,Chapter 01: Professional Nursing Practice
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse completes an admission database and explains that the plan of care and discharg
e goals will be developed with the patient‘s input. The patient states, ―How is this different f
rom what the doctor does?‖ Which response would be most appropriate for the nurse to ma
ke?
a. ―The role of the nurse is to administer medications and other treatments prescrib
ed by your doctor.‖
b. ―The nurse‘s job is to help the doctor by collecting information a
nd communicating any problems that occur.‖
c. ―Nurses perform many of the same procedures as the doctor, but nurses are wi
th the patients for a longer time than the doctor.‖
d. ―In addition to caring for you while you are sick, the nurses will assist you
to develop an individualized plan to maintain your health.‖
ANS: D
This response is consistent with the American Nurses Association (ANA) definition of nurs
ing, which describes the role of nurses in promoting health. The other responses describe so me
of the dependent and collaborative functions of the nursing role but do not accurately d escribe
the nurse‘s role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
2. The nurse describes to a student nurse how to use evidence-
based practice guidelines when caring for patients. Which statement, if made by the nur
se, would be the most accurate?
a. ―Inferences from clinical research studies are used as a guide.‖
b. ―Patient care is based on clinical judgment, experience, and traditions.‖
c. ―Data are evaluated to show that the patient outcomes are consistently met.‖
d. ―Recommendations are based on research, clinical expertise, and patie
nt preferences.‖
ANS: D
Evidence-based practice (EBP) is the use of the best research-
based evidence combined with clinician expertise. Clinical judgment based on the nurse‘s cl
inical experience is part of EBP, but clinical decision making should also incorporate curren
t research and research-
based guidelines. Evaluation of patient outcomes is important, but interventions should be b
ased on research from randomized control studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 15
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teaches a student nurse about how to apply the nursing process when providi
ng patient care. Which statement, if made by the student nurse, indicates that teaching was
successful?
a. ―The nursing process is a scientific-
based method of diagnosing the patient‘s health care problems.‖
, b. ―The nursing process is a problem-solving tool used to identify and treat patients‘
health care needs.‖
c. ―The nursing process is used primarily to explain nursing interventions to oth
y6
er health care professionals.‖
d. ―The nursing process is based on nursing theory that incorporates t
he biopsychosocial nature of humans.‖
ANS: B
The nursing process is a problem-
solving approach to the identification and treatment of patients‘ problems. Diagnosis is onl
y one phase of the nursing process. The primary use of the nursing process is in patient car
e, not to establish nursing theory or explain nursing interventions to other health care profe
ssionals.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A patient has been admitted to the hospital for surgery and tells the nurse, ―I do not feel c
omfortable leaving my children with my parents.‖ Which action should the nurse take next
?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patient‘s feelings about the child-care arrangements.
d. Call the patient‘s parents to determine whether adequate child care is bei
ng provided.
ANS: C
Because a complete assessment is necessary in order to identify a problem and choose an a
ppropriate intervention, the nurse‘s first action should be to obtain more information. The o
ther actions may be appropriate, but more assessment is needed before the best intervention
can be chosen.
DIF: Cognitive Level: Apply (application) REF: 6
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Assessmen
t MSC: NCLEX: Psychosocial Integrity
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ul
cer on the left hip. Which nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patient‘s major problem is the impaired skin integrity as demonstrated by the presence
of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure b
y frequently repositioning the patient. Although left-
sided weakness is a problem for the patient, the nurse cannot treat the weakness. The ―risk f
or‖ diagnosis is not appropriate for this patient, who already has impaired tissue integrity. T he
patient does have ineffective tissue perfusion, but the impaired skin integrity diagnosis i
ndicates more clearly what the health problem is.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
, 6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to
excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this
patient?
a. Patient has a balanced intake and output.
b. Patient‘s bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patient‘s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid v
olume that was identified in the nursing diagnosis statement. The other statements would no
t indicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purp
ose of the evaluation phase of the nursing process?
a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care plan in the progress notes of the medical record
c. To decide whether the patient‘s health problems have been completely resolved
d. To establish if the patient agrees that the nursing care provided was satisfactory
ANS: A
Evaluation consists of determining whether the desired patient outcomes have been met a
nd whether the nursing interventions were appropriate. The other responses do not descri be
the evaluation phase.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
8. The nurse interviews a patient while completing the health history and physical examinatio
n. What is the purpose of the assessment phase of the nursing process?
a. To teach interventions that relieve health problems
b. To use patient data to evaluate patient care outcomes
c. To obtain data with which to diagnose patient problems
d. To help the patient identify realistic outcomes for health problems
ANS: C
During the assessment phase, the nurse gathers information about the patient to diagnose pat
ient problems. The other responses are examples of the planning, intervention, and evaluati on
phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
9. Which nursing diagnosis statement is written correctly?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to response to biopsy test results
d. Altered urinary elimination related to urinary tract infection
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse completes an admission database and explains that the plan of care and discharg
e goals will be developed with the patient‘s input. The patient states, ―How is this different f
rom what the doctor does?‖ Which response would be most appropriate for the nurse to ma
ke?
