CH 1 Med Surg

LeMone/Burke/Bauldoff, Medical-Surgical Nursing 5th Edition Test Bank
Chapter 1
Question 1
Type: MCSA
The nurse is instructing a patient on the role of diet, exercise, and medication to control type 2 diabetes. The nurse
is practicing which of the following core competencies for healthcare professionals?
1. provide patient-centered care
2. work in interdisciplinary teams
. use evidence-based practice
!. apply quality improvement
Corre"t #ns$er:
%ationale 1! The nurse instructing the patient is an example of the competency provide patient-centered care.
%ationale 2! The core competency work in interdisciplinary teams in"ol"es collaboration between disciplines to
pro"ide continuous and reliable care.
%ationale ! #sing best research when pro"iding patient care is an example of the core competency use evidence-
based practice.
%ationale !! $dentifying safety ha%ards and measuring &uality is an example of the core competency apply
quality improvement.
&lo'al %ationale: $n 2''(, the )ational Academy of Sciences proposed a set of fi"e core competencies that all
healthcare professionals should possess to meet the needs of the twenty*first century. The nurse instructing the
patient is an example of the competency providing patient-centered care. Collaboration between disciplines to
pro"ide continuous and reliable care is an example of the core competency work in interdisciplinary teams. #sing
best research when pro"iding patient care is an example of the core competency use evidence-based practice.
$dentifying safety ha%ards and measuring &uality are examples of the core competency apply quality
improvement.
Co(niti)e Le)el: Analy%ing
Client *eed: Safe +ffecti"e Care +n"ironment
Client *eed +u':
*ursin(/,nte(rated Con"epts: )ursing ,rocess! Assessment
Learnin( -ut"o.e: . -escribe the core competencies for healthcare professionals! provide patient-centered
care, work in interdisciplinary teams, use evidence-based practice, apply quality improvement, and use
informatics.
.eMone/0ur1e/0auldoff, Medical-Surgical Nursing 2th +dition Test 0an1
Copyright 2' by ,earson +ducation, $nc.

Question 2
Type: MCSA
3hich of the following is an example of the nurse who is utili%ing the core competency use informatics when
pro"iding patient care?
1. searching through a database of articles to find current research on wound care
2. documenting the effecti"eness of pain medication for a patient
. discussing the effecti"eness of bedside physical therapy with the therapist
!. changing the sharps container in a patient4s room
Corre"t #ns$er:
%ationale 1! Searching through a database of articles to find current research on wound care is an example of
using informatics.
%ationale 2! -ocumenting the effecti"eness of pain medication for a patient is an example of providing patient-
centered care.
%ationale ! -iscussing the effecti"eness of bedside physical therapy with the therapist is an example of working
in interdisciplinary teams.
%ationale !! Changing the sharp4s container is an example of applying quality improvement.
&lo'al %ationale: +xamples of the nurse using the core competency of using informatics include the use of
technology to communicate, manage 1nowledge, decrease errors, and support critical thin1ing acti"ities. The
acti"ity of searching through a database of articles to find current research on wound care is an example of the use
of informatics. -ocumenting the effecti"eness of pain medication for a patient is an example of providing patient-
centered care. -iscussing the effecti"eness of bedside physical therapy with the therapist is an example of
working in interdisciplinary teams. Changing the sharps container in a patient4s room is an example of applying
quality improvement.
Client *eed +u':
*ursin(/,nte(rated Con"epts: )ursing ,rocess! +"aluation
informatics.

Question
Type: MCMA
The nurse who plans to implement evidence-based practice when pro"iding patient care would include which of
the following acti"ities?
+tandard Te/t: Select all that apply.
1. ,articipate in education and research acti"ities when possible.
2. $ntegrate research findings with clinical care to maximi%e patient outcomes.
. Ser"e on the committee to create critical pathways for patient care.
!. 5einforce hand hygiene techni&ues with unlicensed assisti"e personnel.
5. Contact +n"ironmental Ser"ices to inform of a malfunctioning infusion pump.
Corre"t #ns$er: ,2
%ationale 1! ,articipate in education and research acti"ities when possible. This is an example of an acti"ity
when implementing evidence-based practice in the pro"ision of patient care.
%ationale 2! $ntegrate research findings with clinical care to maximi%e patient outcomes. This is an example of an
acti"ity when implementing evidence-based practice in the pro"ision of patient care.
%ationale ! Ser"e on the committee to create critical pathways for patient care. This is an example of work in
interdisciplinary teams.
%ationale !! 5einforce hand hygiene techni&ues with unlicensed assisti"e personnel. This is an example of
applying quality improvement.
%ationale 5! Contact +n"ironmental Ser"ices to inform of a malfunctioning infusion pump. This is an example of
applying quality improvement.
&lo'al %ationale:
Co(niti)e Le)el: Applying
Client *eed +u':
*ursin(/,nte(rated Con"epts: )ursing ,rocess! ,lanning
Learnin( -ut"o.e: . -escribe the core competencies for healthcare professionals! patient*centered care,
interdisciplinary teams, e"idence*based practice, &uality impro"ement, and informatics.

