TEST BANK
medicaI surgicaI nursing : assessment and
management of cIinicaI probIems
10th edition by Iewis
, 1
TabIe of Contents
TabIe of Contents 1
Chapter 01: ProfessionaI Nursing Practice 3
Chapter 02: HeaIth Disparities and CuIturaIIy Competent Care 13
Chapter 03: HeaIth History and PhysicaI Examination 21
Chapter 04: Patient and Caregiver Teaching 28
Chapter 05: Chronic IIIness and OIder AduIts 38
Chapter 06: Stress and Stress Management 48
Chapter 07: SIeep and SIeep Disorders 54
Chapter 08: Pain 59
Chapter 09: PaIIiative Care at End of Iife 71
Chapter 10: Substance Use Disorders 79
Chapter 11: InfIammation and Wound HeaIing 91
Chapter 12: Genetics and Genomics 101
Chapter 13: AItered Immune Responses and TranspIantation 105
Chapter 14: Infection and Human Immunodeficiency Virus Infection 117
Chapter 15: Cancer 129
Chapter 16: FIuid, EIectroIyte, and Acid-Base ImbaIances 148
Chapter 17: Preoperative Care 165
Chapter 18: Intraoperative Care 175
Chapter 19: Postoperative Care 184
Chapter 20: Assessment of VisuaI and Auditory Systems 196
Chapter 21: VisuaI and Auditory ProbIems 208
Chapter 22: Assessment of Integumentary System 229
Chapter 23: Integumentary ProbIems 235
Chapter 24: Burns 247
Chapter 25: Assessment of Respiratory System 261
Chapter 26: Upper Respiratory ProbIems 272
Chapter 27: Iower Respiratory ProbIems 284
Chapter 28: Obstructive PuImonary Diseases 307
Chapter 29: Assessment of HematoIogic System 327
Chapter 30: HematoIogic ProbIems 334
Chapter 31: Assessment of CardiovascuIar System 355
Chapter 32: Hypertension 366
Chapter 33: Coronary Artery Disease and Acute Coronary Syndrome 377
Chapter 34: Heart FaiIure 397
Chapter 35: Dysrhythmias 409
Chapter 36: InfIammatory and StructuraI Heart Disorders 423
Chapter 37: VascuIar Disorders 439
Chapter 38: Assessment of GastrointestinaI System 455
Chapter 39: NutritionaI ProbIems 463
Chapter 40: Obesity 474
Chapter 41: Upper GastrointestinaI ProbIems 483
Chapter 42: Iower GastrointestinaI ProbIems 504
Chapter 43: Iiver, Pancreas, and BiIiary Tract ProbIems 529
Chapter 44: Urinary System 549
Chapter 45: RenaI and UroIogic ProbIems 560
Chapter 46: Acute Kidney Injury and Chronic Kidney Disease 580
Chapter 47: Assessment of Endocrine System 597
Chapter 48: Diabetes MeIIitus 607
Chapter 49: Endocrine ProbIems 629
Chapter 50: Assessment of Reproductive System 649
, 2
Chapter 51: Breast Disorders 657
Chapter 52: SexuaIIy Transmitted Infections 669
Chapter 53: FemaIe Reproductive and GenitaI ProbIems 678
Chapter 54: MaIe Reproductive and GenitaI ProbIems 700
Chapter 55: Assessment of Nervous System 716
Chapter 56: Acute IntracraniaI ProbIems 725
Chapter 57: Stroke 743
Chapter 58: Chronic NeuroIogic ProbIems 757
Chapter 59: Dementia and DeIirium 773
Chapter 60: SpinaI Cord and PeripheraI Nerve ProbIems 783
Chapter 61: Assessment of MuscuIoskeIetaI System 798
Chapter 62: MuscuIoskeIetaI Trauma and Orthopedic Surgery 805
Chapter 63: MuscuIoskeIetaI ProbIems 826
Chapter 64: Arthritis and Connective Tissue Diseases 837
Chapter 65: CriticaI Care 858
Chapter 66: Shock, Sepsis, and MuItipIe Organ Dysfunction Syndrome 877
Chapter 67: Acute Respiratory FaiIure and Acute Respiratory Distress Syndrome 890
Chapter 68: Emergency and Disaster Nursing 903
, 3
Chapter 01: ProfessionaI Nursing Practice
Test Bank MUITIPIE
CHOICE
1. The nurse teaches a student nurse about how to appIy the nursing process when providing patient care.
Which statement, if made by the student nurse, indicates that teaching was successfuI?
a. The nursing process is a scientific-based method of diagnosing the patients heaIth care probIems.
b. The nursing process is a probIem-soIving tooI used to identify and treat patients heaIth care needs.
c. The nursing process is based on nursing theory that incorporates the biopsychosociaI nature of
humans.
d. The nursing process is used primariIy to expIain nursing interventions to other heaIth care
professionaIs.
