Introductory Medical-Surgical Nursing Workbook –
Answer Guide and Concept Review (11th Edition)
1. What is the primary purpose of the nursing process?
a) To delegate tasks to nursing assistants
b) To provide a systematic framework for patient-centered care
c) To document care for legal purposes
d) To diagnose medical conditions
2. During the assessment phase, the nurse collects data through:
a) Implementation and evaluation only
b) Diagnosis and planning
c) Subjective and objective data collection
d) Only physician's orders
3. A patient's statement, "I have a sharp pain in my stomach," is an example of:
a) Objective data
b) A nursing diagnosis
c) Subjective data
d) An intervention
4. The "Evaluation" phase of the nursing process involves:
a) Determining patient outcomes have been met
b) Collecting new baseline data
c) Writing new nursing diagnoses
d) Completing all physician orders
5. Which action is the best example of maintaining medical asepsis?
a) Performing sterile catheterization
b) Washing hands before patient contact
c) Wearing a sterile gown in the OR
d) Placing a patient in a protective environment
6. The single most effective way to prevent the spread of infection is:
a) Wearing gloves at all times
,b) Proper hand hygiene
c) Administering antibiotics prophylactically
d) Isolating all patients
7. When moving a patient up in bed, the nurse should primarily use which
principle to prevent self-injury?
a) Use a narrow base of support
b) Keep knees straight and bend at the waist
c) Use your own body weight and leg muscles
d) Pull the patient quickly and smoothly
8. A patient with a pulse oximeter reading of 89% should be assessed for:
a) Hypertension
b) Hypoxia
c) Hyperventilation
d) Fever
9. The "rights" of medication administration include all EXCEPT:
a) Right patient, right medication, right dose
b) Right route, right time, right documentation
c) Right to refuse, right education
d) Right to choose their own medication
10. Before administering any medication, the nurse's priority action is to:
a) Check the patient's allergy status
b) Document the administration
c) Crush the pill if the patient has difficulty swallowing
d) Ask the family if it's okay to give
Fluids, Electrolytes, and Acid-Base Balance
11. A patient with severe vomiting is at highest risk for which acid-base
imbalance?
a) Respiratory acidosis
, b) Respiratory alkalosis
c) Metabolic acidosis
d) Metabolic alkalosis
12. The primary electrolyte responsible for maintaining fluid balance in the
extracellular space is:
a) Potassium
b) Magnesium
c) Sodium
d) Calcium
13. A key clinical manifestation of hyperkalemia (high potassium) is:
a) Muscle weakness and cardiac dysrhythmias
b) Tetany and positive Chvostek's sign
c) Fluid overload and hypertension
d) Deep, rapid Kussmaul respirations
14. The most accurate indicator of a patient's fluid volume status is:
a) Daily weight
b) Blood pressure
c) Skin turgor
d) Patient's reported thirst
15. Trousseau's sign and Chvostek's sign are indicative of:
a) Hypernatremia
b) Hypocalcemia
c) Hyperkalemia
d) Hypomagnesemia
16. A patient with heart failure is prescribed a diuretic. The nurse should closely
monitor for:
a) Hyperkalemia
b) Fluid overload
c) Hypokalemia
d) Hypertension
Answer Guide and Concept Review (11th Edition)
1. What is the primary purpose of the nursing process?
a) To delegate tasks to nursing assistants
b) To provide a systematic framework for patient-centered care
c) To document care for legal purposes
d) To diagnose medical conditions
2. During the assessment phase, the nurse collects data through:
a) Implementation and evaluation only
b) Diagnosis and planning
c) Subjective and objective data collection
d) Only physician's orders
3. A patient's statement, "I have a sharp pain in my stomach," is an example of:
a) Objective data
b) A nursing diagnosis
c) Subjective data
d) An intervention
4. The "Evaluation" phase of the nursing process involves:
a) Determining patient outcomes have been met
b) Collecting new baseline data
c) Writing new nursing diagnoses
d) Completing all physician orders
5. Which action is the best example of maintaining medical asepsis?
a) Performing sterile catheterization
b) Washing hands before patient contact
c) Wearing a sterile gown in the OR
d) Placing a patient in a protective environment
6. The single most effective way to prevent the spread of infection is:
a) Wearing gloves at all times
,b) Proper hand hygiene
c) Administering antibiotics prophylactically
d) Isolating all patients
7. When moving a patient up in bed, the nurse should primarily use which
principle to prevent self-injury?
a) Use a narrow base of support
b) Keep knees straight and bend at the waist
c) Use your own body weight and leg muscles
d) Pull the patient quickly and smoothly
8. A patient with a pulse oximeter reading of 89% should be assessed for:
a) Hypertension
b) Hypoxia
c) Hyperventilation
d) Fever
9. The "rights" of medication administration include all EXCEPT:
a) Right patient, right medication, right dose
b) Right route, right time, right documentation
c) Right to refuse, right education
d) Right to choose their own medication
10. Before administering any medication, the nurse's priority action is to:
a) Check the patient's allergy status
b) Document the administration
c) Crush the pill if the patient has difficulty swallowing
d) Ask the family if it's okay to give
Fluids, Electrolytes, and Acid-Base Balance
11. A patient with severe vomiting is at highest risk for which acid-base
imbalance?
a) Respiratory acidosis
, b) Respiratory alkalosis
c) Metabolic acidosis
d) Metabolic alkalosis
12. The primary electrolyte responsible for maintaining fluid balance in the
extracellular space is:
a) Potassium
b) Magnesium
c) Sodium
d) Calcium
13. A key clinical manifestation of hyperkalemia (high potassium) is:
a) Muscle weakness and cardiac dysrhythmias
b) Tetany and positive Chvostek's sign
c) Fluid overload and hypertension
d) Deep, rapid Kussmaul respirations
14. The most accurate indicator of a patient's fluid volume status is:
a) Daily weight
b) Blood pressure
c) Skin turgor
d) Patient's reported thirst
15. Trousseau's sign and Chvostek's sign are indicative of:
a) Hypernatremia
b) Hypocalcemia
c) Hyperkalemia
d) Hypomagnesemia
16. A patient with heart failure is prescribed a diuretic. The nurse should closely
monitor for:
a) Hyperkalemia
b) Fluid overload
c) Hypokalemia
d) Hypertension
