Test Bank for Lewis's Medical-Surgical
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Nursing, 12th Edition by Mariann M. Hard
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ing, Jeffrey Kwong, Debra Hagler Chapter
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1-69
,Chapter 01: Professional Nursing
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Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
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MULTIPLE CHOICE hi
1. The nurse completes an admission database and explains that the plan of care and discharge g
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oals will be developed with the patient‘s input. The patient asks, “How is this different from what
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the physician does?” Which response would the nurse provide?
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a. “The role of the nurse is to administer medications and other treatments prescribed by
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your physician.”i hi
b. “In addition to caring for you while you are sick, the nurses will help you plan to mai
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
ntain your health.” hi hi
c. “The nurse‘s job is to collect information and communicate any problems that oc
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cur to the physician.” hi hi hi
d. “Nurses perform many of the same procedures as the physician, but nurses are wi
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th the patients for a longer time than the physician.”
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ANS: B hi
The American Nurses Association (ANA) definition of nursing describes the role of nurses in pr
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omoting health. The other responses describe dependent and collaborative functions of the nur
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sing role but do not accurately describe the nurse‘s unique role in the health care system.
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DIF: Cognitive Level: Analyze (Analysis)
h i h i hi hi hi
TOP: Nursing Process: Implementation
h i hi hi h i h i h i MSC: NCLEX: Safe and Effective Care Environment
h i hi hi hi hi hi
2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
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a. “Patient care is based on clinical judgment, experience, and traditions.”
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b. “Data are analyzed later to show that the patient outcomes are consistently met.”
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c. “Research from all published articles are used as a guide for planning patient care.” hi hi hi hi hi hi hi hi hi hi hi hi hi
d. “Recommendations are based on research, clinical expertise, and patient pr hi hi hi hi hi hi hi hi hi
eferences.”
ANS: D hi
Evidence-based practice (EBP) is the use of the best research- hi hi hi hi hi hi hi hi hi
based evidence combined with clinician expertise and consideration of patient preferences. Cli
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nical judgment based on the nurse‘s clinical experience is part of EBP, but clinical decision m
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aking should also incorporate current research and research-
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based guidelines. Evaluation of patient outcomes is important, but data analysis is not required t
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o use EBP. All published articles do not provide research evidence; interventions should be bas
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ed on credible research, preferably randomized controlled studies with a large number of subjec
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ts.
DIF: Cognitive Level: Understand (Comprehension) hi hi hi
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
hi hi hi hi h i hi hi hi hi hi
3. Which statement by the nurse provides a clear explanation of the nursing process?
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a. “The nursing process is a research method of diagnosing the patient‘s health care pr
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oblems.”
b. “The nursing process is used primarily to explain nursing interventions to other he
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alth care professionals.” hi hi
c. “The nursing process is a problem-solving tool used to identify and manage the
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, patients‘ health care needs.” hi hi hi
d. “The nursing process is based on nursing theory that incorporates the bi
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opsychosocial nature of humans.” hi hi hi
ANS: C hi
The nursing process is a problem-
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solving approach to the identification and treatment of patients‘ problems. Nursing process do
hi hi hi hi hi hi hi hi hi hi hi hi
es not require research methods for diagnosis. The primary use of the nursing process is in patien
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
t care, not to establish nursing theory or explain nursing interventions to other health care profe
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
ssionals.
DIF: Cognitive Level: Understand (Comprehension) hi hi hi
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
hi hi hi hi h i hi hi hi hi hi
4. A patient admitted to the hospital for surgery tells the nurse, “I do not feel comfortable lea
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
ving my children with my parents.” Which action would the nurse take next?
hi hi hi hi hi hi hi hi hi hi hi hi
a. Reassure the patient that these feelings are common for parents. hi hi hi hi hi hi hi hi hi
b. Have the patient call the children to ensure that they are doing well.
hi hi hi hi hi hi hi hi hi hi hi hi
c. Gather information on the patient‘s concerns about the child care arrangements.
hi h i hi hi hi hi hi h i h i hi
d. Call the patient‘s parents to determine whether adequate child care is being pr
hi hi hi hi hi hi hi hi hi hi hi hi
ovided.