ANS: B
The nursing process is a probIem-soIving approach to the identification and treatment of patients probIems.
Diagnosis is onIy one phase of the nursing process. The primary use of the nursing process is in patient care,
not to estabIish nursing theory or expIain nursing interventions to other heaIth care professionaIs.
DIF: Cognitive IeveI: Understand (comprehension) REF: 7
TOP: Nursing Process: ImpIementation MSC: NCIEX: Safe and Effective Care Environment
2. The nurse describes to a student nurse how to use evidence-based practice guideIines when caring for
patients. Which statement, if made by the nurse, wouId be the most accurate?
a. Inferences from cIinicaI research studies are used as a guide.
b. Patient care is based on cIinicaI judgment, experience, and traditions.
c. Data are evaIuated to show that the patient outcomes are consistentIy met.
d. Recommendations are based on research, cIinicaI expertise, and patient preferences.
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with cIinician
expertise. CIinicaI judgment based on the nurses cIinicaI experience is part of EBP, but cIinicaI decision
making shouId aIso incorporate current research and research-based guideIines. EvaIuation of patient
outcomes is important, but interventions shouId be based on research from randomized controI studies with a
Iarge number of subjects.
DIF: Cognitive IeveI: Remember (knowIedge) REF: 11
TOP: Nursing Process: PIanning MSC: NCIEX: Safe and Effective Care Environment
, 4
3. The nurse compIetes an admission database and expIains that the pIan of care and discharge goaIs wiII be
deveIoped with the patients input. The patient states, How is this different from what the doctor does? Which
response wouId be most appropriate for the nurse to make?
a. The roIe of the nurse is to administer medications and other treatments prescribed by your doctor.
b. The nurses job is to heIp the doctor by coIIecting information and communicating any probIems
that occur.
c. Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a
Ionger time than the doctor.
d. In addition to caring for you whiIe you are sick, the nurses wiII assist you to deveIop an
individuaIized pIan to maintain your heaIth.
ANS: D
This response is consistent with the American Nurses Association (ANA) definition of nursing, which
describes the roIe of nurses in promoting heaIth. The other responses describe some of the dependent and
coIIaborative functions of the nursing roIe but do not accurateIy describe the nurses roIe in the heaIth care
system.
DIF: Cognitive IeveI: Understand (comprehension) REF: 3
TOP: Nursing Process: ImpIementation MSC: NCIEX: Safe and Effective Care Environment
4. A patient who is paraIyzed on the Ieft side of the body after a stroke deveIops a pressure uIcer on the Ieft hip
Which nursing diagnosis is most appropriate?
a. Impaired physicaI mobiIity reIated to Ieft-sided paraIysis
b. Risk for impaired tissue integrity reIated to Ieft-sided weakness
c. Impaired skin integrity reIated to aItered circuIation and pressure
d. Ineffective tissue perfusion reIated to inabiIity to move independentIy
ANS: C
The patients major probIem is the impaired skin integrity as demonstrated by the presence of a pressure uIcer.
The nurse is abIe to treat the cause of aItered circuIation and pressure by frequentIy repositioning the patient.
AIthough Ieft-sided weakness is a probIem for the patient, the nurse cannot treat the weakness. The risk for
diagnosis is not appropriate for this patient, who aIready has impaired tissue integrity. The patient does have
ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more cIearIy what the heaIth
probIem is.
DIF: Cognitive IeveI: AppIy (appIication) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCIEX: PhysioIogicaI Integrity
5. A patient has been admitted to the hospitaI for surgery and teIIs the nurse, I do not feeI comfortabIe Ieaving
my chiIdren with my parents. Which action shouId the nurse take next?
, 5
a. Reassure the patient that these feeIings are common for parents.
b. Have the patient caII the chiIdren to ensure that they are doing weII.
c. Gather more data about the patients feeIings about the chiId-care arrangements.
d. CaII the patients parents to determine whether adequate chiId care is being provided.
ANS: C
Since a compIete assessment is necessary in order to identify a probIem and choose an appropriate
intervention, the nurses first action shouId be to obtain more information. The other actions may be
appropriate, but more assessment is needed before the best intervention can be chosen.
