,Chapter 01: Professional Nursing Practice Lewis:
j j j j j
Medical-SurgicalNursing,10thEdition
j j j j
MULTIPLE CHOICE j
1. The nurse completes an admission database and explains that the plan of care and discharge goals
j j j j j j j j j j j j j j j
will be developed with the patient’s input. The patient states, “How is this different from what the
j j j j j j j j j j j j j j j j j
doctor does?” Which response would be most appropriate for the nurse to make?
j j j j j j j j j j j j j
a. “The role of the nurse is to administer medications and other treatments prescribed by
j j j j j j j j j j j j j
your doctor.”
j j
b. “The nurse’s job is to help the doctor by collecting information and
j j j j j j j j j j j
communicating any problems that occur.”
j j j j j
c. “Nurses perform many of the same procedures as the doctor, but nurses are with the
j j j j j j j j j j j j j j
patients for a longer time than the doctor.”
j j j j j j j j
d. “In addition to caring for you while you are sick, the nurses will assist you to
j j j j j j j j j j j j j j j
develop an individualized plan to maintain your health.”
j j j j j j j j
ANS: D j
This response is consistent with the American Nurses Association (ANA) definition of nursing,
j j j j j j j j j j j j
which describes the role of nurses in promoting health. The other responses describe some of the
j j j j j j j j j j j j j j j j
dependent and collaborative functions of the nursing role but do not accurately describe the nurse’s
j j j j j j j j j j j j j j j
role in the health care system.
j j j j j j
DIF: Cognitive Level: Understand (comprehension) REF: 3 j j j j j
TOP: Nursing Process: Implementation
j MSC: NCLEX: Safe and Effective Care Environment j j j j j j j j
2. The nurse describes to a student nurse how to use evidence-based practice guidelines when
j j j j j j j j j j j j j
j caring for patients. Which statement, if made by the nurse, would be the most accurate?
j j j j j j j j j j j j j j
a. “Inferences from clinical research studies are used as a guide.” j j j j j j j j j
b. “Patient care is based on clinical judgment, experience, and traditions.” j j j j j j j j j
c. “Data are evaluated to show that the patient outcomes are consistently met.”
j j j j j j j j j j j
d. “Recommendations arebased on research, clinical expertise, and patient j j j j j j j j
preferences.”
j
ANS: D j
Evidence-based practice (EBP) is the use of the best research-based evidence combined with j j j j j j j j j j j j
clinician expertise. Clinical judgment based on the nurse’s clinical experience is part of EBP, but
j j j j j j j j j j j j j j j
clinical decision making should also incorporate current research and research-based guidelines.
j j j j j j j j j j j
Evaluation of patient outcomes is important, but interventions should be based on research from
j j j j j j j j j j j j j j
randomized control studies with a large number of subjects.
j j j j j j j j j
DIF: Cognitive Level: Remember (knowledge) REF: 15 j j j j j
TOP: Nursing Process: Planning
j MSC: NCLEX: Safe and Effective Care Environment j j j j j j j j
3. The nurse teaches a student nurse about how to apply the nursing process when providing
j j j j j j j j j j j j j j
patient care. Which statement, if made by the student nurse, indicates that teaching was
j j j j j j j j j j j j j j
successful?
j
a. “The nursing process is a scientific-based method of diagnosing the patient’s
j j j j j j j j j j
health care problems.”
j j j
b. “The nursing process is a problem-solving tool used to identify and treat patients’
j j j j j j j j j j j j
, health care needs.” j j
c. “The nursing process is used primarilyto explain nursing interventions to other
j j j j j j j j j j j
health care professionals.”
j j j
d. “The nursing process is based on nursing theory that incorporates the
j j j j j j j j j j
biopsychosocial nature of humans.”
