Nursing Process and Patient Care: Multiple Choice Questions and Answers | Exams Nursing

Lewis Ch.1 -Test 1 Med Surg

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 states, "How is this different from what the doctor

does?" Which response would be most appropriate for the nurse to make?

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 information and communicating any problems that

occur."

c. "Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a

longer time than the doctor."

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. The nurse describes to a student nurse how to use evidence-based practice

guidelines when caring for patients. Which statement, if made by the nurse, would be the most

accurate?

a. "Inferences from clinical research studies are used as a guide."

b. "Patient care is based on clinical judgment, experience, and traditions."

c. "Data are evaluated to show that the patient outcomes are consistently met."

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. 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 interventions should be based on research from randomized control studies

with a large number of subjects. The nurse teaches a student nurse about how to apply the nursing

process when providing patient care. Which statement, if made by the student nurse, indicates that

teaching was successful?

a. "The nursing process is a scientific-based method of diagnosing the patient's health care problems."

b. "The nursing process is a problem-solving tool used to identify and treat patients' health care needs."

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Lewis Ch.1 - Test 1 Med Surg

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 states, "How is this different from what the doctor does?" Which response would be most appropriate for the nurse to make? 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 information and communicating any problems that occur." c. "Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a longer time than the doctor." 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. The nurse describes to a student nurse how to use evidence-based practice guidelines when caring for patients. Which statement, if made by the nurse, would be the most accurate? a. "Inferences from clinical research studies are used as a guide." b. "Patient care is based on clinical judgment, experience, and traditions." c. "Data are evaluated to show that the patient outcomes are consistently met." 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. 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 interventions should be based on research from randomized control studies with a large number of subjects. The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which statement, if made by the student nurse, indicates that teaching was successful? a. "The nursing process is a scientific-based method of diagnosing the patient's health care problems." b. "The nursing process is a problem-solving tool used to identify and treat patients' health care needs."

c. "The nursing process is based on nursing theory that incorporates the biopsychosocial nature of humans." d. "The nursing process is used primarily to explain nursing interventions to other health care professionals." 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. A patient has been admitted to the hospital for surgery and tells the nurse, "I do not feel comfortable leaving my children with my parents." 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. Gather more data about the patient's feelings about the child-care arrangements. d. Call the patient's parents to determine whether adequate child care is being provided. ANS: C 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. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip. Which nursing diagnosis is most appropriate? 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. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. Which outcome would the nurse recognize as most appropriate for this patient? a. Patient has a balanced intake and output. b. Patient's bedding is changed when it becomes damp.

characteristic as the etiology. The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse include in the nursing diagnosis statement? a. The problem and the suggested patient goals or outcomes b. The problem with possible causes and the planned interventions c. The problem, its cause, and objective data that support the problem d. The problem with an etiology and the signs and symptoms of the problem ANS: D When writing nursing diagnoses, this format should be used: problem, etiology, and signs and symptoms. 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. A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to delegate to experienced unlicensed assistive personnel (UAP)? a. Monitor for shortness of breath or fatigue after ambulation. b. Instruct the patient about the need to alternate activity and rest. 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 UAP education includes accurate vital sign measurement. Assessment and patient teaching require registered nurse education and scope of practice and cannot be delegated. A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate? a. Measurement of a patient's urine output by UAP b. Administration of oral medications by LPN/LVN c. Check for the presence of bowel sounds and flatulence by UAP d. Care of a patient with diabetes by RN who usually works on the pediatric unit ANS: C Assessment requires RN education and scope of practice and cannot be delegated to an LPN/LVN or UAP. The other assignments made by the RN are appropriate. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Complete the initial admission assessment and plan of care. b. Document teaching completed before a diagnostic procedure.

c. Instruct a patient about low-fat, reduced sodium dietary restrictions. d. Obtain bedside blood glucose on a patient before insulin administration. ANS: D The education and scope of practice of the LPN/LVN include activities such as obtaining glucose testing using a finger stick. 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. A nurse is assigned as a case manager for a hospitalized patient with a spinal cord injury. The patient can expect the nurse functioning in this role to perform which activity? a. Care for the patient during hospitalization for the injuries. b. Assist the patient with home care activities during recovery. c. Determine what medical care the patient needs for optimal rehabilitation. d. Coordinate the services that the patient receives in the hospital and at home. ANS: D 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 either the acute or home setting. The case manager coordinates and advocates for care but does not determine what medical care is needed; that would be completed by the health care provider or other provider. The nurse is caring for an older adult patient who had surgery to repair a fractured hip. The patient needs continued nursing care and physical therapy to improve mobility before returning home. The nurse will help to arrange for transfer of this patient to which facility? a. A skilled care facility b. A residential care facility c. A transitional care facility d. An intermediate care facility ANS: C 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. A home care nurse is planning care for a patient who has just been diagnosed with type 2 diabetes mellitus. 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. State nurse practice act d. LPN/LVN teaching abilities e. Experience of the LPN/LVN ANS: A, B, C, E The nurse should assess the experience of LPN/LVNs when delegating. In addition, state nurse practice acts and institutional policies must be considered. In general, LPN/LVN scope of practice includes caring for patients who are stable, while registered nurses should provide most of the care for unstable patients. Since LPN/LVN scope of practice does not include patient education, this will not be part of the delegation process. The nurse is administering medications to a patient. Which actions by the nurse during this process are consistent with promoting safe delivery of care (select all that apply)? a. Throws away a medication that is not labeled b. Uses a hand sanitizer before preparing a medication c. Identifies the patient by the room number on the door d. Checks lab 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 two 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. The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a health care provider. In which order should the nurse make the following statements? (Put a comma and a space between each answer choice [A, B, C, D].) a. "The patient needs to be evaluated immediately and may need intubation and mechanical ventilation." b. "The patient was admitted yesterday with heart failure and has been receiving furosemide (Lasix) for diuresis, but urine output has been low." c. "The patient has crackles audible throughout the posterior chest and the most recent oxygen saturation is 89%. Her condition is very unstable." d. "This is the nurse on the surgical unit. After assessing the patient, I am very concerned about increased shortness of breath over the past hour." ANS: D, B, C, A The order of the nurse's statements follows the SBAR format.

Nursing Process and Patient Care: Multiple Choice Questions and Answers, Exams of Nursing

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Lewis Ch.1 - Test 1 Med Surg