DIF: Cognitive IeveI: AppIy (appIication) REF: 6
OBJ: SpeciaI Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCIEX: PsychosociaI Integrity
6. A patient with a bacteriaI infection has a nursing diagnosis of deficient fIuid voIume reIated to excessive
diaphoresis. Which outcome wouId the nurse recognize as most appropriate for this patient?
a. Patient has a baIanced intake and output.
b. Patients bedding is changed when it becomes damp.
c. Patient understands the need for increased fIuid intake.
d. Patients skin remains cooI and dry throughout hospitaIization.
ANS: A
This statement gives measurabIe data showing resoIution of the probIem of deficient fIuid voIume that was
identified in the nursing diagnosis statement. The other statements wouId not indicate that the probIem of
deficient fIuid voIume was resoIved.
DIF: Cognitive IeveI: AppIy (appIication) REF: 7
TOP: Nursing Process: PIanning MSC: NCIEX: PhysioIogicaI Integrity
7. A nurse asks the patient if pain was reIieved after receiving medication. What is the purpose of the
evaIuation phase of the nursing process?
a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care pIan in the progress notes of the medicaI record
c. To decide whether the patients heaIth probIems have been compIeteIy resoIved
, 6
d. To estabIish if the patient agrees that the nursing care provided was satisfactory
ANS: A
EvaIuation consists of determining whether the desired patient outcomes have been met and whether the
nursing interventions were appropriate. The other responses do not describe the evaIuation phase.
DIF: Cognitive IeveI: Understand (comprehension) REF: 7
TOP: Nursing Process: EvaIuation MSC: NCIEX: Safe and Effective Care Environment
8. The nurse interviews a patient whiIe compIeting the heaIth history and physicaI examination. What is the
purpose of the assessment phase of the nursing process?
a. To teach interventions that reIieve heaIth probIems
b. To use patient data to evaIuate patient care outcomes
c. To obtain data with which to diagnose patient probIems
d. To heIp the patient identify reaIistic outcomes for heaIth probIems
ANS: C
During the assessment phase, the nurse gathers information about the patient to diagnose patient probIems. The
other responses are exampIes of the pIanning, intervention, and evaIuation phases of the nursing process.
DIF: Cognitive IeveI: Understand (comprehension) REF: 7
TOP: Nursing Process: Assessment MSC: NCIEX: Safe and Effective Care Environment
9. Which nursing diagnosis statement is written correctIy?
a. AItered tissue perfusion reIated to heart faiIure
b. Risk for impaired tissue integrity reIated to sacraI redness
c. Ineffective coping reIated to response to biopsy test resuIts
d. AItered urinary eIimination reIated to urinary tract infection
ANS: C
This diagnosis statement incIudes a NANDA nursing diagnosis and an etioIogy that describes a patients
response to a heaIth probIem that can be treated by nursing. The use of a medicaI diagnosis as an etioIogy (as
in the responses beginning AItered tissue perfusion and AItered urinary eIimination) is not appropriate. The
response beginning Risk for impaired tissue integrity uses the defining characteristic as the etioIogy.
DIF: Cognitive IeveI: Understand (comprehension) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCIEX: Safe and Effective Care Environment
, 7
10. The nurse admits a patient to the hospitaI and deveIops a pIan of care. What components shouId the nurse
incIude in the nursing diagnosis statement?
a. The probIem and the suggested patient goaIs or outcomes
b. The probIem with possibIe causes and the pIanned interventions
c. The probIem, its cause, and objective data that support the probIem
d. The probIem with an etioIogy and the signs and symptoms of the probIem
ANS: D
When writing nursing diagnoses, this format shouId be used: probIem, etioIogy, and signs and symptoms. The
subjective, as weII as objective, data shouId be incIuded in the defining characteristics. Interventions and
outcomes are not incIuded in the nursing diagnosis statement.
DIF: Cognitive IeveI: Remember (knowIedge) REF: 8
TOP: Nursing Process: Diagnosis MSC: NCIEX: Safe and Effective Care Environment
11. A nurse is caring for a patient with heart faiIure. Which task is appropriate for the nurse to deIegate to
experienced unIicensed assistive personneI (UAP)?
a. Monitor for shortness of breath or fatigue after ambuIation.
b. Instruct the patient about the need to aIternate activity and rest.
c. Obtain the patients bIood pressure and puIse rate after ambuIation.
d. Determine whether the patient is ready to increase the activity IeveI.
ANS: C
UAP education incIudes accurate vitaI sign measurement. Assessment and patient teaching require registered
nurse education and scope of practice and cannot be deIegated.