j j j j
ANS: B j
The nursing process is a problem-solving approach to the identification and treatment of patients’
j j j j j j j j j j j j j
problems. Diagnosis is onlyone phase of the nursing process. The primaryuse of the nursing process
j j j j j j j j j j j j j j j j j
is in patient care, not to establish nursing theory or explain nursing interventions to other health care
j j j j j j j j j j j j j j j j j
professionals.
j
DIF: Cognitive Level: Understand (comprehension) REF: 5 j j j j j
TOP: Nursing Process: Implementation
j MSC: NCLEX: Safe and Effective Care Environment j j j j j j j j
4. A patient has been admitted to the hospital for surgery and tells the nurse, “I do not feel comfortable
j j j j j j j j j j j j j j j j j j
leaving my children with my parents.” Which action should the nurse take next?
j j j j j j j j j j j j j
a. Reassure the patient that these feelings are common for parents. j j j j j j j j j
b. Have the patient call the children to ensure that they are doing well.
j j j j j j j j j j j j
c. Gather more data about the patient’s feelings about the child-care arrangements. j j j j j j j j j j
d. Call the patient’s parents to determine whether adequate child careis being
j j j j j j j j j j j
provided.j
ANS: C j
Because a complete assessment is necessary in order to identify a problem and choose an
j j j j j j j j j j j j j j
appropriate intervention, the nurse’s first action should be to obtain more information. The other
j j j j j j j j j j j j j j
actions maybe appropriate, but more assessment is needed before the best intervention can be
j j j j j j j j j j j j j j j
chosen.
j
DIF: Cognitive Level: Apply (application) REF: 6 j j j
OBJ: Special Questions: Prioritization
j TOP: NursingProcess: Assessment j j j j j
MSC: NCLEX: Psychosocial Integrity
j j j j
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the
j j j j j j j j j j j j j j j j j j j j
j left hip. Which nursing diagnosis is most appropriate?
j j j j j j j
a. Impaired physical mobility related to left-sided paralysis j j j j j j
b. Risk for impaired tissue integrity related to left-sided weakness
j j j j j j j j
c. Impaired skin integrity related to altered circulation and pressure j j j j j j j j
d. Ineffective tissue perfusion related to inability to move independently j j j j j j j j
ANS: C j
The patient’s major problem is the impaired skin integrity as demonstrated by the presence of a
j j j j j j j j j j j j j j j
pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by frequently
j j j j j j j j j j j j j j j j j
repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot
j j j j j j j j j j j j j j j
treat the weakness. The “risk for” diagnosis is not appropriate for this patient, who already has
j j j j j j j j j j j j j j j j
impaired tissue integrity. The patient does have ineffective tissue perfusion, but the impaired skin
j j j j j j j j j j j j j j
integrity diagnosis indicates more clearly what the health problem is.
j j j j j j j j j j
DIF: Cognitive Level: Apply (application) REF: 7 j j j
TOP: Nursing Process: Diagnosis
j MSC: NCLEX: Physiological Integrity j j j j j
, 6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to
j j j j j j j j j j j j j j j
j excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this patient?
j j j j j j j j j j j j
a. Patient has a balanced intake and output. j j j j j j
b. Patient’s bedding is changed when it becomes damp. j j j j j j j
c. Patient understands the need for increased fluid intake. j j j j j j j
d. Patient’s skin remains cool and drythroughout hospitalization. j j j j j j j
ANS: A j
This statement gives measurable data showing resolution of the problem of deficient fluid volume
j j j j j j j j j j j j j
that was identified in the nursingdiagnosis statement. The other statements would not indicate that
j j j j j j j j j j j j j j j
the problem of deficient fluid volume was resolved.