Question !
Type: MCSA
3hich of the following acti"ities would the community health nurse implement to exemplify the core competency
provide patient-centered care?
1. smo1ing cessation classes and literature for members in the community
2. increasing the hours for the physician to see patients in the community
. attending a continuing education program on clean water initiati"es
!. e"aluating the effecti"eness of weight reduction strategies for community members
Corre"t #ns$er:
%ationale 1! Smo1ing cessation classes and literature for members in the community is an example of an acti"ity
to provide patient-centered care.
%ationale 2! $ncreasing the hours for the physician to see patients in the community is an acti"ity to support the
competency of working in interdisciplinary teams.
%ationale ! Attending a continuing education program on clean water initiati"es is an acti"ity to support the
competency of using evidence-based practice.
%ationale !! +"aluating the effecti"eness of weight reduction strategies for community members is an acti"ity to
support the competency of applying quality improvement.
&lo'al %ationale: Acti"ities to exemplify the core competency provide patient-centered care should be focused
on disease pre"ention, wellness, and promotion of healthy lifestyles. The acti"ity 6smo1ing cessation classes and
literature for members in the community7 is an example of an acti"ity to provide patient-centered care. $ncreasing
the hours for the physician to see patients in the community is an acti"ity to support the competency of working in
interdisciplinary teams. Attending a continuing education program on clean water initiati"es is an acti"ity to
support the competency of using evidence-based practice. +"aluating the effecti"eness of weight reduction
strategies for community members is an acti"ity to support the competency of applying quality improvement.
Client *eed +u':
informatics.

Question 5
Type: MCSA
The nurse, instructing a patient on weight reduction and smo1ing cessation, is implementing which of the
following codes of nursing practice?
1. $nternational Council of )urses Code for )urses
2. American )urses Association Standards of ,rofessional ,ractice
. American )urses Association Code of +thics for )urses
!. State 0oard of )ursing
Corre"t #ns$er:
%ationale 1! The nurse who instructs a patient on weight reduction and smo1ing cessation is promoting health
and pre"enting illness which exemplifies the $nternational Council of )urses Code for )ursing.
%ationale 2! The American )urses Association Standards of ,rofessional ,ractice are standards, not a code, and
focus on specific beha"iors to address &uality practice, practice e"aluation, education, collegiality, collaboration,
ethics, research, resource utili%ation, and leadership.
%ationale ! The American )urses Association Code of +thics for )urses has nine statements which address the
nurse4s professional relationships, commitment to patients, patient rights, nursing practice, competency,
conditions of employment, and contributions to the science of nursing, collaboration, and nursing "alues.
%ationale !! The state boards of nursing do not publish codes for nursing.
&lo'al %ationale: The $nternational Council of )urses Code for )urses specifies what nurses are accountable for
in terms of people, practice, society, cowor1ers, and the profession. The philosophical base for this code is that the
nurse who instructs a patient on weight reduction and smo1ing cessation is promoting health and pre"enting
illness, which exemplifies the $nternational Council of )urses Code for )ursing. The American )urses
Association Standards of ,rofessional ,ractice are standards, not a code, and focus on specific beha"iors to
address &uality practice, practice e"aluation, education, collegiality, collaboration, ethics, research, resource
utili%ation, and leadership. The American )urses Association Code of +thics for )urses has nine statements which
address the nurse4s professional relationships, commitment to patients, patient rights, nursing practice,
competency, conditions of employment, and contributions to the science of nursing, collaboration, and nursing
"alues. The state boards of nursing do not publish codes for nursing.
Client *eed +u':
Learnin( -ut"o.e: 2. +xplain the importance of nursing codes and standards as guidelines for clinical nursing
practice.

Question 0
Type: MCSA
To practice within the American )urses Association Standards of ,rofessional ,ractice, the nurse would
implement which of the following acti"ities?
1. $ntegrate research findings into practice.
2. $mplement a patient4s plan of care.
. +"aluate patient progress toward identified outcomes.
!. Analy%e assessment data to determine issues.
Corre"t #ns$er:
%ationale 1! The nurse who is practicing within the American )urses Association Standards of ,rofessional
,ractice would integrate research findings into practice. The standards focus on beha"iors to address &uality
practice, practice e"aluation, education, collegiality, collaboration, ethics, research, resource utili%ation, and
leadership.
%ationale 2! $mplementing a patient4s plan of care is an example of adhering to the American )urses Association
Standards of ,ractice.
%ationale ! +"aluating patient progress toward identified outcomes is an example of adhering to the American
)urses Association Standards of ,ractice.
%ationale !! Analy%ing assessment data to determine issues is an example of adhering to the American )urses
Association Standards of ,ractice.
&lo'al %ationale: The American )urses Association Standards of ,rofessional ,ractice focus on beha"iors to
address &uality practice, practice e"aluation, education, collegiality, collaboration, ethics, research, resource
utili%ation, and leadership. The nurse who is practicing within these standards would integrate research findings
into practice. The other acti"ities would be implemented when the nurse is adhering to the American )urses
Association Standards of ,ractice.
Client *eed +u':
practice.