ANS: C hi
Because a complete assessment is necessary in order to identify a problem and choose an appr
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
opriate intervention, the nurse‘s first action should be to obtain more information. The other ac
hi hi hi hi hi hi hi hi hi hi hi hi hi hi
tions may be appropriate, but more assessment is needed before the best intervention can be chos
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
en.
DIF: Cognitive Level: Analyze (Analysis) hi hi hi
TOP: Nursing Process: Assessment
h i MSC: NCLEX: Psychosocial Integrity hi hi h i hi hi
5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis. W
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
hich expected outcome would the nurse select for this patient?
hi hi hi hi hi hi hi hi hi
a. Patient has a balanced intake and output. hi hi hi hi hi hi
b. Patient‘s bedding is kept clean and free of moisture. hi hi hi hi hi hi hi hi
c. Patient understands the need for increased fluid intake. hi hi hi h i hi h i hi
d. Patient‘s skin remains cool and dry throughout hospitalization. hi hi hi hi hi hi hi
ANS: A hi
Balanced intake and output gives measurable data showing resolution of the problem of deficient
hi hi hi hi hi hi hi hi hi hi hi hi hi
fluid volume. The other statements would not indicate that the problem of hypovolemia was r
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
esolved.
DIF: Cognitive Level: Apply (Application) hi hi hi
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
hi hi hi hi h i hi hi
6. Which statement describes the purpose of the evaluation phase of the nursing process?
hi hi hi hi hi hi hi hi hi hi hi hi
a. To document the nursing care plan in the progress notes of the health record
hi hi hi hi hi hi hi hi hi hi hi hi hi
b. To determine if interventions have been effective in meeting patient outcomes
hi hi hi h i hi h i hi h i hi h i
c. To decide whether the patient‘s health problems have been completely resolved
hi h i h i hi h i hi hi hi h i hi
d. To establish if the patient agrees that the nursing care provided was satisfactory
hi hi hi hi hi hi hi hi hi hi hi hi
ANS: B hi
, Evaluation consists of determining whether the desired patient outcomes have been met and w
hi hi hi hi hi hi hi hi hi hi hi hi hi
hether the nursing interventions were appropriate. The other responses do not describe the eva
hi hi hi hi hi hi hi hi hi hi hi hi hi
luation phase. hi
DIF: Cognitive Level: Understand (Comprehension) hi hi hi
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
hi hi hi hi h i hi hi hi hi hi
7. Which statement describes the purpose of the assessment phase of the nursing process?
hi h i hi hi h i hi hi h i hi hi h i hi
a. To teach interventions that relieve health problems
hi hi hi hi hi h i
b. To use patient data to evaluate patient care outcomes
hi hi hi hi hi hi hi hi
c. To obtain data to diagnose patient strengths and problems
hi hi hi hi hi hi hi hi
d. To help the patient identify realistic outcomes for health problems
hi hi hi hi hi hi h i hi hi
ANS: C hi
During the assessment phase, the nurse gathers information about the patient to diagnose patient
hi hi hi hi hi hi hi hi hi hi hi hi hi hi
strengths and problems. The other responses are examples of the planning, intervention, and e
hi hi hi hi hi hi hi hi hi hi hi hi hi
valuation phases of the nursing process. hi hi hi hi hi
DIF: Cognitive Level: Understand (Comprehension) hi hi hi
TOP: Nursing Process: Assessment
h i MSC: NCLEX: Safe and Effective Care Environment
hi hi h i hi hi hi hi hi
8. When developing the plan of care, which components would the nurse include in the clinical pr
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
oblem statement? hi
a. The problem and the suggested patient goals or outcomes
hi hi hi hi hi hi hi hi
b. The problem, its causes, and the signs and symptoms of the problem
hi hi hi hi hi hi hi hi hi hi hi
c. The problem with the possible etiology and the planned interventions
hi h i hi hi hi hi hi h i hi
d. The problem, its pathophysiology, and the expected outcome
hi h i hi h i hi hi hi
ANS: B hi
When writing clinical problems or nursing diagnoses, the subjective as well as objective data to
hi hi hi hi hi hi hi hi hi hi hi hi hi hi
support the problem‘s existence should be included. Goals, outcomes, and interventions are not i
hi hi hi hi hi hi hi hi hi hi hi hi hi hi
ncluded in the problem statement. hi hi hi hi
DIF: Cognitive Level: Understand (Comprehension) hi hi hi
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
hi hi hi hi h i hi hi hi hi hi
9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
hi hi hi hi hi hi hi hi hi hi hi hi
a. Instruct the patient about the need to alternate activity and rest.