j j j j j j j j
DIF: Cognitive Level: Apply (application) REF: 7 j j j
TOP: Nursing Process: Planning
j MSC: NCLEX: Physiological Integrity j j j j j
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the
j j j j j j j j j j j j j j j j j
j evaluation phase of the nursing process? j j j j j
a. To determine if interventions have been effective in meeting patient outcomes
j j j j j j j j j j
b. To document the nursing care plan in the progress notes of the medical record
j j j j j j j j j j j j j
c. To decide whether the patient’s health problems have been completely resolved
j j j j j j j j j j
d. To establish if the patient agrees that the nursing care provided was satisfactory
j j j j j j j j j j j j
ANS: A j
Evaluation consists of determining whether the desired patient outcomes have been met and j j j j j j j j j j j j
whether the nursing interventions were appropriate. The other responses do not describe the
j j j j j j j j j j j j j
evaluation phase.
j j
DIF: Cognitive Level: Understand (comprehension)
j j REF: 5 j j j j j
TOP: Nursing Process: Evaluation
j MSC: NCLEX: Safe and Effective Care Environment j j j j j j j j
8. The nurse interviews a patient while completing the health history and physical examination. What
j j j j j j j j j j j j j
is the purpose of the assessment phase of the nursing process?
j j j j j j j j j j j
a. To teach interventions that relieve health problems
j j j j j j
b. To use patient data to evaluate patient care outcomes
j j j j j j j j
c. To obtain data with which to diagnose patient problems
j j j j j j j j
d. To help the patient identify realistic outcomes for health problems
j j j j j j j j j
ANS: C j
During the assessment phase, the nurse gathers information about the patient to diagnose patient
j j j j j j j j j j j j j
problems. The other responses are examples of the planning, intervention, and evaluation phases of
j j j j j j j j j j j j j j
the nursing process.
j j j
DIF: Cognitive Level: Understand (comprehension)
j j REF: 5 j j j j j
TOP: Nursing Process: Assessment
j MSC: NCLEX: Safe and Effective Care Environment j j j j j j j j
9. Which nursing diagnosis statement is written correctly?
j j j j j j
a. Altered tissue perfusion related to heart failure j j j j j j
b. Risk for impaired tissue integrity related to sacral redness
j j j j j j j j
c. Ineffective coping related to response to biopsy test results j j j j j j j j
d. Altered urinary elimination related to urinary tract infection j j j j j j j
j j j j j
Medical-SurgicalNursing,10thEdition
j j j j
MULTIPLE CHOICE j
1. The nurse completes an admission database and explains that the plan of care and discharge goals
j j j j j j j j j j j j j j j
will be developed with the patient’s input. The patient states, “How is this different from what the
j j j j j j j j j j j j j j j j j
doctor does?” Which response would be most appropriate for the nurse to make?
j j j j j j j j j j j j j
a. “The role of the nurse is to administer medications and other treatments prescribed by
j j j j j j j j j j j j j
your doctor.”
j j
b. “The nurse’s job is to help the doctor by collecting information and
j j j j j j j j j j j
communicating any problems that occur.”
j j j j j
c. “Nurses perform many of the same procedures as the doctor, but nurses are with the
j j j j j j j j j j j j j j
patients for a longer time than the doctor.”
j j j j j j j j
d. “In addition to caring for you while you are sick, the nurses will assist you to
j j j j j j j j j j j j j j j
develop an individualized plan to maintain your health.”
j j j j j j j j
ANS: D j
This response is consistent with the American Nurses Association (ANA) definition of nursing,
j j j j j j j j j j j j
which describes the role of nurses in promoting health. The other responses describe some of the
j j j j j j j j j j j j j j j j
dependent and collaborative functions of the nursing role but do not accurately describe the nurse’s
j j j j j j j j j j j j j j j
role in the health care system.
j j j j j j
DIF: Cognitive Level: Understand (comprehension) REF: 3 j j j j j
TOP: Nursing Process: Implementation
j MSC: NCLEX: Safe and Effective Care Environment j j j j j j j j
2. The nurse describes to a student nurse how to use evidence-based practice guidelines when
j j j j j j j j j j j j j
j caring for patients. Which statement, if made by the nurse, would be the most accurate?
