Lewis: Medical-Surgical Nursing, 7th Edition Test Bank Chapter 1: Nursing Practice Today/RATED A

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Lewis: Medical-Surgical Nursing, 7th Edition Test Bank Chapter 1: Nursing Practice Today MULTIPLE CHOICE 1. When the nurse explains to the patient that together they will plan the patient’... s care and set goals to achieve by discharge, the patient says, “How is that different from what the doctor does?” Which response by the nurse is most appropriate? 2. When providing patient care using evidence-based practice, the nurse uses 3. The nurse uses the nursing process in the care of patients primarily 4. An elderly, emaciated patient is admitted to the intensive care unit (ICU). The nurse plans an every-2-hours turning schedule to prevent skin breakdown. In this case, the nursing action is considered to be 5. A patient who has been admitted to the hospital for gallbladder surgery tells the nurse on admission, “I do not feel right about leaving my children with my neighbor.” During assessment of the patient, an appropriate nursing action by the nurse is to 6. A patient with a stroke is paralyzed on the left side of the body and is not responsive enough to turn or move independently in bed. A pressure ulcer has developed on the patient’s left hip. The best nursing diagnosis for this patient is 7. A patient with an infection has a nursing diagnosis of fluid volume deficit related to excessive diaphoresis. An appropriate patient outcome identified by the nurse is that the 8. A patient has a nursing diagnosis of activity intolerance related to prolonged bed rest as manifested by the patient’s report of weakness and fatigue. An appropriate NOC outcome and NIC intervention for this nursing diagnosis would be 9. The nurse reads on the care plan that a patient is at risk for developing an infection. The nurse recognizes that this patient problem 10. A nursing activity that is carried out during the evaluation phase of the nursing process is 11. During the assessment phase of the nursing process, the nurse a. obtains data with which to diagnose patient problems. b. teaches interventions to relieve patient health problems. c. uses patient data to develop priority nursing diagnoses. d. helps the patient identify realistic outcomes to health problems. Correct Answer: A Rationale: During the assessment phase, the nurse gathers information about the patient. The other responses are examples of the intervention, diagnosis, and planning phases of the nursing process. Cognitive Level: Knowledge Text Reference: p. 10 Nursing Process: Assessment NCLEX: Safe and Effective Care Environment 12. An example of a correctly written nursing diagnosis statement is a. altered tissue perfusion related to heart failure. b. ineffective coping related to response to biopsy test results. c. altered urinary elimination related to urinary tract infection. d. risk for impaired tissue integrity related to sacral redness. Correct Answer: B Rationale: This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patient’s response to a health problem and can be treated by nursing. The use of a medical diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered urinary elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity” uses the defining characteristics as the etiology. Cognitive Level: Comprehension Text Reference: p. 11 Nursing Process: Diagnosis NCLEX: Safe and Effective Care Environment 13. The nurse writes a complete nursing diagnosis statement by including a. a problem, its cause, and objective data that support the problem. b. a problem with all its possible causes and the planned interventions. c. a problem and the suggested patient goals or outcomes. d. a problem with its etiology and the signs and symptoms of the problem. Correct Answer: D Rationale: The PES format is used when writing nursing diagnoses. The subjective, as well as objective, data should be included in the defining characteristics. Interventions and outcomes are not included in the nursing diagnosis statement. Cognitive Level: Knowledge Text Reference: p. 11 Nursing Process: Diagnosis NCLEX: Safe and Effective Care Environment 14. Which of these tasks is appropriate for the registered nurse to delegate to a licensed practical nurse? a. Documenting patient teaching about a routine surgical procedure b. Administering an oral pain medication to a patient c. Teaching a patient how to self-administer insulin d. Completing the initial admission assessment and plan of care Correct Answer: B Rationale: The education and scope of practice of the LPN/LVN include administration of oral medications. Patient teaching and the initial assessment and development of the plan of care are nursing actions that require RN-level education and scope of practice. Cognitive Level: Application Text Reference: p. 15 Nursing Process: Planning NCLEX: Safe and Effective Care Environment [Show More]

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