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Chapter 01: Introduction to Medical-Surgical Nursing Practice in CanadaLewis: Medical-Surgical
Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE :
1. The nurse is caring for a client with a new diagnosis of pneumonia and
explains to the client that together they will plan the client’s care and set
goals for discharge. The client asks, “How is that different from what the
doctor does?” Which response by the nurse is most appropriate?
a. “The role of the nurse is to administer medications and other treatments prescribed
by your doctor.”
b. “The nurse’s job is to help the doctor by collecting data and communicating when
there are problems.”
c. “Nurses perform many of the procedures done by physicians, but nurses are here in
the hospital for a longer time than doctors.”
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 Canadian Nurses Association (CNA) definition of nursing.
Registered nurses are self-regulated health care professionals who work autonomously and in
collaboration with others. RNs enable individuals, families, groups, communities and populations to
achieve their optimal level of health. RNs coordinate health care, deliver direct services, and support
clients in their self-care decisions and actions in situations of health, illness, injury, and disability in all
stages of life. The other responses describe some of the dependent and collaborative functions of the
nursing role but do not accurately describe the nurse’s role in the health care system.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
2. When caring for clients using evidence-informed practice, which of the following does the nurse use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the client outcomes are met
ANS: C
Evidence-informed nursing practice is a continuous interactive process involving the explicit,
conscientious, and judicious consideration of the best available evidence to provide care. Four primary
elements are: (a) clinical state, setting, and circumstances; (b) client preferences and actions; (c) best
research evidence, and (d) health care resources. Clinical judgement based on the nurse’s clinical
experience is part of EIP, but clinical decision making also should incorporate current research and
research-based guidelines. Evidence from one clinical research study does not provide an adequate
substantiation for interventions. Evaluation of client outcomes is important, but interventions should be
based on research from randomized control studies with a large number of subjects.
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DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
3. Which of the following best explains the nurses’ primary use of the nursing process when providing
care to clients?
a. To explain nursing interventions to other health care professionals
b. As a problem-solving tool to identify and treat clients’ health care needs
c. As a scientific-based process of diagnosing the client’s health care problems
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
ANS: B
The nursing process is an assertive problem-solving approach to the identification and treatment of
clients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing
process is in client care, not to establish nursing theory or explain nursing interventions to other health
care professionals.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
4. The nurse is caring for a critically ill client in the intensive care unit and plans an every-2-hour turning
schedule to prevent skin breakdown. Which type of nursing function is demonstrated with this turning
schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D
When implementing collaborative nursing actions, the nurse is responsible primarily for monitoring
for complications of acute illness or providing care to prevent or treat complications. Independent
nursing actions are focused on health promotion, illness prevention, and client advocacy. A dependent
action would require a physician order to implement. Cooperative nursing functions are not described
as one of the formal nursing functions.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
5. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the nurse, “I
do not feel right about leaving my children with my neighbour.” Which action should the nurse take
next?
a. Reassure the client that these feelings are common for parents.
b. Have the client call the children to ensure that they are doing well.
c. Call the neighbour to determine whether adequate childcare is being provided.
d. Gather more data about the client’s feelings about the childcare arrangements.
ANS: D
Since 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.
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DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity
6. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and assesses a
pressure injury on the client’s left hip. Which of the following is the most appropriate nursing
diagnosis for this client?
a. Impaired physical mobility related to decrease in muscle control (left-sided
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
protecting tissue integrity
c. Impaired skin integrity related to pressure over bony prominence (impaired
circulation)
d. Ineffective peripheral tissue perfusion related to sedentary lifestyle
ANS: C
The client’s major problem is the impaired skin integrity as demonstrated by the presence of a pressure
injury. The nurse is able to treat the cause of impaired circulation and pressure over bony prominence
by frequently repositioning the client. Although left-sided weakness is a problem for the client, the
nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this client, who already
has impaired tissue integrity. The client does have ineffective peripheral tissue perfusion, but the
impaired skin integrity diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis
MSC: NCLEX: Physiological Integrity
7. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid volume related
to excessive fluid loss through normal route (diaphoresis). Which of the following is an appropriate
client outcome?
a. Client has a balanced intake and output.
b. Client’s bedding is changed when it becomes damp.
c. Client understands the need for increased fluid intake.
d. Client’s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid volume that
was identified in the nursing diagnosis statement. The other statements would not indicate that the
problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
8. Which of the following represents a nursing activity that is carried out during the evaluation phase of
the nursing process?
a. Determining if interventions have been effective in meeting client outcomes.
b. Documenting the nursing care plan in the progress notes in the medical record.
c. Deciding whether the client’s health problems have been completely resolved.
d. Asking the client to evaluate whether the nursing care provided was satisfactory.
ANS: A
