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