Question 1
Type: MCSA
The nurse who prescribes strategies and alternati"es to assist a patient achie"e expected outcomes is practicing
within which of the American )urses Association Standards of ,ractice?
1. planning
2. assessment
. diagnosis
!. implementation
Corre"t #ns$er:
%ationale 1! The American )urses Association Standards of ,ractice follow the nursing process. The nurse who
prescribes strategies and alternati"es to assist a patient achie"e expected outcomes is practicing within the
planning of the standards.
%ationale 2! Assessment acti"ities include data collection.
%ationale ! -iagnosis acti"ities include the analy%ing of data to determine issues.
%ationale !! $mplementation acti"ities include implementation of the plan of care and coordination of care
deli"ery.
&lo'al %ationale: The American )urses Association Standards of ,ractice follow the nursing process. The nurse
who prescribes strategies and alternati"es to assist a patient achie"e expected outcomes is practicing within the
planning of the standards. Assessment acti"ities include data collection. -iagnosis acti"ities include the analy%ing
of data to determine issues. $mplementation acti"ities include implementation of the plan of care and coordination
of care deli"ery.
Client *eed +u':
practice.

Question 2
Type: MCSA
A terminally ill patient says that the only thing he fears about dying is the pain. The nurse, following the
$nternational Council of )urses Code for )urses, would plan which of the following for the patient?
1. measures to alle"iate suffering
2. modified acti"ities of daily li"ing
. enforcement of strict bed rest
!. dietary inter"entions to maximi%e strength
Corre"t #ns$er:
%ationale 1! Since the philosophical base for the $nternational Council of )urses Code for )urses is the
responsibility to promote health, pre"ent illness, and alle"iate suffering, the nurse should plan measures to
alle"iate the patient4s suffering.
%ationale 2! Modified acti"ities of daily li"ing may not reduce the pain the terminally ill patient fears and would
be incorrect.
%ationale ! +nforcement of strict bed rest may not reduce the pain the terminally ill patient fears and would be
incorrect.
%ationale !! -ietary inter"entions to maximi%e strength may not reduce the pain the terminally ill patient fears
and would be incorrect.
&lo'al %ationale: Since the philosophical base for the $nternational Council of )urses Code for )urses is the
responsibility to promote health, pre"ent illness, and alle"iate suffering, the nurse should plan measures to
alle"iate the patient4s suffering. Modified acti"ities of daily li"ing, enforcement of strict bed rest, and dietary
inter"entions to maximi%e strength may not reduce the pain the terminally ill patient fears and would be incorrect.
Client *eed +u':
practice.

Question 3
Type: MCSA
A patient angrily tells the nurse that he has been waiting o"er an hour for pain medication. 3hen applying critical
thin1ing, with which of the following should the nurse respond to this patient?
1. 6$ understand your anger and am sorry for the delay. $ ha"e your pain medication now.7
2. 6$ had other patients who needed my attention first so $ did a few things before getting the pain medication.7
. 6$ needed to find out what your medication is and if you can ha"e more when you as1ed.7
!. 6$t seems that you always as1 for pain medication when $ am trying to do other things.7
Corre"t #ns$er:
%ationale 1! 8ne beha"ior associated with critical thin1ing is ha"ing empathy and understanding why the patient
is angry when ha"ing to wait for pain medication. The best response for the nurse to ma1e to the patient is 6$
understand your anger and am sorry for the delay. $ ha"e your pain medication now.7
%ationale 2! 6$ had other patients who needed my attention first so $ did a few things before getting the pain
medication7 is not an example of a critical thin1ing beha"ior and would be incorrect or inappropriate for the nurse
to respond to the patient.
%ationale ! 6$ needed to find out what your medication is and if you can ha"e more when you as1ed7 is not an
example of a critical thin1ing beha"ior and would be incorrect or inappropriate for the nurse to respond to the
patient.
%ationale !! 6$t seems that you always as1 for pain medication when $ am trying to do other things7 is not an
example of a critical thin1ing beha"ior and would be incorrect or inappropriate for the nurse to respond to the
patient.
&lo'al %ationale: 8ne beha"ior associated with critical thin1ing is ha"ing empathy and understanding why the
patient is angry when ha"ing to wait for pain medication. The best response for the nurse to ma1e to the patient is
6$ understand your anger and am sorry for the delay. $ ha"e your pain medication now.7 The other choices are not
examples of critical thin1ing beha"iors and would be incorrect or inappropriate for the nurse to respond to the
patient.
Client *eed +u':
*ursin(/,nte(rated Con"epts: )ursing ,rocess! $mplementation
Learnin( -ut"o.e: (. Apply the attitudes, mental habits, and s1ills necessary for critical thin1ing when using
the nursing process in patient care.