a. ―The role of the nurse is to administer medications and other treatments prescrib
ed by your doctor.‖
b. ―The nurse‘s job is to help the doctor by collecting information a
nd communicating any problems that occur.‖
c. ―Nurses perform many of the same procedures as the doctor, but nurses are wi
th the patients for a longer time than the doctor.‖
d. ―In addition to caring for you while you are sick, the nurses will assist you
to develop an individualized plan to maintain your health.‖
ANS: D
This response is consistent with the American Nurses Association (ANA) definition of nurs
ing, which describes the role of nurses in promoting health. The other responses describe so me
of the dependent and collaborative functions of the nursing role but do not accurately d escribe
the nurse‘s role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
2. The nurse describes to a student nurse how to use evidence-
based practice guidelines when caring for patients. Which statement, if made by the nur
se, would be the most accurate?
a. ―Inferences from clinical research studies are used as a guide.‖
b. ―Patient care is based on clinical judgment, experience, and traditions.‖
c. ―Data are evaluated to show that the patient outcomes are consistently met.‖
d. ―Recommendations are based on research, clinical expertise, and patie
nt preferences.‖
ANS: D
Evidence-based practice (EBP) is the use of the best research-
based evidence combined with clinician expertise. Clinical judgment based on the nurse‘s cl
inical experience is part of EBP, but clinical decision making should also incorporate curren
t research and research-
based guidelines. Evaluation of patient outcomes is important, but interventions should be b
ased on research from randomized control studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 15
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teaches a student nurse about how to apply the nursing process when providi
ng patient care. Which statement, if made by the student nurse, indicates that teaching was
successful?
a. ―The nursing process is a scientific-
based method of diagnosing the patient‘s health care problems.‖
, b. ―The nursing process is a problem-solving tool used to identify and treat patients‘
health care needs.‖
c. ―The nursing process is used primarily to explain nursing interventions to oth
y6
er health care professionals.‖
d. ―The nursing process is based on nursing theory that incorporates t
he biopsychosocial nature of humans.‖
ANS: B
The nursing process is a problem-
solving approach to the identification and treatment of patients‘ problems. Diagnosis is onl
y one phase of the nursing process. The primary use of the nursing process is in patient car
e, not to establish nursing theory or explain nursing interventions to other health care profe
ssionals.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A patient has been admitted to the hospital for surgery and tells the nurse, ―I do not feel c
omfortable leaving my children with my parents.‖ Which action should the nurse take next
?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patient‘s feelings about the child-care arrangements.
d. Call the patient‘s parents to determine whether adequate child care is bei
ng provided.
ANS: C
Because a complete assessment is necessary in order to identify a problem and choose an a
ppropriate intervention, the nurse‘s first action should be to obtain more information. The o
ther actions may be appropriate, but more assessment is needed before the best intervention
can be chosen.
DIF: Cognitive Level: Apply (application) REF: 6
OBJ: Special Questions: Prioritization
TOP: Nursing Process: Assessmen
t MSC: NCLEX: Psychosocial Integrity
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ul
cer on the left hip. Which nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patient‘s major problem is the impaired skin integrity as demonstrated by the presence
of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure b
y frequently repositioning the patient. Although left-
sided weakness is a problem for the patient, the nurse cannot treat the weakness. The ―risk f
or‖ diagnosis is not appropriate for this patient, who already has impaired tissue integrity. T he
patient does have ineffective tissue perfusion, but the impaired skin integrity diagnosis i
ndicates more clearly what the health problem is.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
, 6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to
excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this
patient?
a. Patient has a balanced intake and output.
b. Patient‘s bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patient‘s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid v
olume that was identified in the nursing diagnosis statement. The other statements would no
t indicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purp
ose of the evaluation phase of the nursing process?
a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care plan in the progress notes of the medical record
c. To decide whether the patient‘s health problems have been completely resolved
d. To establish if the patient agrees that the nursing care provided was satisfactory
ANS: A
Evaluation consists of determining whether the desired patient outcomes have been met a
nd whether the nursing interventions were appropriate. The other responses do not descri be
the evaluation phase.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
8. The nurse interviews a patient while completing the health history and physical examinatio
n. What is the purpose of the assessment phase of the nursing process?
a. To teach interventions that relieve health problems
b. To use patient data to evaluate patient care outcomes
c. To obtain data with which to diagnose patient problems
d. To help the patient identify realistic outcomes for health problems
ANS: C
During the assessment phase, the nurse gathers information about the patient to diagnose pat
ient problems. The other responses are examples of the planning, intervention, and evaluati on
phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
9. Which nursing diagnosis statement is written correctly?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to response to biopsy test results
d. Altered urinary elimination related to urinary tract infection