hi hi hi hi hi hi hi hi hi hi
b. Monitor level of shortness of breath or fatigue after ambulation.
hi hi hi hi hi hi hi hi hi
c. Obtain the patient‘s blood pressure and pulse rate after ambulation.
hi hi hi hi hi h i hi hi hi
d. Determine whether the patient is ready to increase the activity level. hi hi hi h i hi hi hi hi hi hi
ANS: C hi
AP education includes accurate vital sign measurement. Assessment and patient teaching require
hi hi hi hi hi hi hi hi hi hi hi hi
registered nurse education and scope of practice and cannot be delegated.
hi hi hi hi hi hi hi hi hi hi
DIF: Cognitive Level: Apply (Application) hi hi hi
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
hi hi hi hi h i hi hi hi hi hi
hi hi hi hi
Nursing, 12th Edition by Mariann M. Hard
hi hi hi hi hi hi
ing, Jeffrey Kwong, Debra Hagler Chapter
hi hi hi hi hi hi
1-69
,Chapter 01: Professional Nursing
hi hi hi
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
hi hi hi hi hi
MULTIPLE CHOICE hi
1. The nurse completes an admission database and explains that the plan of care and discharge g
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
oals will be developed with the patient‘s input. The patient asks, “How is this different from what
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
the physician does?” Which response would the nurse provide?
hi hi hi hi hi hi hi hi hi
a. “The role of the nurse is to administer medications and other treatments prescribed by
hi hi hi hi hi hi hi hi hi hi hi hi hi h
your physician.”i hi
b. “In addition to caring for you while you are sick, the nurses will help you plan to mai
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
ntain your health.” hi hi
c. “The nurse‘s job is to collect information and communicate any problems that oc
hi hi hi hi hi hi hi hi hi hi hi hi
cur to the physician.” hi hi hi
d. “Nurses perform many of the same procedures as the physician, but nurses are wi
hi hi hi hi hi hi hi hi hi hi hi hi hi
th the patients for a longer time than the physician.”
hi hi hi hi hi hi hi hi hi
ANS: B hi
The American Nurses Association (ANA) definition of nursing describes the role of nurses in pr
hi hi hi hi hi hi hi hi hi hi hi hi hi hi
omoting health. The other responses describe dependent and collaborative functions of the nur
hi hi hi hi hi hi hi hi hi hi hi hi
sing role but do not accurately describe the nurse‘s unique role in the health care system.
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
DIF: Cognitive Level: Analyze (Analysis)
h i h i hi hi hi
TOP: Nursing Process: Implementation
h i hi hi h i h i h i MSC: NCLEX: Safe and Effective Care Environment
h i hi hi hi hi hi
2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
h i h i hi h i hi hi h i hi hi h i h i hi
a. “Patient care is based on clinical judgment, experience, and traditions.”
hi hi hi hi hi hi hi hi hi
b. “Data are analyzed later to show that the patient outcomes are consistently met.”
hi hi hi hi hi hi hi hi hi hi hi hi
c. “Research from all published articles are used as a guide for planning patient care.” hi hi hi hi hi hi hi hi hi hi hi hi hi
d. “Recommendations are based on research, clinical expertise, and patient pr hi hi hi hi hi hi hi hi hi
eferences.”