Question 14
Type: MCSA
3hich of the following should the nurse do with patient admission assessment data that would demonstrate
di"ergent thin1ing?
1. $dentify abnormal data for further analy%ing.
2. 9ocus on normal data to rule out health problems
. -iscriminate information as facts or guesses
!. Thin1 about the information to determine solutions
Corre"t #ns$er:
%ationale 1! -i"ergent thin1ing, a critical*thin1ing s1ill, means ha"ing the ability to weigh the importance of
information. The nurse should sort out the data that are rele"ant from data that are irrele"ant for the patient and
abnormal data are usually considered rele"ant.
%ationale 2! )ormal data are helpful but may not change the care to pro"ide to the patient. This is not di"ergent
thin1ing because it does not weigh the importance of the information.
%ationale ! -iscriminating information as facts or guesses describes the critical*thin1ing s1ill of reasoning.
%ationale !! Thin1ing about the information to determine solutions describes the critical* thin1ing s1ill of
reflection.
&lo'al %ationale: -i"ergent thin1ing, a critical*thin1ing s1ill, means ha"ing the ability to weigh the importance
of information. The nurse should sort out the data that are rele"ant from data that are irrele"ant for the patient.
Abnormal data are usually considered rele"ant: normal data are helpful but may not change the care to pro"ide to
the patient. -iscriminating information as facts or guesses describes the critical*thin1ing s1ill of reasoning.
Thin1ing about the information to determine solutions describes the critical* thin1ing s1ill of reflection.
Client *eed +u':

Question 11
Type: MCMA
The nurse, utili%ing critical*thin1ing beha"iors when pro"iding patient care, would demonstrate which of the
following?
1. thin1 independently
2. creati"ity
. ma1e decisions based on feelings
!. easily influenced
5. find easy answers to problems
Corre"t #ns$er: ,2
%ationale 1! Thin1 independently. Criti"al thinkin( in)ol)es 'ein( a'le to think independently in order to
.ake sound "lini"al de"isions 'ased on sound thinkin( and 5ud(.ent.
%ationale 2! Creati"ity. *urses need to think of $ays to pro)ide 6uality patient "are in the .ost "ost7
effe"ti)e .anner.
%ationale ! Ma1e decisions based on feelings. Criti"al thinkin( in)ol)es 'ein( a'le to listen and 'e fair and
.akin( de"isions 'ased upon $hat is learned and not $hat is felt.
%ationale !! +asily influenced. Criti"al thinkin( in)ol)es 'ein( a'le to think independently and not 'ein(
easily influen"ed 'y others8 "o..ents and 'eliefs.
%ationale 5! 9ind easy answers to problems. Criti"al thinkin( in)ol)es dis"ipline so that the nurse does not
stop at easy ans$ers 'ut rather sear"hes for the 'est possi'le solutions.
&lo'al %ationale:
Client *eed +u':

Question 12
Type: MCSA
The nurse is identifying nursing diagnoses appropriate for a patient4s plan of care. 3hich of the following would
the nurse use to determine the nursing diagnoses?
1. diagnostic reasoning
2. effecti"e communication techni&ues
. identify outcome criteria
!. set priorities
Corre"t #ns$er:
%ationale 1! Ma1ing a diagnosis is a complex process and the nurse uses diagnostic reasoning to choose nursing
diagnoses that best define the indi"idual patient4s health problems. -iagnostic reasoning is a form of clinical
;udgment used to ma1e decisions about which label, or diagnosis, best describes the patterns of data. +lements of
the clinical ;udgment process include data gathering and "alidation, data categori%ation, intuition, and prior
clinical experience.
%ationale 2! +ffecti"e communication techni&ues would be needed when conducting the assessment of the
patient.
%ationale ! $dentification of outcome criteria is a part of the planning phase of the nursing process.
%ationale !! Setting priority is an acti"ity conducted during the implementation phase of the nursing process.
&lo'al %ationale: Ma1ing a diagnosis is a complex process and the nurse uses diagnostic reasoning to choose
nursing diagnoses that best define the indi"idual patient4s health problems. -iagnostic reasoning is a form of
clinical ;udgment used to ma1e decisions about which label, or diagnosis, best describes the patterns of data.
+lements of the clinical ;udgment process include data gathering and "alidation, data categori%ation, intuition, and
prior clinical experience. +ffecti"e communication techni&ues would be needed when conducting the assessment
of the patient. $dentification of outcome criteria is a part of the planning phase of the nursing process. Setting
priority is an acti"ity conducted during the implementation phase of the nursing process.
Client *eed +u':
*ursin(/,nte(rated Con"epts: )ursing ,rocess! -iagnosis