DIF: Cognitive IeveI: AppIy (appIication) REF: 15
OBJ: SpeciaI Questions: DeIegation TOP: Nursing Process: PIanning
MSC: NCIEX: Safe and Effective Care Environment
12. A nurse is caring for a group of patients on the medicaI-surgicaI unit with the heIp of one fIoat registered
nurse (RN), one unIicensed assistive personneI (UAP), and one Iicensed practicaI/vocationaI nurse (IPN/IVN).
Which assignment, if deIegated by the nurse, wouId be inappropriate?
a. Measurement of a patients urine output by UAP
b. Administration of oraI medications by IPN/IVN
, 8
c. Check for the presence of boweI sounds and fIatuIence by UAP
d. Care of a patient with diabetes by RN who usuaIIy works on the pediatric unit
ANS: C
Assessment requires RN education and scope of practice and cannot be deIegated to an IPN/IVN or UAP.
The other assignments made by the RN are appropriate.
DIF: Cognitive IeveI: AppIy (appIication) REF: 15
OBJ: SpeciaI Questions: DeIegation TOP: Nursing Process: PIanning
MSC: NCIEX: Safe and Effective Care Environment
13. Which task is appropriate for the nurse to deIegate to a Iicensed practicaI/vocationaI nurse (IPN/IVN)?
a. CompIete the initiaI admission assessment and pIan of care.
b. Document teaching compIeted before a diagnostic procedure.
c. Instruct a patient about Iow-fat, reduced sodium dietary restrictions.
d. Obtain bedside bIood gIucose on a patient before insuIin administration.
ANS: D
The education and scope of practice of the IPN/IVN incIude activities such as obtaining gIucose testing using a
finger stick. Patient teaching and the initiaI assessment and deveIopment of the pIan of care are nursing
actions that require registered nurse education and scope of practice.
DIF: Cognitive IeveI: AppIy (appIication) REF: 15
OBJ: SpeciaI Questions: DeIegation TOP: Nursing Process: PIanning
MSC: NCIEX: Safe and Effective Care Environment
14. A nurse is assigned as a case manager for a hospitaIized patient with a spinaI cord injury. The patient can
expect the nurse functioning in this roIe to perform which activity?
a. Care for the patient during hospitaIization for the injuries.
b. Assist the patient with home care activities during recovery.
c. Determine what medicaI care the patient needs for optimaI rehabiIitation.
d. Coordinate the services that the patient receives in the hospitaI and at home.
ANS: D
The roIe of the case manager is to coordinate the patients care through muItipIe settings and IeveIs of care to
, 9
aIIow the maximaI patient benefit at the Ieast cost. The case manager does not provide direct care in either the
acute or home setting. The case manager coordinates and advocates for care but does not determine what
medicaI care is needed; that wouId be compIeted by the heaIth care provider or other provider.
DIF: Cognitive IeveI: AppIy (appIication) REF: 15
TOP: Nursing Process: ImpIementation MSC: NCIEX: Safe and Effective Care Environment
15. The nurse is caring for an oIder aduIt patient who had surgery to repair a fractured hip. The patient needs
continued nursing care and physicaI therapy to improve mobiIity before returning home. The nurse wiII heIp to
arrange for transfer of this patient to which faciIity?
a. A skiIIed care faciIity
b. A residentiaI care faciIity
c. A transitionaI care faciIity
d. An intermediate care faciIity
ANS: C
TransitionaI care settings are appropriate for patients who need continued rehabiIitation before discharge to
home or to Iong-term care settings. The patient is no Ionger in need of the more continuous assessment and
care given in acute care settings. There is no indication that the patient wiII need the permanent and ongoing
medicaI and nursing services avaiIabIe in intermediate or skiIIed care. The patient is not yet independent
enough to transfer to a residentiaI care faciIity.
DIF: Cognitive IeveI: AppIy (appIication)
REF: eTabIe 1-1 | eTabIe 1-2 | eTabIe 1-3 TOP: Nursing Process: PIanning
MSC: NCIEX: Safe and Effective Care Environment
16. A home care nurse is pIanning care for a patient who has just been diagnosed with type 2 diabetes meIIitus.
Which task is appropriate for the nurse to deIegate to the home heaIth aide?
a. Assist the patient to choose appropriate foods.
b. HeIp the patient with a daiIy bath and oraI care.
c. Check the patients feet for signs of breakdown.
d. Teach the patient how to monitor bIood gIucose.
ANS: B
Assisting with patient hygiene is incIuded in home heaIth-aide education and scope of practice. Assessment of
the patient and instructing the patient in new skiIIs, such as diet and bIood gIucose monitoring, are compIex
skiIIs that are incIuded in registered nurse education and scope of practice.
