Chapter 01: Professional Nursing
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
MULTIPLE CHOICE
- The nurse completes an admission database and explains that the plan of care and discharge
goals will be developed with the patient‘s input. The patient asks, “How is this different from
what the physician does?” Which response would the nurse provide?
a. “The role of the nurse is to administer medications and other treatments prescribed
by your physician.”
b. “In addition to caring for you while you are sick, the nurses will help you plan to
maintain your health.”
c. “The nurse‘s job is to collect information and communicate any problems that
occur to the physician.”
d. “Nurses perform many of the same procedures as the physician, but nurses are
with the patients for a longer time than the physician.”
ANS: B
The American Nurses Association (ANA) definition of nursing describes the role of nurses in
promoting health. The other responses describe dependent and collaborative functions of the
nursing role but do not accurately describe the nurse‘s unique role in the health care system.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment - Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
a. “Patient care is based on clinical judgment, experience, and traditions.”
b. “Data are analyzed later to show that the patient outcomes are consistently met.”
c. “Research from all published articles are used as a guide for planning patient care.”
d. “Recommendations are based on research, clinical expertise, and patient
preferences.”
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with
clinician expertise and consideration of patient preferences. Clinical judgment based on the
nurse‘s clinical experience is part of EBP, but clinical decision making should also
incorporate current research and research-based guidelines. Evaluation of patient outcomes is
important, but data analysis is not required to use EBP. All published articles do not provide
research evidence; interventions should be based on credible research, preferably randomized
controlled studies with a large number of subjects.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment - Which statement by the nurse provides a clear explanation of the nursing process?
a. “The nursing process is a research method of diagnosing the patient‘s health care
problems.”
b. “The nursing process is used primarily to explain nursing interventions to other
health care professionals.”
c. “The nursing process is a problem-solving tool used to identify and manage the
patients‘ health care needs.”
d. “The nursing process is based on nursing theory that incorporates the
biopsychosocial nature of humans.”
ANS: C
The nursing process is a problem-solving approach to the identification and treatment of
patients‘ problems. Nursing process does not require research methods for diagnosis. The
primary use of the nursing process is in patient care, not to establish nursing theory or explain
nursing interventions to other health care professionals.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
- A patient admitted to the hospital for surgery tells the nurse, “I do not feel comfortable
leaving my children with my parents.” Which action would 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 information on the patient‘s concerns about the child care arrangements.
d. Call the patient‘s parents to determine whether adequate child care is being
provided.
ANS: C
Because a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurse‘s first action should 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 Level: Analyze (Analysis)
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity - A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis.
Which expected outcome would the nurse select for this patient?
a. Patient has a balanced intake and output.
b. Patient‘s bedding is kept clean and free of moisture.
c. Patient understands the need for increased fluid intake.
d. Patient‘s skin remains cool and dry throughout hospitalization.
ANS: A
Balanced intake and output gives measurable data showing resolution of the problem of
deficient fluid volume. The other statements would not indicate that the problem of
hypovolemia was resolved.
DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity - Which statement describes the purpose of the evaluation phase of the nursing process?
a. To document the nursing care plan in the progress notes of the health record
b. To determine if interventions have been effective in meeting patient outcomes
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: B
Evaluation 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
evaluation phase.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
- Which statement describes 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 to diagnose patient strengths and 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
patient strengths and problems. The other responses are examples of the planning,
intervention, and evaluation phases of the nursing process.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment - When developing the plan of care, which components would the nurse include in the clinical
problem statement?
a. The problem and the suggested patient goals or outcomes
b. The problem, its causes, and the signs and symptoms of the problem
c. The problem with the possible etiology and the planned interventions
d. The problem, its pathophysiology, and the expected outcome
ANS: B
When writing clinical problems or nursing diagnoses, the subjective as well as objective data
to support the problem‘s existence should be included. Goals, outcomes, and interventions are
not included in the problem statement.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment - Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
a. Instruct the patient about the need to alternate activity and rest.
b. Monitor level of shortness of breath or fatigue after ambulation.
c. Obtain the patient‘s blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level.
ANS: C
AP education includes accurate vital sign measurement. Assessment and patient teaching
require registered nurse education and scope of practice and cannot be delegated.
DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment - A nurse is caring for a group of patients on the medical-surgical unit with the help of one float
registered nurse (RN), one assistive personnel (AP), and one licensed practical/vocational
nurse (LPN/VN). Which assignment, if delegated by the nurse, would be outside that
individual‘s scope of practice?
a. Check for the presence of bowel sounds by AP
b. Administration of oral medications by LPN/VN
c. Insulin administration by float RN from the pediatric unit
d. Measurement of a patient‘s urinary catheter output by AP
ANS: A
Assessment requires RN education and scope of practice so it cannot be delegated to an
LPN/VN or AP. The other assignments made by the RN are appropriate for the role of the
team member.
DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment - Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse
(LPN/VN)?
a. Complete the initial admission assessment and plan of care.
b. Measure bedside blood glucose before administering insulin.
c. Document teaching completed before a diagnostic procedure.
d. Instruct a patient about low-fat, reduced sodium dietary restrictions.
ANS: B
The education and scope of practice of the LPN/LVN include activities such as obtaining
glucose testing using a finger stick and administering insulin. Patient teaching and the initial
assessment and development of the plan of care are nursing actions that require registered
nurse education and scope of practice.
DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment - A nurse is assigned as a case manager for a hospitalized patient who has a spinal cord injury.
Which activity can the patient expect the nurse in this role to perform?
a. Care for the patient during hospitalization for the injuries.
b. Assist the patient with home care activities during recovery.
c. Coordinate the services the patient receives in the hospital and at home.
d. Determine what medical care the patient needs for optimal rehabilitation.
ANS: C
The role of the case manager is to coordinate the patient‘s care through multiple settings and
levels of care to allow the maximal patient benefit at the least cost. The case manager does not
provide direct care in the acute or home setting. The case manager coordinates and advocates
for care. The HCP determines what medical care is needed.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment - The nurse is caring for an older adult patient who needs continued nursing care and physical
therapy to improve mobility after surgery to repair a fractured hip. The nurse would help to
arrange for transfer of the patient to which type of facility?