Question 1
Type: MCSA
The nurse plans and implements care for a patient based upon nursing 1nowledge and s1ills. The nurse is
functioning within which of the following roles?
1. caregi"er
2. ad"ocate
. educator
!. leader
Corre"t #ns$er:
%ationale 1! The caregi"er role for the nurse today is both independent and collaborati"e. )urses independently
ma1e assessments and plan and implement patient care based on nursing 1nowledge and s1ills.
%ationale 2! The nurse functioning as a patient ad"ocate acti"ely promotes the patient4s rights to autonomy and
free choice.
%ationale ! The nurse who is functioning in the role of educator nurse assesses learning needs, plans and
implements teaching methods to meet those needs, and e"aluates the effecti"eness of the teaching.
%ationale !! The nurse functioning in the role of leader directs, delegates, and coordinates nursing acti"ities.
&lo'al %ationale: The caregi"er role for the nurse today is both independent and collaborati"e. )urses
independently ma1e assessments and plan and implement patient care based on nursing 1nowledge and s1ills. The
nurse functioning as a patient ad"ocate acti"ely promotes the patient4s rights to autonomy and free choice. The
nurse who is functioning in the role of educator nurse assesses learning needs, plans and implements teaching
methods to meet those needs, and e"aluates the effecti"eness of the teaching. The nurse functioning in the role of
leader directs, delegates, and coordinates nursing acti"ities.
Client *eed +u':
Learnin( -ut"o.e: <. +xplain the acti"ities and characteristics of the nurse as caregi"er, educator, ad"ocate,
leader and manager, and researcher.

Question 1!
Type: MCSA
A patient tells the nurse that he does not understand the surgical procedure the physician told him he needed.
3hich of the following should the nurse do to ad"ocate for this patient?
1. Contact the physician and as1 that the procedure be explained to the patient.
2. +xplain the procedure to the patient.
. -ocument that the patient does not understand the proposed surgical procedure.
!. $nstruct the patient in alternati"es to the surgical procedure.
Corre"t #ns$er:
%ationale 1! The nurse as patient ad"ocate acti"ely promotes the patient4s rights to autonomy and free choice.
The nurse should protect the patient4s right to self*determination about the surgical procedure.
%ationale 2! The nurse should not explain the procedure to the patient. This is not patient ad"ocacy.
%ationale ! The nurse should not do anything beyond documenting the patient4s lac1 of understanding about the
procedure.
%ationale !! The nurse should not pro"ide alternati"es to the surgical procedure.
&lo'al %ationale: The nurse as patient ad"ocate acti"ely promotes the patient4s rights to autonomy and free
choice. The nurse should protect the patient4s right to self*determination about the surgical procedure. The nurse
should not explain the procedure to the patient. The nurse should not do anything beyond documenting the
patient4s lac1 of understanding about the procedure. The nurse should not pro"ide alternati"es to the surgical
procedure.
Client *eed +u':

Question 15
Type: MCSA
The nurse, instructing a patient newly diagnosed with type 2 diabetes, reminds the patient about an annual dilated
retinal eye examination in addition to annual urine tests to measure protein le"els. The nurse is functioning within
which of the following roles with this patient?
1. educator
2. researcher
. ad"ocate
!. leader
Corre"t #ns$er:
%ationale 1! The nurse is functioning as an educator by instructing the patient on annual tests to maintain health.
%ationale 2! As a researcher, the nurse would ha"e a goal to impro"e the care nurses pro"ide to patients.
%ationale ! As an ad"ocate, the nurse acti"ely promotes the patient4s rights to autonomy and free choice.
%ationale !! As a leader, the nurse manages time, people, and resources by delegating, directing, and coordinating
nursing acti"ities.
&lo'al %ationale: The nurse is functioning as an educator by instructing the patient on annual tests to maintain
health. As a researcher, the nurse would ha"e a goal to impro"e the care nurses pro"ide to patients. As an
ad"ocate, the nurse acti"ely promotes the patient4s rights to autonomy and free choice. As a leader, the nurse
manages time, people, and resources by delegating, directing, and coordinating nursing acti"ities.
Client *eed: =ealth ,romotion and Maintenance
Client *eed +u':