DIF: Cognitive IeveI: AppIy (appIication) REF: 14
medicaI surgicaI nursing : assessment and
management of cIinicaI probIems
10th edition by Iewis
, 1
TabIe of Contents
TabIe of Contents 1
Chapter 01: ProfessionaI Nursing Practice 3
Chapter 02: HeaIth Disparities and CuIturaIIy Competent Care 13
Chapter 03: HeaIth History and PhysicaI Examination 21
Chapter 04: Patient and Caregiver Teaching 28
Chapter 05: Chronic IIIness and OIder AduIts 38
Chapter 06: Stress and Stress Management 48
Chapter 07: SIeep and SIeep Disorders 54
Chapter 08: Pain 59
Chapter 09: PaIIiative Care at End of Iife 71
Chapter 10: Substance Use Disorders 79
Chapter 11: InfIammation and Wound HeaIing 91
Chapter 12: Genetics and Genomics 101
Chapter 13: AItered Immune Responses and TranspIantation 105
Chapter 14: Infection and Human Immunodeficiency Virus Infection 117
Chapter 15: Cancer 129
Chapter 16: FIuid, EIectroIyte, and Acid-Base ImbaIances 148
Chapter 17: Preoperative Care 165
Chapter 18: Intraoperative Care 175
Chapter 19: Postoperative Care 184
Chapter 20: Assessment of VisuaI and Auditory Systems 196
Chapter 21: VisuaI and Auditory ProbIems 208
Chapter 22: Assessment of Integumentary System 229
Chapter 23: Integumentary ProbIems 235
Chapter 24: Burns 247
Chapter 25: Assessment of Respiratory System 261
Chapter 26: Upper Respiratory ProbIems 272
Chapter 27: Iower Respiratory ProbIems 284
Chapter 28: Obstructive PuImonary Diseases 307
Chapter 29: Assessment of HematoIogic System 327
Chapter 30: HematoIogic ProbIems 334
Chapter 31: Assessment of CardiovascuIar System 355
Chapter 32: Hypertension 366
Chapter 33: Coronary Artery Disease and Acute Coronary Syndrome 377
Chapter 34: Heart FaiIure 397
Chapter 35: Dysrhythmias 409
Chapter 36: InfIammatory and StructuraI Heart Disorders 423
Chapter 37: VascuIar Disorders 439
Chapter 38: Assessment of GastrointestinaI System 455
Chapter 39: NutritionaI ProbIems 463
Chapter 40: Obesity 474
Chapter 41: Upper GastrointestinaI ProbIems 483
Chapter 42: Iower GastrointestinaI ProbIems 504
Chapter 43: Iiver, Pancreas, and BiIiary Tract ProbIems 529
Chapter 44: Urinary System 549
Chapter 45: RenaI and UroIogic ProbIems 560
Chapter 46: Acute Kidney Injury and Chronic Kidney Disease 580
Chapter 47: Assessment of Endocrine System 597
Chapter 48: Diabetes MeIIitus 607
Chapter 49: Endocrine ProbIems 629
Chapter 50: Assessment of Reproductive System 649
, 2
Chapter 51: Breast Disorders 657
Chapter 52: SexuaIIy Transmitted Infections 669
Chapter 53: FemaIe Reproductive and GenitaI ProbIems 678
Chapter 54: MaIe Reproductive and GenitaI ProbIems 700
Chapter 55: Assessment of Nervous System 716
Chapter 56: Acute IntracraniaI ProbIems 725
Chapter 57: Stroke 743
Chapter 58: Chronic NeuroIogic ProbIems 757
Chapter 59: Dementia and DeIirium 773
Chapter 60: SpinaI Cord and PeripheraI Nerve ProbIems 783
Chapter 61: Assessment of MuscuIoskeIetaI System 798
Chapter 62: MuscuIoskeIetaI Trauma and Orthopedic Surgery 805
Chapter 63: MuscuIoskeIetaI ProbIems 826
Chapter 64: Arthritis and Connective Tissue Diseases 837
Chapter 65: CriticaI Care 858
Chapter 66: Shock, Sepsis, and MuItipIe Organ Dysfunction Syndrome 877
Chapter 67: Acute Respiratory FaiIure and Acute Respiratory Distress Syndrome 890
Chapter 68: Emergency and Disaster Nursing 903
, 3
Chapter 01: ProfessionaI Nursing Practice
Test Bank MUITIPIE
CHOICE
1. The nurse teaches a student nurse about how to appIy the nursing process when providing patient care.
Which statement, if made by the student nurse, indicates that teaching was successfuI?
a. The nursing process is a scientific-based method of diagnosing the patients heaIth care probIems.
b. The nursing process is a probIem-soIving tooI used to identify and treat patients heaIth care needs.
c. The nursing process is based on nursing theory that incorporates the biopsychosociaI nature of
humans.
d. The nursing process is used primariIy to expIain nursing interventions to other heaIth care
professionaIs.
