1. The nurse has admitted a patient with a new diagnosis of pneumonia and explained to the
patient that together they will plan the patient’s care and set goals for discharge. The
patient says, “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 American Nurses Association (ANA) definition of
nursing, which describes the role of nurses in promoting health. 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 REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care
Environment
2. When providing patient care using evidence-based practice, the nurse uses
a. clinical judgment based on experience.
b. evidence from a clinical research study.
c. evidence-based guidelines in addition to clinical expertise.
d. evaluation of data showing that the patient outcomes are met.
ANS: C
Evidence-based practice (EBP) is the use of the best research-based evidence combined
with clinician expertise. Clinical judgment based on the nurse’s clinical experience is part
of EBP, 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 patient outcomes is important,
but interventions should be based on research from randomized control studies with a
large number of subjects.
3. The nurse primarily uses the nursing process in the care of patients
a. to explain nursing interventions to other health care professionals
b. as a problem-solving tool to identify and treat patients’ health care needs
c. as a scientific-based process of diagnosing the patient’s health care problems
d. to establish nursing theory that incorporates the biopsychosocial nature of humans
ANS: B
The nursing process is a problem-solving approach to the identification and treatment of
patients’ problems. Diagnosis is only one phase of the nursing process. 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: Comprehension REF: 10
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care
Environment
4. The nurse plans an every 2-hour turning schedule to prevent skin breakdown for a
critically ill patient in the intensive care unit. In this case, the nursing action is considered
to be
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 patient 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 REF: 10-11
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care
Environment
5. A patient who has been admitted to the hospital for surgery tells the nurse, “I do not feel
right about leaving my children with my neighbor.” 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. Call the neighbor to determine whether adequate childcare is being provided.
d. Gather more data about the patient’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.
6. A patient with a stroke is paralyzed on the left side of the body and has developed a
pressure ulcer on the left hip. The best nursing diagnosis for this patient is
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 by frequently repositioning the patient. Although left-sided weakness is a
problem for the patient, the nurse cannot treat the weakness. The “risk for” diagnosis is
not appropriate for this patient, who already has impaired tissue integrity. The patient
does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates
more clearly what the health problem is.
7. A patient with an infection has a nursing diagnosis of deficient fluid volume related to
excessive diaphoresis. An appropriate patient outcome identified by the nurse is that the
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
volume that was identified in the nursing diagnosis statement. The other statements
would not indicate that the problem of deficient fluid volume was resolved.
8. A nursing activity that is carried out during the evaluation phase of the nursing process is
a. determining if interventions have been effective in meeting patient outcomes.
b. documenting the nursing care plan in the progress notes in the medical record.
c. deciding whether the patient’s health problems have been completely resolved.
d. asking the patient to evaluate whether the nursing care provided was satisfactory.
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