Question 10
Type: MCSA
3hich of the following leadership acti"ities would the nurse perform when pro"iding care within the primary
nursing care deli"ery model?
1. Communicate with patients, families, other care pro"iders, and plans patient discharge.
2. Ser"e as the team leader by ma1ing assignments and being responsible for all care pro"ided.
. Ma1e referrals and manages the &uality of care to include timeliness and cost.
!. Manage a caseload of patients and the health team members pro"iding care to the patients.
Corre"t #ns$er:
%ationale 1! 3hen pro"iding care to patients within the primary nursing care deli"ery model, leadership acti"ities
of the nurse include communicating with patients, families, and other care pro"iders, and planning the discharge
of the patients.
%ationale 2! $n the team nursing care deli"ery model, leadership acti"ities of the nurse include ser"ing as the
team leader, ma1ing assignments, and being responsible for all care pro"ider.
%ationale ! $n the case management care deli"ery model, leadership acti"ities of the nurse include ma1ing
referrals and managing the &uality of care to include timeliness and cost.
%ationale !! $n the case management care deli"ery model, leadership acti"ities of the nurse include managing a
caseload of patients and managing the health team members pro"iding care to the patients.
&lo'al %ationale: 3hen pro"iding care to patients within the primary nursing care deli"ery model, leadership
acti"ities of the nurse include communicating with patients, families, and other care pro"iders, and planning the
discharge of the patients. $n the team nursing care deli"ery model, leadership acti"ities of the nurse include
ser"ing as the team leader, ma1ing assignments, and being responsible for all care pro"ider. $n the case
management care deli"ery model, leadership acti"ities of the nurse include ma1ing referrals, managing the &uality
of care to include timeliness and cost, managing a caseload of patients, and managing the health team members
pro"iding care to the patients.
Client *eed +u':

Question 11
Type: MCSA
The nurse is using a specific process to plan smo1ing cessation acti"ities for a patient. 3hich of the following is
this nurse most li1ely using to plan the care for this patient?
1. nursing process
2. critical pathways
. e"idence*based practice
!. "ariance analy%ing
Corre"t #ns$er:
%ationale 1! The nursing process is a series of critical*thin1ing acti"ities that nurses use to pro"ide care to
patients. The purpose of care may be to promote wellness, restore health, or facilitate coping with a disability or
death.
%ationale 2! The use of critical pathways is primarily used to manage disease conditions.
%ationale ! The use of e"idence*based practice is primarily used to manage disease conditions.
%ationale !! The use of "ariance analy%ing implies the use of statistical*based research.
&lo'al %ationale: The nursing process is a series of critical*thin1ing acti"ities that nurses use to pro"ide care to
patients. The purpose of care may be to promote wellness, restore health, or facilitate coping with a disability or
death. The use of critical pathways and e"idence*based practice are primarily used to manage disease conditions.
The use of "ariance analy%ing implies the use of statistical*based research.
Client *eed +u':
Learnin( -ut"o.e: 2. Apply the attitudes, mental habits, and s1ills necessary for critical thin1ing when using

Question 12
Type: MCSA
3hich of the following best demonstrates a nurse using critical thin1ing when pro"iding patient care?
1. A nurse lists alternati"e inter"entions a"ailable to pro"ide patient care.
2. A nurse chec1s a laboratory manual before pro"iding care.
. A nurse is confused when the only planned inter"ention fails to help a patient.
!. A nurse chec1s e"ery inter"ention with the charge nurse before pro"iding care.
Corre"t #ns$er:
%ationale 1! Critical thin1ing is thin1ing about ones own thin1ing. $t is self*directed thin1ing that in"ol"es
attitudes and s1ills. The purpose of the thin1ing, le"el of 1nowledge, pre;udices, information sources, option
identification, and personal "alues should all be considered with critical thin1ing.
%ationale 2! Although the nurse may use a laboratory manual when planning or pro"iding care, it is not the best
selection.
%ationale ! The nurse who is unable to employ alternati"e inter"entions lac1s some of the basic characteristics
associated with critical thin1ing.
%ationale !! The nurse who is unable to ma1e independent decisions lac1s some of the basic characteristics
associated with critical thin1ing.
&lo'al %ationale: Critical thin1ing is thin1ing about ones own thin1ing. $t is self*directed thin1ing that in"ol"es
attitudes and s1ills. The purpose of the thin1ing, le"el of 1nowledge, pre;udices, information sources, option
identification, and personal "alues should all be considered with critical thin1ing. Although the nurse may use a
laboratory manual when planning or pro"iding care, it is not the best selection. The nurse who is unable to ma1e
independent decisions or employ alternati"e inter"entions lac1s some of the basic characteristics associated with
critical thin1ing.
Client *eed +u':

Question 13
Type: MCSA
A new nurse tells her mentor, 6>ou always seem so poised when you interact with the patient. $t is as if you
always 1now what to do. Can you teach me how to do that?7 3hat characteristic does this mentor possess in
relation to critical thin1ing?
1. self*confidence
2. independent thin1ing
. empathy
!. discipline
Corre"t #ns$er:
%ationale 1! Confidence in one4s own decisions is gained through the use of critical thin1ing.
%ationale 2! $ndependent thin1ing is demonstrated by the ability to ma1e decisions with minimal input from
others.
%ationale ! +mpathy in"ol"es being able to relate in an understanding manner with others.
%ationale !! -iscipline in"ol"es self*control.
&lo'al %ationale: Confidence in one4s own decisions is gained through the use of critical thin1ing. $ndependent
thin1ing is demonstrated by the ability to ma1e decisions with minimal input from others. +mpathy in"ol"es
being able to relate in an understanding manner with others. -iscipline in"ol"es self*control.
Client *eed +u':