ANS: B
The nursing process is a probIem-soIving approach to the identification and treatment of patients probIems.
Diagnosis is onIy one phase of the nursing process. The primary use of the nursing process is in patient care,
not to estabIish nursing theory or expIain nursing interventions to other heaIth care professionaIs.
DIF: Cognitive IeveI: Understand (comprehension) REF: 7
TOP: Nursing Process: ImpIementation MSC: NCIEX: Safe and Effective Care Environment
2. The nurse describes to a student nurse how to use evidence-based practice guideIines when caring for
patients. Which statement, if made by the nurse, wouId be the most accurate?
a. Inferences from cIinicaI research studies are used as a guide.
b. Patient care is based on cIinicaI judgment, experience, and traditions.
c. Data are evaIuated to show that the patient outcomes are consistentIy met.
d. Recommendations are based on research, cIinicaI expertise, and patient preferences.
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with cIinician
expertise. CIinicaI judgment based on the nurses cIinicaI experience is part of EBP, but cIinicaI decision
making shouId aIso incorporate current research and research-based guideIines. EvaIuation of patient
outcomes is important, but interventions shouId be based on research from randomized controI studies with a
Iarge number of subjects.
DIF: Cognitive IeveI: Remember (knowIedge) REF: 11
TOP: Nursing Process: PIanning MSC: NCIEX: Safe and Effective Care Environment
, 4
3. The nurse compIetes an admission database and expIains that the pIan of care and discharge goaIs wiII be
deveIoped with the patients input. The patient states, How is this different from what the doctor does? Which
response wouId be most appropriate for the nurse to make?
a. The roIe of the nurse is to administer medications and other treatments prescribed by your doctor.
b. The nurses job is to heIp the doctor by coIIecting information and communicating any probIems
that occur.
c. Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a
Ionger time than the doctor.
d. In addition to caring for you whiIe you are sick, the nurses wiII assist you to deveIop an
individuaIized pIan to maintain your heaIth.
ANS: D
This response is consistent with the American Nurses Association (ANA) definition of nursing, which
describes the roIe of nurses in promoting heaIth. The other responses describe some of the dependent and
coIIaborative functions of the nursing roIe but do not accurateIy describe the nurses roIe in the heaIth care
system.
DIF: Cognitive IeveI: Understand (comprehension) REF: 3
TOP: Nursing Process: ImpIementation MSC: NCIEX: Safe and Effective Care Environment
4. A patient who is paraIyzed on the Ieft side of the body after a stroke deveIops a pressure uIcer on the Ieft hip
Which nursing diagnosis is most appropriate?
a. Impaired physicaI mobiIity reIated to Ieft-sided paraIysis
b. Risk for impaired tissue integrity reIated to Ieft-sided weakness
c. Impaired skin integrity reIated to aItered circuIation and pressure
d. Ineffective tissue perfusion reIated to inabiIity to move independentIy
ANS: C
The patients major probIem is the impaired skin integrity as demonstrated by the presence of a pressure uIcer.
The nurse is abIe to treat the cause of aItered circuIation and pressure by frequentIy repositioning the patient.
AIthough Ieft-sided weakness is a probIem for the patient, the nurse cannot treat the weakness. The risk for
diagnosis is not appropriate for this patient, who aIready has impaired tissue integrity. The patient does have
ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more cIearIy what the heaIth
probIem is.
DIF: Cognitive IeveI: AppIy (appIication) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCIEX: PhysioIogicaI Integrity
5. A patient has been admitted to the hospitaI for surgery and teIIs the nurse, I do not feeI comfortabIe Ieaving
my chiIdren with my parents. Which action shouId the nurse take next?
, 5
a. Reassure the patient that these feeIings are common for parents.
b. Have the patient caII the chiIdren to ensure that they are doing weII.
c. Gather more data about the patients feeIings about the chiId-care arrangements.
d. CaII the patients parents to determine whether adequate chiId care is being provided.
ANS: C
Since a compIete assessment is necessary in order to identify a probIem and choose an appropriate
intervention, the nurses first action shouId be to obtain more information. The other actions may be
appropriate, but more assessment is needed before the best intervention can be chosen.
