Test Bank for Lewis's Medical-Surgical
Nursing, 12th Edition by Mariann M.
Harding, Jeffrey Kwong, Debra Hagler
Chapter 1-69
,Chapter 01: Professional Nursing
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Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
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MULTIPLE CHOICE wi
1. The nurse completes an admission database and explains that the plan of care and dischar
wi wi wi wi wi wi wi wi wi wi wi wi wi wi
ge goals will be developed with the patient‗s input. The patient asks, ―How is this different
wi wi wi wi wi wi wi wi wi wi wi wi wi wi wi wi
from what the physician does?‖ Which response would the nurse provide?
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a. ―The role of the nurse is to administer medications and other treatments prescribe
wi wi wi wi wi wi wi wi wi wi wi wi
d by your physician.‖
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b. ―In addition to caring for you while you are sick, the nurses will help you plan t
wi wi wi wi wi wi wi wi wi wi wi wi wi wi wi wi
o maintain your health.‖
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c. ―The nurse‗s job is to collect information and communicate any problems th
wi wi wi wi wi wi wi wi wi wi wi
at occur to the physician.‖
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d. ―Nurses perform many of the same procedures as the physician, but nurses ar
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e with the patients for a longer time than the physician.‖
wi wi wi wi wi wi wi wi wi wi
ANS: B wi
The American Nurses Association (ANA) definition of nursing describes the role of nurses i
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n promoting health. The other responses describe dependent and collaborative functions of
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the nursing role but do not accurately describe the nurse‗s unique role in the health care
wi wi wi wi wi wi wi wi wi wi wi wi wi wi wi wi wi
system.
DIF: w i w i Cognitive Level: Analyze (Analysis) wi wi wi
TOP: w i Nursing Process: Implementation wi wi w i w i w i MSC: NCLEX: Safe and Effective Care Environment
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2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
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a. ―Patient care is based on clinical judgment, experience, and traditions.‖
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b. ―Data are analyzed later to show that the patient outcomes are consistently met.‖
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c. ―Research from all published articles are used as a guide for planning patient care.‖
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d. ―Recommendations are based on research, clinical expertise, and patien wi wi wi wi wi wi wi wi
t preferences.‖
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ANS: D wi
Evidence-based practice (EBP) is the use of the best research- wi wi wi wi wi wi wi wi wi
based evidence combined with clinician expertise and consideration of patient preferences
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. Clinical judgment based on the nurse‗s clinical experience is part of EBP, but clinical d
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ecision making should also incorporate current research and research-
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based guidelines. Evaluation of patient outcomes is important, but data analysis is not requi
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red to use EBP. All published articles do not provide research evidence; interventions shou
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ld be based on credible research, preferably randomized controlled studies with a large nu
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mber of subjects. wi wi
DIF: Cognitive Level: Understand (Comprehension)
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TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
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3. Which statement by the nurse provides a clear explanation of the nursing process?
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a. ―The nursing process is a research method of diagnosing the patient‗s health car
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e problems.‖ wi
b. ―The nursing process is used primarily to explain nursing interventions to othe
wi wi wi wi wi wi wi wi wi wi wi
r health care professionals.‖
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c. ―The nursing process is a problem-solving tool used to identify and manage the
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, patients‗ health care needs.‖ wi wi wi
d. ―The nursing process is based on nursing theory that incorporates th
wi wi wi wi wi wi wi wi wi wi
e biopsychosocial nature of humans.‖
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ANS: C wi
The nursing process is a problem-
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solving approach to the identification and treatment of patients‗ problems. Nursing proces
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s does not require research methods for diagnosis. The primary use of the nursing process i
wi wi wi wi wi wi wi wi wi wi wi wi wi wi wi
s in patient care, not to establish nursing theory or explain nursing interventions to other h
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ealth care professionals.wi wi
DIF: Cognitive Level: Understand (Comprehension) wi wi wi
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
wi wi wi wi w i wi wi wi wi wi
4. A patient admitted to the hospital for surgery tells the nurse, ―I do not feel comfortabl
wi wi wi wi wi wi wi wi wi wi wi wi wi wi wi
e leaving my children with my parents.‖ Which action would the nurse take next
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?
a. Reassure the patient that these feelings are common for parents.
