CHAPTER 1 TEST BANK;
PROFESSIONAL NURSING LEWIS’S
MEDICAL-SURGICAL NURSING, 12TH
EDITION |
[Document subtitle]
, Term
Name: Score:
1 of 19
Which actions by a nurse would demonstrate an aspect of nursing clinical judgment? (Select all that apply.)
a. Identifying priority problems
b. Noticing a change in patient status
c. Memorizing the steps of a procedure
d. Assessing data about a patient situation
e. Generating possible solutions to a patient problem
f. Making decisions based on the implications of a patient's situation
ANS: A, B, D, E, F
Clinical judgment is evident when the nurse assesses data or situations, notices a change in a
patient's status, identifies priority problems, generates the best possible solutions, and makes decisions
about patient care based on analysis of the situation. Clinical judgment is not memorizing a list of facts or
the steps of a procedure.
ANS: A, B, D, E
National Patient Safety Goals have been established to promote safe delivery of care. The nurse
should use at least 2 reliable ways to identify the patient such as asking the patient's full name and
date of birth before medication administration. Other actions that improve patient safety include
performing hand hygiene, disposing of unlabeled medications, completing appropriate assessments
before administering medications, and giving a list of the current medicines to the patient and caregiver
before discharge.
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.
ANS: A, B, C, E
The nurse should assess the experience of LPN/VNs when delegating. In addition, state nurse practice
acts and agency policies must be considered. In general, while the LPN/VN scope of practice includes
caring for patients who are stable, registered nurses should provide most of the care for unstable
patients. Because the LPN/VN scope of practice does not include patient education, this will not be
part of the delegation process.
2 of 19
A home care nurse is planning care for a patient who has just been diagnosed with type 2 diabetes. Which
, Term
task is appropriate for the nurse to delegate to the home health aide? a. Assist the patient to choose
appropriate foods.
b. Help the patient with a daily bath and oral care.
c. Check the patient's feet for signs of breakdown.
d. Teach the patient how to monitor blood glucose.
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.
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.
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.
ANS: B
Assisting with patient hygiene is included in home health-aide education and scope of practice.
Assessment of the patient and instructing the patient in new skills, such as diet and
blood glucose monitoring, are complex skills that are included in registered nurse education
and scope of practice.
3 of 19
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
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.
PROFESSIONAL NURSING LEWIS’S
MEDICAL-SURGICAL NURSING, 12TH
EDITION |
[Document subtitle]
, Term
Name: Score:
1 of 19
Which actions by a nurse would demonstrate an aspect of nursing clinical judgment? (Select all that apply.)
a. Identifying priority problems
b. Noticing a change in patient status
c. Memorizing the steps of a procedure
d. Assessing data about a patient situation
e. Generating possible solutions to a patient problem
f. Making decisions based on the implications of a patient's situation
ANS: A, B, D, E, F
Clinical judgment is evident when the nurse assesses data or situations, notices a change in a
patient's status, identifies priority problems, generates the best possible solutions, and makes decisions
about patient care based on analysis of the situation. Clinical judgment is not memorizing a list of facts or
the steps of a procedure.
ANS: A, B, D, E
National Patient Safety Goals have been established to promote safe delivery of care. The nurse
should use at least 2 reliable ways to identify the patient such as asking the patient's full name and
date of birth before medication administration. Other actions that improve patient safety include
performing hand hygiene, disposing of unlabeled medications, completing appropriate assessments
before administering medications, and giving a list of the current medicines to the patient and caregiver
before discharge.
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.
ANS: A, B, C, E
The nurse should assess the experience of LPN/VNs when delegating. In addition, state nurse practice
acts and agency policies must be considered. In general, while the LPN/VN scope of practice includes
caring for patients who are stable, registered nurses should provide most of the care for unstable
patients. Because the LPN/VN scope of practice does not include patient education, this will not be
part of the delegation process.
2 of 19
A home care nurse is planning care for a patient who has just been diagnosed with type 2 diabetes. Which
, Term
task is appropriate for the nurse to delegate to the home health aide? a. Assist the patient to choose
appropriate foods.
b. Help the patient with a daily bath and oral care.
c. Check the patient's feet for signs of breakdown.
d. Teach the patient how to monitor blood glucose.
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.
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.
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.
ANS: B
Assisting with patient hygiene is included in home health-aide education and scope of practice.
Assessment of the patient and instructing the patient in new skills, such as diet and
blood glucose monitoring, are complex skills that are included in registered nurse education
and scope of practice.
3 of 19
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
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.