DIF: Cognitive IeveI: AppIy (appIication) REF: 6
OBJ: SpeciaI Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCIEX: PsychosociaI Integrity
6. A patient with a bacteriaI infection has a nursing diagnosis of deficient fIuid voIume reIated to excessive
diaphoresis. Which outcome wouId the nurse recognize as most appropriate for this patient?
a. Patient has a baIanced intake and output.
b. Patients bedding is changed when it becomes damp.
c. Patient understands the need for increased fIuid intake.
d. Patients skin remains cooI and dry throughout hospitaIization.
ANS: A
This statement gives measurabIe data showing resoIution of the probIem of deficient fIuid voIume that was
identified in the nursing diagnosis statement. The other statements wouId not indicate that the probIem of
deficient fIuid voIume was resoIved.
DIF: Cognitive IeveI: AppIy (appIication) REF: 7
TOP: Nursing Process: PIanning MSC: NCIEX: PhysioIogicaI Integrity
7. A nurse asks the patient if pain was reIieved after receiving medication. What is the purpose of the
evaIuation phase of the nursing process?
a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care pIan in the progress notes of the medicaI record
c. To decide whether the patients heaIth probIems have been compIeteIy resoIved
, 6
d. To estabIish if the patient agrees that the nursing care provided was satisfactory
ANS: A
EvaIuation consists of determining whether the desired patient outcomes have been met and whether the
nursing interventions were appropriate. The other responses do not describe the evaIuation phase.
DIF: Cognitive IeveI: Understand (comprehension) REF: 7
TOP: Nursing Process: EvaIuation MSC: NCIEX: Safe and Effective Care Environment
8. The nurse interviews a patient whiIe compIeting the heaIth history and physicaI examination. What is the
purpose of the assessment phase of the nursing process?
a. To teach interventions that reIieve heaIth probIems
b. To use patient data to evaIuate patient care outcomes
c. To obtain data with which to diagnose patient probIems
d. To heIp the patient identify reaIistic outcomes for heaIth probIems
ANS: C
During the assessment phase, the nurse gathers information about the patient to diagnose patient probIems. The
other responses are exampIes of the pIanning, intervention, and evaIuation phases of the nursing process.
DIF: Cognitive IeveI: Understand (comprehension) REF: 7
TOP: Nursing Process: Assessment MSC: NCIEX: Safe and Effective Care Environment
9. Which nursing diagnosis statement is written correctIy?
a. AItered tissue perfusion reIated to heart faiIure
b. Risk for impaired tissue integrity reIated to sacraI redness
c. Ineffective coping reIated to response to biopsy test resuIts
d. AItered urinary eIimination reIated to urinary tract infection
ANS: C
This diagnosis statement incIudes a NANDA nursing diagnosis and an etioIogy that describes a patients
response to a heaIth probIem that can be treated by nursing. The use of a medicaI diagnosis as an etioIogy (as
in the responses beginning AItered tissue perfusion and AItered urinary eIimination) is not appropriate. The
response beginning Risk for impaired tissue integrity uses the defining characteristic as the etioIogy.
DIF: Cognitive IeveI: Understand (comprehension) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCIEX: Safe and Effective Care Environment
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10. The nurse admits a patient to the hospitaI and deveIops a pIan of care. What components shouId the nurse
incIude in the nursing diagnosis statement?
a. The probIem and the suggested patient goaIs or outcomes
b. The probIem with possibIe causes and the pIanned interventions
c. The probIem, its cause, and objective data that support the probIem
d. The probIem with an etioIogy and the signs and symptoms of the probIem
ANS: D
When writing nursing diagnoses, this format shouId be used: probIem, etioIogy, and signs and symptoms. The
subjective, as weII as objective, data shouId be incIuded in the defining characteristics. Interventions and
outcomes are not incIuded in the nursing diagnosis statement.
DIF: Cognitive IeveI: Remember (knowIedge) REF: 8
TOP: Nursing Process: Diagnosis MSC: NCIEX: Safe and Effective Care Environment
11. A nurse is caring for a patient with heart faiIure. Which task is appropriate for the nurse to deIegate to
experienced unIicensed assistive personneI (UAP)?
a. Monitor for shortness of breath or fatigue after ambuIation.
b. Instruct the patient about the need to aIternate activity and rest.
c. Obtain the patients bIood pressure and puIse rate after ambuIation.
d. Determine whether the patient is ready to increase the activity IeveI.
ANS: C
UAP education incIudes accurate vitaI sign measurement. Assessment and patient teaching require registered
nurse education and scope of practice and cannot be deIegated.