j j j j j j j j j j j j j j
a. “Inferences from clinical research studies are used as a guide.” j j j j j j j j j
b. “Patient care is based on clinical judgment, experience, and traditions.” j j j j j j j j j
c. “Data are evaluated to show that the patient outcomes are consistently met.”
j j j j j j j j j j j
d. “Recommendations arebased on research, clinical expertise, and patient j j j j j j j j
preferences.”
j
ANS: D j
Evidence-based practice (EBP) is the use of the best research-based evidence combined with j j j j j j j j j j j j
clinician expertise. Clinical judgment based on the nurse’s clinical experience is part of EBP, but
j j j j j j j j j j j j j j j
clinical decision making should also incorporate current research and research-based guidelines.
j j j j j j j j j j j
Evaluation of patient outcomes is important, but interventions should be based on research from
j j j j j j j j j j j j j j
randomized control studies with a large number of subjects.
j j j j j j j j j
DIF: Cognitive Level: Remember (knowledge) REF: 15 j j j j j
TOP: Nursing Process: Planning
j MSC: NCLEX: Safe and Effective Care Environment j j j j j j j j
3. The nurse teaches a student nurse about how to apply the nursing process when providing
j j j j j j j j j j j j j j
patient care. Which statement, if made by the student nurse, indicates that teaching was
j j j j j j j j j j j j j j
successful?
j
a. “The nursing process is a scientific-based method of diagnosing the patient’s
j j j j j j j j j j
health care problems.”
j j j
b. “The nursing process is a problem-solving tool used to identify and treat patients’
j j j j j j j j j j j j
, health care needs.” j j
c. “The nursing process is used primarilyto explain nursing interventions to other
j j j j j j j j j j j
health care professionals.”
j j j
d. “The nursing process is based on nursing theory that incorporates the
j j j j j j j j j j
biopsychosocial nature of humans.”
j j j j
ANS: B j
The nursing process is a problem-solving approach to the identification and treatment of patients’
j j j j j j j j j j j j j
problems. Diagnosis is onlyone phase of the nursing process. The primaryuse of the nursing process
j j j j j j j j j j j j j j j j j
is in patient care, not to establish nursing theory or explain nursing interventions to other health care
j j j j j j j j j j j j j j j j j
professionals.
j
DIF: Cognitive Level: Understand (comprehension) REF: 5 j j j j j
TOP: Nursing Process: Implementation
j MSC: NCLEX: Safe and Effective Care Environment j j j j j j j j
4. A patient has been admitted to the hospital for surgery and tells the nurse, “I do not feel comfortable
j j j j j j j j j j j j j j j j j j
leaving my children with my parents.” Which action should the nurse take next?
j j j j j j j j j j j j j
a. Reassure the patient that these feelings are common for parents. j j j j j j j j j
b. Have the patient call the children to ensure that they are doing well.
j j j j j j j j j j j j
c. Gather more data about the patient’s feelings about the child-care arrangements. j j j j j j j j j j
d. Call the patient’s parents to determine whether adequate child careis being
j j j j j j j j j j j
provided.j
ANS: C j
Because a complete assessment is necessary in order to identify a problem and choose an
j j j j j j j j j j j j j j
appropriate intervention, the nurse’s first action should be to obtain more information. The other
j j j j j j j j j j j j j j
actions maybe appropriate, but more assessment is needed before the best intervention can be
j j j j j j j j j j j j j j j
chosen.
j
DIF: Cognitive Level: Apply (application) REF: 6 j j j
OBJ: Special Questions: Prioritization
j TOP: NursingProcess: Assessment j j j j j
MSC: NCLEX: Psychosocial Integrity
j j j j
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the
j j j j j j j j j j j j j j j j j j j j
j left hip. Which nursing diagnosis is most appropriate?
