v z v z v z v z v z v z v z v z
d. Call the patient‗s parents to determine whether adequate c
v z v z v z v z vz v z v z v z
hild care is being provided. vz v z v z v z
ANS: v z C
Because a complete assessment is necessary in order to identify a proble
v z v z v z v z v z v z v z v z v z v z v z
m and choose an appropriate intervention, the nurse‗s first action should be to
v z vz v z v z v z v z v z v z v z v z v z v z
obtain more information. The other actions may be appropriate, but more asse
v z v z vz v z v z v z v z v z v z v z v z v z
ssment is needed before the best intervention can be chosen.
v z v z vz v z v z v z v z v z v z
DIF: Cognitive Level: Analyze (Analysis) vz v z v z
TOP: Nursing Process: Assessment MSC: v z v z v z NCLEX: Psychosocial Integrity v z v z
5. A patient with a bacterial infection is hypovolemic due to a feve
v z v z v z v z v z v z v z v z v z v z v z
r and excessive diaphoresis. Which expected outcome would the n
v z vz v z v z v z v z v z v z v z
urse select for this patient?
v z vz v z v z
a. Patient has a balanced intake and output.v z v z v z v z v z v z
b. Patient‗s bedding is kept clean and free of moisture.
v z v z v z v z v z v z v z v z
c. Patient understands the need for increased fluid intake.
v z v z v z v z v z v z v z
d. Patient‗s skin remains cool and dry throughout hospitalization.
v z v z v z v z v z vz v z
ANS: v z A
Balanced intake and output gives measurable data showing resolution of the pro
v z v z v z v z v z v z v z v z v z v z v z
blem of deficient fluid volume. The other statements would not indicate that th
vz v z v z v z v z v z v z v z v z v z v z v z
e problem of hypovolemia was resolved.
v z v z v z v z v z
DIF: Cognitive Level: Apply (Application) v z v z v z
TOP: Nursing Process: Planning MSC:
vz vz vz v z
NCLEX: Physiological Integrity v z v z
6. Which v z statement describes the purpose of the evaluation phase of the nursing process?
v z v z v z v z v z v z v z v z v z v z v z
a. To v z document the nursing care plan in the progress notes of the health record
v z v z v z v z v z v z v z v z v z v z v z v z
b. To v z determine if interventions have been effective in meeting patient outcomes
v z v z v z v z v z v z v z v z v z
c. To v z decide whether the patient‗s health problems have been completely resolved
v z v z v z v z v z v z v z v z v z
d. To v z establish if the patient agrees that the nursing care provided was satisfactory
v z v z v z v z v z v z v z v z v z v z v z
ANS: v z B
, 5
Evaluation consists of determining whether the desired patient outcomes have
v z v z v z v z v z v z v z v z v z v z
been met and whether the nursing interventions were appropriate. The other resp
vz v z v z v z v z v z v z v z v z v z v z
onses do not describe the evaluation phase.
v z vz v z v z v z v z
DIF: Cognitive Level: Understand (Comprehension)
v z v z v z TOP: Nursing
Process: Evaluation MSC: vz v z
NCLEX: Safe and Effective Care Environment
v z v z v z v z v z
7. Which v z statement describes the purpose of the assessment phase of the nursing process?
v z v z v z v z v z v z v z v z v z v z v z
a. To v z teach interventions that relieve health problems
v z v z v z v z v z
b. To v z use patient data to evaluate patient care outcomes
v z v z v z v z v z v z v z
c. To v z obtain data to diagnose patient strengths and problems
v z v z v z v z v z v z v z
d. To v z help the patient identify realistic outcomes for health problems
v z v z v z v z v z v z v z v z
ANS: v z C
During the assessment phase, the nurse gathers information about the patient to
v z v z v z v z v z v z v z v z v z v z v z v
zdiagnose patient strengths and problems. The other responses are examples of t
v z v z v z v z v z v z v z v z v z v z v z
he planning, intervention, and evaluation phases of the nursing process.
vz v z v z v z v z v z v z v z v z
DIF: Cognitive Level: Understand (Comprehension) v z v z vz
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
v z v z v z v z v z v z v z v z
8. When developing the plan of care, which components would the nurse i
v z v z v z v z v z v z v z v z v z v z v z
nclude in the clinical problem statement?
vz v z v z v z v z
a. The problem and the suggested patient goals or outcomes
v z v z v z v z v z v z v z v z
b. The problem, its causes, and the signs and symptoms of the problem
v z v z v z v z v z v z v z v z v z v z v z
c. The problem with the possible etiology and the planned interventions
v z v z v z v z v z v z v z v z v z
d. The problem, its pathophysiology, and the expected outcome
v z v z v z v z v z v z v z
ANS: v z B
When writing clinical problems or nursing diagnoses, the subjective as well
v z v z v z v z v z v z v z v z v z v z
v as objective data to support the problem‗s existence should be included.
z vz v z v z v z v z v z v z v z v z v z v
zGoals, outcomes, and interventions are not included in the problem statement.
vz v z v z v z v z v z v z v z v z v z
DIF: Cognitive Level: Understand (Comprehension)
v z v z v z
TOP: Nursing Process: Diagnosis MSC:
vz vz vz v z
NCLEX: Safe and Effective Care Environment
v z v z v z v z v z
9. Which patient care task would the nurse delegate to experienced assistive personnel (A
v z v z v z v z v z v z v z v z v z v z v z v z
P)?
a. Instruct the patient about the need to alternate activity and rest.
v z v z v z v z v z v z v z v z v z v z
b. Monitor level of shortness of breath or fatigue after ambulation.
v z v z v z v z v z v z v z v z v z
c. Obtain the patient‗s blood pressure and pulse rate after ambulation.
v z v z v z v z v z v z v z v z v z
d. Determine whether the patient is ready to increase the activity level.
v z v z v z v z v z v z v z v z v z v z
ANS: v z C
AP education includes accurate vital sign measurement. Assessment and patient t
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eaching require registered nurse education and scope of practice and cannot be
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delegated.
DIF: Cognitive Level: Apply (Application) v z v z v z
TOP: Nursing Process: Planning MSC:
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NCLEX: Safe and Effective Care Environment
v z v z v z v z v z
