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Understanding Medical Surgical Nursing 5th Edition Test Bank
Chapter 1. Critical Thinking and the Nursing Process
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. After receiving morning report, which patient should the licensed
practical nurse/licensed vocational nurse (LPN/LVN) assess first?
A. A patient who needs discharge teaching
B. A patient who needs assistance to ambulate
C. A patient who states, “No one cares about me.”
D. A patient who has a temperature of 106°F (41.1°C)
____ 2. During a class discussion, two nursing students demonstrated intellectual courage. What action did the
nursing students perform?
A. Considered being in the other person’s situation
B. Expected proof that the use of restraints is safe
C. Conducted additional research on the use of restraints in patient care
D. Listened to each other’s point of view regarding the use of patient restraints
____ 3. The nursing staff is planning a celebratory dinner and cake for a newly licensed practical nurse. Which
of the new nurse’s human needs is supported by these actions?
A. Self-esteem
B. Physiological
C. Self-actualization
D. Safety and security
____ 4. A patient with a newly fractured femur reports a pain level of 8/10, and analgesic medication is not
due for another 50 minutes. Which actions should the nurse take?
A. Reposition the patient.
B. Give the medication in 30 minutes.
C. Notify the registered nurse (RN) or physician.
D. Tell the patient it is too early for pain medication.
____ 5. The nursing instructor is planning a teaching session on critical thinking for students. What should the
instructor say when explaining critical thinking?
A. “Collect data concerning the patient’s problem.”
B. “Think of different ways to help relieve a patient’s problem.”
C. “Determine if an action worked to eliminate a patient problem.”
D. “Use knowledge and skills to make the best decision for patient care.”
____ 6. The nurse is planning care and setting goals for a newly admitted patient. Who should the nurse
include when conducting these nursing actions?
A. Patient
B. Nurse manager
, Understanding Medical Surgical Nursing 5th Edition Test Bank
C. Patient’s family members
D. Patient’s health care provider (HCP)
____ 7. While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes serosanguineous
drainage on the patient’s dressing. Which statement should the nurse use to document the finding?
A. “Normal drainage noted.”
B. “Moderate drainage recently noted.”
C. “Scant serosanguineous drainage seen on dressing.”
D. “Pale pink drainage, 2 cm by 1 cm, noted on dressing.”
____ 8. The nurse is caring for a patient who is scheduled for surgery. Which data should the nurse collect to
identify safety and security needs?
A. Meal patterns
B. Sleep patterns
C. Anxiety about surgery
D. Effectiveness of pain medication
____ 9. The nurse is reviewing data collected during patient care. Which data should the nurse document as
objective?
A. Patient is pleasant.
B. Urine output is 300 mL.
C. “It has been a good day.”
D. Patient’s appetite is poor.
____ 10. The nurse is determining diagnoses appropriate for a patient recovering from surgery. Which nursing
diagnoses should the nurse identify as the highest priority for this patient?
A. Acute pain
B. Impaired mobility
C. Deficient knowledge
D. Impaired skin integrity
____ 11. The nurse suspects a patient is experiencing adverse effects to a newly prescribed antihypertensive
medication. After being informed that the effects are expected, the nurse remains concerned and
conducts an Internet search on the patient’s manifestations. Which critical thinking behavior did the
nurse implement?
A. Sense of justice
B. Intellectual courage
C. Intellectual empathy
D. Intellectual perseverance
____ 12. The nurse is identifying outcomes for a patient with a Fluid Volume Deficit. Which outcome should
the nurse use to guide the patient’s care?
A. Patient’s fluid intake will be measured daily.
B. Patient’s intake will be 3000 mL daily.
C. Fluids will be at the bedside for the patient.
D. Fluids the patient likes will be at the bedside.
____ 13. The nurse is caring for a patient with the diagnosis of Fluid Volume Excess. Which information
should the LPN/LVN use to determine if care was effective?
A. Restrict the patient’s fluid intake.
B. Measure the patient’s daily weight.
C. Teach the patient to monitor fluid balance.
D. Discuss the patient’s care plan with the RN.
____ 14. A RN delegates a patient care assignment to the LPN/LVN. Which phase of the nursing process
should the LPN/LVN perform independently?
, Understanding Medical Surgical Nursing 5th Edition Test Bank
A. Assessment
B. Planning care
C. Implementation
D. Nursing diagnosis
____ 15. The nurse is caring for a patient with a painful back injury that occurred 6 months ago. Which three-
part nursing diagnosis should the nurse use to guide this patient’s care?