Question 24
Type: MCSA
The nurse stops to thin1 about a pre"ious patient care situation before pro"iding care to a current patient. This
nurse is using what critical*thin1ing s1ill?
1. reflection
2. di"ergent thin1ing
. reasoning
!. clarifying
Corre"t #ns$er: <
%ationale 1! 5eflection occurs when time is ta1en to thin1 about a situation and compare it to other similar
situations.
%ationale 2! -i"ergent thin1ing in"ol"es thin1ing about multiple items simultaneously.
%ationale ! 5easoning allows the nurse to use the powers of deduction.
%ationale !! Clarifying is the use of thin1ing s1ills to enhance clarity and reduce confusion.
&lo'al %ationale: 5eflection occurs when time is ta1en to thin1 about a situation and compare it to other similar
situations. -i"ergent thin1ing in"ol"es thin1ing about multiple items simultaneously. 5easoning allows the nurse
to use the powers of deduction. Clarifying is the use of thin1ing s1ills to enhance clarity and reduce confusion.
Client *eed +u':

Question 21
Type: MCSA
The nurse wor1ing on a &uality impro"ement study wants to e"aluate a patient care process. 3hich of the
following can the nurse use to e"aluate this process?
1. nursing process
2. critical pathway
. "ariance analy%ing
!. e"idence*based practice
Corre"t #ns$er:
%ationale 1! The nursing process can ser"e as a framewor1 for the e"aluation of &uality care.
%ationale 2! The use of critical pathways would not pro"ide the best, recommended means to e"aluate a patient
care process.
%ationale ! The use of "ariance analy%ing would not pro"ide the best, recommended means to e"aluate a patient
care process.
%ationale !! The use of e"idence*based practice would not pro"ide the best, recommended means to e"aluate a
patient care process.
&lo'al %ationale: The nursing process can ser"e as a framewor1 for the e"aluation of &uality care. The use of
critical pathways, "ariance analy%ing, and e"idence*based practice would not pro"ide the best, recommended
means to e"aluate a patient care process.
Client *eed +u':

Question 22
Type: MCSA
The nurse is re"iewing the outcome of patient care that was pro"ided. 3hich of the following nursing process
steps should the nurse use next?
1. e"aluation
2. assessment
. implementation
!. planning
Corre"t #ns$er:
%ationale 1! The data gained during the e"aluation of pro"ided patient care ser"es as the assessment. The nurse
can then proceed to create a nursing diagnosis based upon this information. The steps in the nursing process are
interrelated, interdependent, and used cyclically.
%ationale 2! -uring the assessment phase, the nurse is acti"ely collecting data.
%ationale ! $mplementation is the phase of the nursing process during which the nurse performs inter"entions.
%ationale !! -etermining the needs of patient and de"ising a plan of action ta1e place during the planning phase.
&lo'al %ationale: The data gained during the e"aluation of pro"ided patient care ser"es as the assessment. The
nurse can then proceed to create a nursing diagnosis based upon this information. The steps in the nursing process
are interrelated, interdependent, and used cyclically. -uring the assessment phase, the nurse is acti"ely collecting
data. $mplementation is the phase of the nursing process during which the nurse performs inter"entions.
-etermining the needs of patient and de"ising a plan of action ta1e place during the planning phase.
Client *eed +u':

Question 2
Type: MCSA
A patient tells the nurse, 6$ ha"e pain in my leg when $ stand too long.7 This information would be considered
which of the following?
1. sub;ecti"e data
2. e"aluati"e data
. &ualitati"e data
!. ob;ecti"e data
Corre"t #ns$er:
%ationale 1! $nformation that is percei"ed only by the person experiencing it is called sub;ecti"e data.
%ationale 2! +"aluati"e data is used to assess responses to care that are deli"ered.
%ationale ! ?ualitati"e data refers to the presence or absence of a factor.
%ationale !! 8b;ecti"e data can be measured by someone or something other than the patient.
&lo'al %ationale: $nformation that is percei"ed only by the person experiencing it is called sub;ecti"e data.
+"aluati"e data is used to assess responses to care that are deli"ered. ?ualitati"e data refers to the presence or
absence of a factor. 8b;ecti"e data can be measured by someone or something other than the patient.
Client *eed +u':

Question 2!
Type: MCSA
3hile pro"iding care to a patient, the nurse stops to assess a new patient problem. The assessment in this situation
would be which of the following?
1. a focused assessment
2. an initial assessment
. an ob;ecti"e assessment
!. a sub;ecti"e assessment
Corre"t #ns$er:
%ationale 1! 9ocused assessments enable the nurse to monitor the status of an actual or potential problem that
was pre"iously identified.
%ationale 2! The initial assessment refers to the first interaction.
%ationale ! Sub;ecti"e assessment is not indicated in this scenario.
%ationale !! 8b;ecti"e assessment is not indicated in this scenario.
&lo'al %ationale: 9ocused assessments enable the nurse to monitor the status of an actual or potential problem
that was pre"iously identified. The initial assessment refers to the first interaction. Sub;ecti"e and ob;ecti"e
assessments are not indicated in this scenario.
Client *eed +u':