ANS: D hi
Evidence-based practice (EBP) is the use of the best research- hi hi hi hi hi hi hi hi hi
based evidence combined with clinician expertise and consideration of patient preferences. Cli
hi hi hi hi hi hi hi hi hi hi hi
nical judgment based on the nurse‘s clinical experience is part of EBP, but clinical decision m
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
aking should also incorporate current research and research-
hi hi hi hi hi hi hi
based guidelines. Evaluation of patient outcomes is important, but data analysis is not required t
hi hi hi hi hi hi hi hi hi hi hi hi hi hi
o use EBP. All published articles do not provide research evidence; interventions should be bas
hi hi hi hi hi hi hi hi hi hi hi hi hi hi
ed on credible research, preferably randomized controlled studies with a large number of subjec
hi hi hi hi hi hi hi hi hi hi hi hi hi
ts.
DIF: Cognitive Level: Understand (Comprehension) hi hi hi
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
hi hi hi hi h i hi hi hi hi hi
3. Which statement by the nurse provides a clear explanation of the nursing process?
hi hi hi hi hi hi hi hi hi hi hi hi
a. “The nursing process is a research method of diagnosing the patient‘s health care pr
hi hi hi hi hi hi hi hi hi hi hi hi hi
oblems.”
b. “The nursing process is used primarily to explain nursing interventions to other he
hi hi hi hi hi hi hi hi hi hi hi hi
alth care professionals.” hi hi
c. “The nursing process is a problem-solving tool used to identify and manage the
hi hi hi hi h i hi hi hi hi hi hi hi
, patients‘ health care needs.” hi hi hi
d. “The nursing process is based on nursing theory that incorporates the bi
hi hi hi hi hi hi hi hi hi hi hi
opsychosocial nature of humans.” hi hi hi
ANS: C hi
The nursing process is a problem-
hi hi hi hi hi
solving approach to the identification and treatment of patients‘ problems. Nursing process do
hi hi hi hi hi hi hi hi hi hi hi hi
es not require research methods for diagnosis. The primary use of the nursing process is in patien
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
t care, not to establish nursing theory or explain nursing interventions to other health care profe
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
ssionals.
DIF: Cognitive Level: Understand (Comprehension) hi hi hi
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
hi hi hi hi h i hi hi hi hi hi
4. A patient admitted to the hospital for surgery tells the nurse, “I do not feel comfortable lea
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
ving my children with my parents.” Which action would the nurse take next?
hi hi hi hi hi hi hi hi hi hi hi hi
a. Reassure the patient that these feelings are common for parents. hi hi hi hi hi hi hi hi hi
b. Have the patient call the children to ensure that they are doing well.
hi hi hi hi hi hi hi hi hi hi hi hi
c. Gather information on the patient‘s concerns about the child care arrangements.
hi h i hi hi hi hi hi h i h i hi
d. Call the patient‘s parents to determine whether adequate child care is being pr
hi hi hi hi hi hi hi hi hi hi hi hi
ovided.
ANS: C hi
Because a complete assessment is necessary in order to identify a problem and choose an appr
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
opriate intervention, the nurse‘s first action should be to obtain more information. The other ac
hi hi hi hi hi hi hi hi hi hi hi hi hi hi
tions may be appropriate, but more assessment is needed before the best intervention can be chos
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
en.
DIF: Cognitive Level: Analyze (Analysis) hi hi hi
TOP: Nursing Process: Assessment
h i MSC: NCLEX: Psychosocial Integrity hi hi h i hi hi
5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis. W
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
hich expected outcome would the nurse select for this patient?
hi hi hi hi hi hi hi hi hi
a. Patient has a balanced intake and output. hi hi hi hi hi hi
b. Patient‘s bedding is kept clean and free of moisture. hi hi hi hi hi hi hi hi
c. Patient understands the need for increased fluid intake. hi hi hi h i hi h i hi
d. Patient‘s skin remains cool and dry throughout hospitalization. hi hi hi hi hi hi hi
ANS: A hi
Balanced intake and output gives measurable data showing resolution of the problem of deficient
hi hi hi hi hi hi hi hi hi hi hi hi hi
fluid volume. The other statements would not indicate that the problem of hypovolemia was r
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
esolved.