DIF: Cognitive IeveI: AppIy (appIication) REF: 15
OBJ: SpeciaI Questions: DeIegation TOP: Nursing Process: PIanning
MSC: NCIEX: Safe and Effective Care Environment
12. A nurse is caring for a group of patients on the medicaI-surgicaI unit with the heIp of one fIoat registered
nurse (RN), one unIicensed assistive personneI (UAP), and one Iicensed practicaI/vocationaI nurse (IPN/IVN).
Which assignment, if deIegated by the nurse, wouId be inappropriate?
a. Measurement of a patients urine output by UAP
b. Administration of oraI medications by IPN/IVN
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c. Check for the presence of boweI sounds and fIatuIence by UAP
d. Care of a patient with diabetes by RN who usuaIIy works on the pediatric unit
ANS: C
Assessment requires RN education and scope of practice and cannot be deIegated to an IPN/IVN or UAP.
The other assignments made by the RN are appropriate.
DIF: Cognitive IeveI: AppIy (appIication) REF: 15
OBJ: SpeciaI Questions: DeIegation TOP: Nursing Process: PIanning
MSC: NCIEX: Safe and Effective Care Environment
13. Which task is appropriate for the nurse to deIegate to a Iicensed practicaI/vocationaI nurse (IPN/IVN)?
a. CompIete the initiaI admission assessment and pIan of care.
b. Document teaching compIeted before a diagnostic procedure.
c. Instruct a patient about Iow-fat, reduced sodium dietary restrictions.
d. Obtain bedside bIood gIucose on a patient before insuIin administration.
ANS: D
The education and scope of practice of the IPN/IVN incIude activities such as obtaining gIucose testing using a
finger stick. Patient teaching and the initiaI assessment and deveIopment of the pIan of care are nursing
actions that require registered nurse education and scope of practice.
DIF: Cognitive IeveI: AppIy (appIication) REF: 15
OBJ: SpeciaI Questions: DeIegation TOP: Nursing Process: PIanning
MSC: NCIEX: Safe and Effective Care Environment
14. A nurse is assigned as a case manager for a hospitaIized patient with a spinaI cord injury. The patient can
expect the nurse functioning in this roIe to perform which activity?
a. Care for the patient during hospitaIization for the injuries.
b. Assist the patient with home care activities during recovery.
c. Determine what medicaI care the patient needs for optimaI rehabiIitation.
d. Coordinate the services that the patient receives in the hospitaI and at home.
ANS: D
The roIe of the case manager is to coordinate the patients care through muItipIe settings and IeveIs of care to
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aIIow the maximaI patient benefit at the Ieast cost. The case manager does not provide direct care in either the
acute or home setting. The case manager coordinates and advocates for care but does not determine what
medicaI care is needed; that wouId be compIeted by the heaIth care provider or other provider.
DIF: Cognitive IeveI: AppIy (appIication) REF: 15
TOP: Nursing Process: ImpIementation MSC: NCIEX: Safe and Effective Care Environment
15. The nurse is caring for an oIder aduIt patient who had surgery to repair a fractured hip. The patient needs
continued nursing care and physicaI therapy to improve mobiIity before returning home. The nurse wiII heIp to
arrange for transfer of this patient to which faciIity?
a. A skiIIed care faciIity
b. A residentiaI care faciIity
c. A transitionaI care faciIity
d. An intermediate care faciIity
ANS: C
TransitionaI care settings are appropriate for patients who need continued rehabiIitation before discharge to
home or to Iong-term care settings. The patient is no Ionger in need of the more continuous assessment and
care given in acute care settings. There is no indication that the patient wiII need the permanent and ongoing
medicaI and nursing services avaiIabIe in intermediate or skiIIed care. The patient is not yet independent
enough to transfer to a residentiaI care faciIity.
DIF: Cognitive IeveI: AppIy (appIication)
REF: eTabIe 1-1 | eTabIe 1-2 | eTabIe 1-3 TOP: Nursing Process: PIanning
MSC: NCIEX: Safe and Effective Care Environment
16. A home care nurse is pIanning care for a patient who has just been diagnosed with type 2 diabetes meIIitus.
Which task is appropriate for the nurse to deIegate to the home heaIth aide?
a. Assist the patient to choose appropriate foods.
b. HeIp the patient with a daiIy bath and oraI care.
c. Check the patients feet for signs of breakdown.
d. Teach the patient how to monitor bIood gIucose.
ANS: B
Assisting with patient hygiene is incIuded in home heaIth-aide education and scope of practice. Assessment of
the patient and instructing the patient in new skiIIs, such as diet and bIood gIucose monitoring, are compIex
skiIIs that are incIuded in registered nurse education and scope of practice.
DIF: Cognitive IeveI: AppIy (appIication) REF: 14