A. Pain as evidenced by herniated lumbar disk
B. Acute pain related to inability to sit as evidenced by muscle spasms
C. Chronic pain related to muscle spasms as evidenced by patient pain rating of 8 and
difficulty walking
D. Acute pain related to patient pain rating of 6 as evidenced by muscle spasms and nerve
compression
____ 16. The RN implements an intervention to improve a patient’s appetite. After implementing the
intervention for two meals, the LPN/LVN notes no improvement in the patient’s eating. What action
should the LPN/LVN take?
A. Develop a new plan of care.
B. Revise the patient outcome to one that is achievable.
C. Collaborate on a new nursing diagnosis with the RN.
D. Provide data to the RN to assist in evaluation of the plan.
____ 17. During morning report, the LPN/LVN is assigned a group of patients. Which patient should the
LPN/LVN see first?
A. A patient scheduled for magnetic resonance imaging (MRI) due to back pain
B. A patient reporting constipation and stomach cramps
C. A 2-day postsurgical patient reporting pain at a level of 6
D. A patient with pneumonia who is short of breath and anxious
____ 18. The LPN/LVN is reviewing a patient’s list of nursing diagnoses. Which diagnoses should the
LPN/LVN identify as a priority for this patient?
A. Anxiety
B. Constipation
C. Deficient fluid volume
D. Ineffective airway clearance
____ 19. The nurse is using the nursing process when caring for a patient. In which order should the nurse
implement this process?
A. Nursing diagnosis, intervention, rationale, evaluation, planning
B. Data collection, intervention, nursing diagnosis, rationale, evaluation
C. Assessment, nursing diagnosis, planning, implementation, evaluation
D. Data collection, evaluation, nursing diagnosis, implementation, rationale
____ 20. The nurse is determining a patient’s problems. What step of the nursing process is the nurse
performing?
A. Assessment
B. Outcome planning
C. Nursing diagnosis
D. Nursing intervention
____ 21. The nurse is preparing to determine if a patient is meeting planned outcomes. What measurable
information should the nurse use to make this determination?
A. P-E-S format
B. Objective observations
C. Subjective terminology
D. Open-ended time frames
, Understanding Medical Surgical Nursing 5th Edition Test Bank
____ 22. The nurse is planning a patient’s care based on Maslow’s hierarchy of needs. Which human need
should the nurse identify as requiring his or her immediate attention?
A. Heart rate 38 and irregular
B. Plans to return to college in a year
C. Needs walker adjusted to safely ambulate
D. Desire to learn how to self-inject medication
____ 23. While being taught to apply a topical medication, the patient begins to vomit. Which action should the
nurse take to meet the patient’s human needs?
A. Provide a clean gown before resuming the teaching.
B. Position an emesis basin for patient use while teaching.
C. Provide medication prescribed for nausea and vomiting.
D. Wait for the vomiting to stop and begin the teaching session again.
____ 24. The nurse approaches a person in a restaurant who appears to be experiencing respiratory distress.
Which action should the nurse perform first?
A. Diagnose the problem.
B. Help the person lie down.
C. Gather data from other people.
D. Collect data about the person’s condition.
____ 25. The nurse identifies the diagnosis Fluid Volume Overload as appropriate for a patient with heart
failure. Which collected data should the nurse use to provide evidence for this diagnosis?
A. Skin warm to the touch
B. Oriented to person only
C. Respiratory rate 20 and shallow
D. +3 pitting edema of both feet and ankles
____ 26. After identifying nursing diagnoses, the nurse plans outcomes for a patient with gastroesophageal
reflux disease. Which outcome should the nurse use to evaluate this patient’s care?
A. The patient will have less heartburn.
B. The patient will sleep through the night.
C. The patient’s esophageal burning will resolve 30 minutes after taking oral antacids.
D. The patient will state that burning only occurs when eating foods high in acid content.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 27. After collecting data the nurse identifies diagnoses to guide the patient’s care. Which diagnoses did the
nurse document correctly? (Select all that apply.)
A. Diabetes
B. Acute pain
C. Pancreatitis
D. Activity intolerance
E. Impaired physical mobility
____ 28. A patient with a family history of diabetes is experiencing high blood glucose levels, confusion, an
unsteady gait, and dehydration. Which nursing diagnoses should the nurse identify as appropriate for
this patient’s care? (Select all that apply.)
A. Diabetes
B. Dehydration
C. Risk for falls
D. Hyperglycemia
E. Deficient fluid volume
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