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b. Have the patient call the children to ensure that they are doing well.
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c. Gather information on the patient‗s concerns about the child care arrangements.
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d. Call the patient‗s parents to determine whether adequate child care is bein
wi wi wi wi wi wi wi wi wi wi wi
g provided. wi
ANS: C wi
Because a complete assessment is necessary in order to identify a problem and choose an
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appropriate intervention, the nurse‗s first action should be to obtain more information. Th
i wi wi wi wi wi wi wi wi wi wi wi wi
e other actions may be appropriate, but more assessment is needed before the best interventi
wi wi wi wi wi wi wi wi wi wi wi wi wi wi
on can be chosen.
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DIF: Cognitive Level: Analyze (Analysis) wi wi wi
TOP: Nursing Process: Assessment
w i MSC: NCLEX: Psychosocial Integrity
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5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresi
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s. Which expected outcome would the nurse select for this patient?
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a. Patient has a balanced intake and output. wi wi wi wi wi wi
b. Patient‗s bedding is kept clean and free of moisture. wi wi wi wi wi wi wi wi
c. Patient understands the need for increased fluid intake.
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d. Patient‗s skin remains cool and dry throughout hospitalization.
wi wi wi wi wi wi wi
ANS: A wi
Balanced intake and output gives measurable data showing resolution of the problem of defi
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cient fluid volume. The other statements would not indicate that the problem of hypovole
wi wi wi wi wi wi wi wi wi wi wi wi wi
mia was resolved. wi wi
DIF: Cognitive Level: Apply (Application) wi wi wi
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
wi wi wi wi w i wi wi
6. Which statement describes the purpose of the evaluation phase of the nursing process?
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a. To document the nursing care plan in the progress notes of the health record
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b. To determine if interventions have been effective in meeting patient outcomes
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c. To decide whether the patient‗s health problems have been completely resolved
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d. To establish if the patient agrees that the nursing care provided was satisfactory
wi wi wi wi wi wi wi wi wi wi wi wi
ANS: B wi
, Evaluation consists of determining whether the desired patient outcomes have been met a
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nd whether the nursing interventions were appropriate. The other responses do not descri
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be the evaluation phase.
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DIF: Cognitive Level: Understand (Comprehension)
wi wi wi
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
wi wi wi wi w i wi wi wi wi wi
7. Which statement describes the purpose of the assessment phase of the nursing process?
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a. To teach interventions that relieve health problems
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b. To use patient data to evaluate patient care outcomes
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c. To obtain data to diagnose patient strengths and problems
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d. To help the patient identify realistic outcomes for health problems
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ANS: C wi
During the assessment phase, the nurse gathers information about the patient to diagnose pat
wi wi wi wi wi wi wi wi wi wi wi wi wi
ient strengths and problems. The other responses are examples of the planning, interventi
wi wi wi wi wi wi wi wi wi wi wi wi
on, and evaluation phases of the nursing process.
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DIF: Cognitive Level: Understand (Comprehension) wi wi wi
TOP: Nursing Process: Assessment
w i MSC: NCLEX: Safe and Effective Care Environment
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8. When developing the plan of care, which components would the nurse include in the clinic
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al problem statement?
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a. The problem and the suggested patient goals or outcomes
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b. The problem, its causes, and the signs and symptoms of the problem
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c. The problem with the possible etiology and the planned interventions
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d. The problem, its pathophysiology, and the expected outcome
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ANS: B wi
When writing clinical problems or nursing diagnoses, the subjective as well as objective d
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ata to support the problem‗s existence should be included. Goals, outcomes, and interventio
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ns are not included in the problem statement.
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DIF: Cognitive Level: Understand (Comprehension)
wi wi wi
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
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9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
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a. Instruct the patient about the need to alternate activity and rest.
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b. Monitor level of shortness of breath or fatigue after ambulation.
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c. Obtain the patient‗s blood pressure and pulse rate after ambulation.
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d. Determine whether the patient is ready to increase the activity level.
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ANS: C wi
AP education includes accurate vital sign measurement. Assessment and patient teaching req
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uire registered nurse education and scope of practice and cannot be delegated.
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DIF: Cognitive Level: Apply (Application) wi wi wi
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
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