DIF: Cognitive Level: Apply (Application) hi hi hi
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
hi hi hi hi h i hi hi
6. Which statement describes the purpose of the evaluation phase of the nursing process?
hi hi hi hi hi hi hi hi hi hi hi hi
a. To document the nursing care plan in the progress notes of the health record
hi hi hi hi hi hi hi hi hi hi hi hi hi
b. To determine if interventions have been effective in meeting patient outcomes
hi hi hi h i hi h i hi h i hi h i
c. To decide whether the patient‘s health problems have been completely resolved
hi h i h i hi h i hi hi hi h i hi
d. To establish if the patient agrees that the nursing care provided was satisfactory
hi hi hi hi hi hi hi hi hi hi hi hi
ANS: B hi
, Evaluation consists of determining whether the desired patient outcomes have been met and w
hi hi hi hi hi hi hi hi hi hi hi hi hi
hether the nursing interventions were appropriate. The other responses do not describe the eva
hi hi hi hi hi hi hi hi hi hi hi hi hi
luation phase. hi
DIF: Cognitive Level: Understand (Comprehension) hi hi hi
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
hi hi hi hi h i hi hi hi hi hi
7. Which statement describes the purpose of the assessment phase of the nursing process?
hi h i hi hi h i hi hi h i hi hi h i hi
a. To teach interventions that relieve health problems
hi hi hi hi hi h i
b. To use patient data to evaluate patient care outcomes
hi hi hi hi hi hi hi hi
c. To obtain data to diagnose patient strengths and problems
hi hi hi hi hi hi hi hi
d. To help the patient identify realistic outcomes for health problems
hi hi hi hi hi hi h i hi hi
ANS: C hi
During the assessment phase, the nurse gathers information about the patient to diagnose patient
hi hi hi hi hi hi hi hi hi hi hi hi hi hi
strengths and problems. The other responses are examples of the planning, intervention, and e
hi hi hi hi hi hi hi hi hi hi hi hi hi
valuation phases of the nursing process. hi hi hi hi hi
DIF: Cognitive Level: Understand (Comprehension) hi hi hi
TOP: Nursing Process: Assessment
h i MSC: NCLEX: Safe and Effective Care Environment
hi hi h i hi hi hi hi hi
8. When developing the plan of care, which components would the nurse include in the clinical pr
hi hi hi hi hi hi hi hi hi hi hi hi hi hi hi
oblem statement? hi
a. The problem and the suggested patient goals or outcomes
hi hi hi hi hi hi hi hi
b. The problem, its causes, and the signs and symptoms of the problem
hi hi hi hi hi hi hi hi hi hi hi
c. The problem with the possible etiology and the planned interventions
hi h i hi hi hi hi hi h i hi
d. The problem, its pathophysiology, and the expected outcome
hi h i hi h i hi hi hi
ANS: B hi
When writing clinical problems or nursing diagnoses, the subjective as well as objective data to
hi hi hi hi hi hi hi hi hi hi hi hi hi hi
support the problem‘s existence should be included. Goals, outcomes, and interventions are not i
hi hi hi hi hi hi hi hi hi hi hi hi hi hi
ncluded in the problem statement. hi hi hi hi
DIF: Cognitive Level: Understand (Comprehension) hi hi hi
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
hi hi hi hi h i hi hi hi hi hi
9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
hi hi hi hi hi hi hi hi hi hi hi hi
a. Instruct the patient about the need to alternate activity and rest.
hi hi hi hi hi hi hi hi hi hi
b. Monitor level of shortness of breath or fatigue after ambulation.
hi hi hi hi hi hi hi hi hi
c. Obtain the patient‘s blood pressure and pulse rate after ambulation.
hi hi hi hi hi h i hi hi hi
d. Determine whether the patient is ready to increase the activity level. hi hi hi h i hi hi hi hi hi hi
ANS: C hi
AP education includes accurate vital sign measurement. Assessment and patient teaching require
hi hi hi hi hi hi hi hi hi hi hi hi
registered nurse education and scope of practice and cannot be delegated.
hi hi hi hi hi hi hi hi hi hi
DIF: Cognitive Level: Apply (Application) hi hi hi
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
hi hi hi hi h i hi hi hi hi hi
