Chapter 01: Professional Nursing
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
MULTIPLE CHOICE
1. 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
2. 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
3. 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
4. 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
5. 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
6. 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
7. 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
8. 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
9. 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
,10. 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
11. 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
12. 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
13. 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?
, a. A skilled care facility
b. A transitional care facility
c. A residential care facility
d. An intermediate care facility
ANS: B
Transitional care settings are appropriate for patients who need continued rehabilitation before
discharge to home or to long-term care settings. The patient is no longer in need of the more
continuous assessment and care given in acute care settings. There is no indication that the
patient will need the permanent and ongoing medical and nursing services available in
intermediate or skilled care. The patient is not yet independent enough to transfer to a
residential care facility.
DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
14. A home care nurse is planning care for a patient who has just been diagnosed with type 2
diabetes. Which task is appropriate for the nurse to delegate to the home health aide?
a. Assist the patient to choose appropriate foods.
b. Help the patient with a daily bath and oral care.
c. Check the patient‘s feet for signs of breakdown.
d. Teach the patient how to monitor blood glucose.
ANS: B
Assisting with patient hygiene is included in home health-aide education and scope of
practice. Assessment of the patient and instructing the patient in new skills, such as diet and
blood glucose monitoring, are complex skills that are included in registered nurse education
and scope of practice.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
15. The nurse is providing education to nursing staff on quality care initiatives. Which statement
is an accurate description of the impact of health care financing on quality care?
a. “If a patient develops a catheter-related infection, the hospital receives additional
funding.”
b. “Payment for patient care is primarily based on clinical outcomes and patient
satisfaction.”
c. “Hospitals are reimbursed for all costs incurred if care is documented
electronically.”
d. “Because hospitals are accountable for overall care, it is not nursing‘s
responsibility to monitor care delivered by others.”
ANS: B
Payment for health care services programs reimburses hospitals for their performance on
overall quality-of-care measures. These measures include clinical outcomes and patient
satisfaction. Nurses are responsible for coordinating complex aspects of patient care,
including the care delivered by others, and identifying issues that are associated with poor
quality care. Payment for care can be withheld if something happens to the patient that is
considered preventable (e.g., acquiring a catheter-related urinary tract infection).
, DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
16. The nurse documenting the patient‘s progress in the electronic health record is demonstrating
competency in which area?
a. Patient-centered care
b. Evidence-based practice
c. Quality improvement
d. Informatics and technology
ANS: D
The nurse is displaying competency in informatics and technology. Using a computerized
information system to document patient needs and progress and communicate vital
information about the patient with the interprofessional care team members provides evidence
that nursing practice standards related to the nursing process have been maintained during the
care of the patient.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. Which information will the nurse consider when deciding what nursing actions to delegate to
a licensed practical/vocational nurse (LPN/VN) who is working on a medical-surgical unit?
(Select all that apply.)
a. Agency policies
b. Stability of the patients
c. State nurse practice act
d. LPN/VN teaching abilities
e. Experience of the LPN/VN
ANS: A, B, C, E
The nurse should assess the experience of LPN/VNs when delegating. In addition, state nurse
practice acts and agency policies must be considered. In general, while the LPN/VN scope of
practice includes caring for patients who are stable, registered nurses should provide most of
the care for unstable patients. Because the LPN/VN scope of practice does not include patient
education, this will not be part of the delegation process.
DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
2. Which actions by the nurse administering medications are consistent with promoting safe
delivery of patient care? (Select all that apply.)
a. Discards a medication that is not labeled.
b. Uses hand sanitizer before preparing a medication.
c. Identifies the patient by the room number on the door.
d. Checks laboratory test results before administering a diuretic.
e. Gives the patient a list of current medications upon discharge.
ANS: A, B, D, E
, National Patient Safety Goals have been established to promote safe delivery of care. The
nurse should use at least 2 reliable ways to identify the patient such as asking the patient‘s full
name and date of birth before medication administration. Other actions that improve patient
safety include performing hand hygiene, disposing of unlabeled medications, completing
appropriate assessments before administering medications, and giving a list of the current
medicines to the patient and caregiver before discharge.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
3. Which actions by a nurse would demonstrate an aspect of nursing clinical judgment? (Select
all that apply.)
a. Identifying priority problems
b. Noticing a change in patient status
c. Memorizing the steps of a procedure
d. Assessing data about a patient situation
e. Generating possible solutions to a patient problem
f. Making decisions based on the implications of a patient‘s situation
ANS: A, B, D, E, F
Clinical judgment is evident when the nurse assesses data or situations, notices a change in a
patient‘s status, identifies priority problems, generates the best possible solutions, and makes
decisions about patient care based on analysis of the situation. Clinical judgment is not
memorizing a list of facts or the steps of a procedure.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
Chapter 02: Social Determinants of Health
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
MULTIPLE CHOICE
1. Which data from the patient‘s health history would be the nurse‘s focus for patient teaching?
a. Family history
b. Age and gender
c. Dietary fat intake
d. Race and ethnicity
ANS: C
Behaviors are strongly linked to many health care problems. The patient‘s fat intake is a
behavior that the patient can change. The other information will be useful as the nurse
develops an individualized plan for improving the patient‘s health but will not be the focus of
patient teaching for behavior change.
DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
,2. The nurse works in a clinic located in a community where many of the residents are Hispanic.
Which strategy, if implemented by the nurse, would decrease health care disparities and
promote health equity for this community?
a. Improve public transportation to the clinic.
b. Update equipment and supplies at the clinic.
c. Teach clinic staff about cultural health beliefs.
d. Obtain low-cost medications for clinic patients.