j j j j j j j
a. Impaired physical mobility related to left-sided paralysis j j j j j j
b. Risk for impaired tissue integrity related to left-sided weakness
j j j j j j j j
c. Impaired skin integrity related to altered circulation and pressure j j j j j j j j
d. Ineffective tissue perfusion related to inability to move independently j j j j j j j j
ANS: C j
The patient’s major problem is the impaired skin integrity as demonstrated by the presence of a
j j j j j j j j j j j j j j j
pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by frequently
j j j j j j j j j j j j j j j j j
repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot
j j j j j j j j j j j j j j j
treat the weakness. The “risk for” diagnosis is not appropriate for this patient, who already has
j j j j j j j j j j j j j j j j
impaired tissue integrity. The patient does have ineffective tissue perfusion, but the impaired skin
j j j j j j j j j j j j j j
integrity diagnosis indicates more clearly what the health problem is.
j j j j j j j j j j
DIF: Cognitive Level: Apply (application) REF: 7 j j j
TOP: Nursing Process: Diagnosis
j MSC: NCLEX: Physiological Integrity j j j j j
, 6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to
j j j j j j j j j j j j j j j
j excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this patient?
j j j j j j j j j j j j
a. Patient has a balanced intake and output. j j j j j j
b. Patient’s bedding is changed when it becomes damp. j j j j j j j
c. Patient understands the need for increased fluid intake. j j j j j j j
d. Patient’s skin remains cool and drythroughout hospitalization. j j j j j j j
ANS: A j
This statement gives measurable data showing resolution of the problem of deficient fluid volume
j j j j j j j j j j j j j
that was identified in the nursingdiagnosis statement. The other statements would not indicate that
j j j j j j j j j j j j j j j
the problem of deficient fluid volume was resolved.
j j j j j j j j
DIF: Cognitive Level: Apply (application) REF: 7 j j j
TOP: Nursing Process: Planning
j MSC: NCLEX: Physiological Integrity j j j j j
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the
j j j j j j j j j j j j j j j j j
j evaluation phase of the nursing process? j j j j j
a. To determine if interventions have been effective in meeting patient outcomes
j j j j j j j j j j
b. To document the nursing care plan in the progress notes of the medical record
j j j j j j j j j j j j j
c. To decide whether the patient’s health problems have been completely resolved
j j j j j j j j j j
d. To establish if the patient agrees that the nursing care provided was satisfactory
j j j j j j j j j j j j
ANS: A j
Evaluation consists of determining whether the desired patient outcomes have been met and j j j j j j j j j j j j
whether the nursing interventions were appropriate. The other responses do not describe the
j j j j j j j j j j j j j
evaluation phase.
j j
DIF: Cognitive Level: Understand (comprehension)
j j REF: 5 j j j j j
TOP: Nursing Process: Evaluation
j MSC: NCLEX: Safe and Effective Care Environment j j j j j j j j
8. The nurse interviews a patient while completing the health history and physical examination. What
j j j j j j j j j j j j j
is the purpose of the assessment phase of the nursing process?
j j j j j j j j j j j
a. To teach interventions that relieve health problems
j j j j j j
b. To use patient data to evaluate patient care outcomes
j j j j j j j j
c. To obtain data with which to diagnose patient problems
j j j j j j j j
d. To help the patient identify realistic outcomes for health problems
j j j j j j j j j
ANS: C j
During the assessment phase, the nurse gathers information about the patient to diagnose patient
j j j j j j j j j j j j j
problems. The other responses are examples of the planning, intervention, and evaluation phases of
j j j j j j j j j j j j j j
the nursing process.
j j j
DIF: Cognitive Level: Understand (comprehension)
j j REF: 5 j j j j j
TOP: Nursing Process: Assessment
j MSC: NCLEX: Safe and Effective Care Environment j j j j j j j j
9. Which nursing diagnosis statement is written correctly?
j j j j j j
a. Altered tissue perfusion related to heart failure j j j j j j
b. Risk for impaired tissue integrity related to sacral redness
j j j j j j j j
c. Ineffective coping related to response to biopsy test results j j j j j j j j
d. Altered urinary elimination related to urinary tract infection j j j j j j j