ANS: C
Health care disparities are caused by stereotyping, biases, and prejudice of health care
providers. The nurse can decrease these through staff education. The other strategies may also
be addressed by the nurse but will not directly impact health disparities.
DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
3. Which information would the nurse collect as a measure of community health?
a. Air pollution levels
b. Number of healthy food stores
c. Most common causes of death
d. Education level of the individuals
ANS: C
Health status measures of a community include birth and death rates, life expectancy, access
to care, and morbidity and mortality rates related to disease and injury. Although air pollution,
access to health food stores, and education level are factors that affect a community‘s health
status, they are not health measures.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
4. The nurse is caring for a patient who has traditional Native American beliefs about health and
illness. Which action by the nurse would demonstrate cultural competence?
a. Explain the hospital schedule for meal times, care, and family visits.
b. Ask the patient whether it is important that a cultural healer is contacted.
c. Avoid asking health questions unless the patient initiates the conversation.
d. Obtain information about the patient‘s cultural beliefs from a family member.
ANS: B
Because the patient has traditional health care beliefs, it is appropriate for the nurse to ask
whether the patient would like a visit by cultural healer. There is no cultural reason for the
nurse to avoid asking the patient questions because these questions are necessary to obtain
health information. The patient (rather than the family) should be consulted first about
personal cultural beliefs. The hospital routines for meals, care, and visits should be adapted to
the patient‘s preferences rather than expecting the patient to adapt to the hospital schedule.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
5. The nurse is caring for a patient being admitted to the hospital who is Asian. Which action
would be respectful for the nurse to take when interviewing this patient?
a. Avoid any eye contact with the patient.
, b. Look directly at the patient when interacting.
c. Observe and follow the patient‘s use of eye contact.
d. Ask a family member about the patient‘s cultural beliefs.
ANS: C
Observation of the patient‘s use of eye contact will be most useful in determining the best way
to communicate effectively with the patient. Looking directly at the patient or avoiding eye
contact may be appropriate, depending on the patient‘s individual cultural beliefs. The nurse
should assess the patient, rather than asking family members about the patient‘s beliefs.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
6. The nurse is caring for a patient who speaks a different language. If an interpreter or
interpretation phone service is not available, which action would the nurse take?
a. Talk slowly so that each word is clearly heard.
b. Use gestures or pictures to demonstrate meaning.
c. Speak loudly in close proximity to the patient‘s ears.
d. Repeat important words so that the patient will recognize them.
ANS: B
The use of gestures or pictures will enable some information to be communicated to the
patient. The other actions will not improve communication with the patient.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
7. Which action would the nurse include in the plan of care for a hospitalized patient who uses
culturally based treatments?
a. Encourage the use of additional diagnostic procedures.
b. Teach the patient that folk remedies will interfere with prescribed orders.
c. Ask the patient to discontinue the cultural treatments during hospitalization.
d. Coordinate the use of requested treatments with prescribed medical therapies.
ANS: D
Many culturally based therapies can be accommodated along with the use of Western
treatments and medications. The nurse should attempt to use both traditional folk treatments
and the ordered Western therapies when possible. Some culturally based treatments can be
effective in treating “Western” diseases. Not all folk remedies interfere with Western
therapies. It may be appropriate for the patient to continue some culturally based treatments
while he or she is hospitalized.
DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning
MSC: NCLEX: Psychosocial Integrity
8. The nurse is caring for a newly admitted patient. Which intervention is considered appropriate
across most cultures?
a. Maintain a personal space of at least 2 ft when assessing the patient.
b. Insist that family members provide most of the patient‘s personal care.
c. Ask permission before touching a patient during the physical assessment.
d. Consider the patient‘s ethnicity as the most important factor in planning care.
, ANS: C
Many cultures consider it disrespectful to touch a patient without asking permission, so asking
a patient for permission is always culturally appropriate. The other actions may be appropriate
for some patients but are not appropriate across most cultural groups or for most individual
patients. Ethnicity may not be the most important factor in planning care, especially if the
patient has urgent physiologic problems.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
9. A staff nurse expresses frustration that a patient who is Native American always has several
family members at the bedside. Which action would the charge nurse take?
a. Request that family members leave until a different nurse can be assigned.
b. Ask about the nurse‘s beliefs regarding family support during hospitalization.
c. Have the nurse explain to the family that too many visitors will tire the patient.
d. Suggest that the nurse ask family members to leave the room during patient care.
ANS: B
The first step in providing culturally competent care is to understand one‘s own beliefs and
values related to health and health care. Asking the nurse about personal beliefs will help
achieve this step. Asking family members to leave the room or explaining that too many
visitors will tire the patient are not culturally appropriate for this patient.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
10. An older patient who is Asian American tells the nurse that she has lived in the United States
for 50 years. The patient speaks English and lives in a predominantly Asian neighborhood.
Which initial action would the nurse take?
a. Include a shaman when planning the patient‘s care.
b. Avoid direct eye contact with the patient during care.
c. Ask the patient about any special cultural beliefs or practices.
d. Involve the patient‘s oldest son to assist with health care decisions.
ANS: C
Further assessment of the patient‘s health care preferences is needed before making further
plans for culturally appropriate care. The other responses indicate stereotyping of the patient
based on ethnicity and would not be appropriate initial actions.
DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning
MSC: NCLEX: Psychosocial Integrity
11. The nurse plans health care for a community with a large number of recent immigrants from
Vietnam. Which intervention would the nurse plan to implement?
a. Hepatitis testing
b. Tuberculosis screening
c. Contraceptive teaching
d. Colonoscopy information
ANS: B