Question 25
Type: MCSA
At the completion of an assessment, the nurse chooses a nursing diagnosis that best defines the patient4s health
problems. 3hich type of clinical ;udgment will this nurse use?
1. diagnostic reasoning
2. e"idence*based practice
. critical pathway
!. nursing process
Corre"t #ns$er:
%ationale 1! -iagnostic reasoning is a form of clinical ;udgment used to ma1e decisions about which diagnostic
label best describes the patterns of patient data.
%ationale 2! +"idence*based practice refers to the implementation of care initiati"es which ha"e been supported
by research.
%ationale ! A critical pathway is a health care plan de"eloped to pro"ide care with a multidisciplinary, managed
action focus.
%ationale !! The nursing process is a systematic method of critically thin1ing used to promote wellness, maintain
health, restore health, or facilitate coping with disability and death.
&lo'al %ationale: -iagnostic reasoning is a form of clinical ;udgment used to ma1e decisions about which
diagnostic label best describes the patterns of patient data. +"idence*based practice refers to the implementation
of care initiati"es which ha"e been supported by research. A critical pathway is a healthcare plan de"eloped to
pro"ide care with a multidisciplinary, managed action focus. The nursing process is a systematic method of
critically thin1ing used to promote wellness, maintain health, restore health, or facilitate coping with disability
and death.
Client *eed +u':

Question 20
Type: MCSA
The nurse is creating outcome criteria for the nursing diagnoses for a patient. 3hich of the following should the
nurse include when creating the criteria?
1. They should be written to address the patient, and be time*specific and measurable.
2. They should be written as nursing goals.
. They should be written as statements.
!. .They should be written as psychomotor only.
Corre"t #ns$er:
%ationale 1! 8utcome criteria for nursing diagnoses are patient*centered, time*specific, and measurable. They are
classified into three domains! cogniti"e, affecti"e, and psychomotor.
%ationale 2! The focus of the outcome criteria is the patient not upon the nurse.
%ationale ! 3hile the outcome criteria are often written as statements, this option does not encompass all of the
criteria the way the correct answer does.
%ationale !! 8utcome criteria are not limited to psychomotor s1ills: they may also be cogniti"e or affecti"e.
&lo'al %ationale: 8utcome criteria for nursing diagnoses are patient*centered, time*specific, and measurable.
They are classified into three domains! cogniti"e, affecti"e, and psychomotor. The focus of the outcome criteria is
the patient not upon the nurse. 3hile the outcome criteria are often written as statements, this option does not
encompass all of the criteria the way the correct answer does. 8utcome criteria are not limited to psychomotor
s1ills: they may also be cogniti"e or affecti"e.
Client *eed +u':

Question 21
Type: MCSA
The nurse is implementing a plan of care for a patient. After pro"iding care, what should the nurse do as the final
step in the process?
1. -ocument.
2. 5eassess the patient.
. )othing.
!. @i"e the charge nurse a report.
Corre"t #ns$er:
%ationale 1! -ocumenting inter"entions is the final component of implementation as well as being a legal
re&uirement.
%ationale 2! 8ngoing assessment of the patient is an essential component of implementation but it is not the final
step.
%ationale ! )ursing action is re&uired after the completion of care.
%ationale !! ,ro"iding report is an ongoing process and not necessarily completed after implementing the plan of
care.
&lo'al %ationale: -ocumenting inter"entions is the final component of implementation as well as being a legal
re&uirement. 8ngoing assessment of the patient is an essential component of implementation but it is not the final
step. )ursing action is re&uired after the completion of care. ,ro"iding report is an ongoing process and not
necessarily completed after implementing the plan of care.
Client *eed +u':

Question 22
Type: MCSA
A patient care issue has been raised about the actions ta1en by a nurse who was as1ed to pro"ide care to a patient
whose healthcare decisions were considered contro"ersial. The unit4s nurse manager is concerned that care was
not appropriately pro"ided. 3hich of the following should be consulted to protect the patient and to e"aluate the
care in &uestion?
1. nursing code of ethics
2. hospital &uality impro"ement guidelines
. nurse practice act
!. critical pathway
Corre"t #ns$er:
%ationale 1! An established code of ethics is one criterion that defines a profession. +thics are principles of
conduct. Codes of ethics for nurses pro"ide a frame of reference for ideal nursing beha"iors that are congruent
with the principles expressed in the Code for )urses.
%ationale 2! ?uality impro"ement efforts are used to assess and ensure care is pro"ided and as a means to
identify needed changes in care practices.
%ationale ! The nurse practice act pro"ides the standards for an indi"idual state4s stance on the nurse4s scope of
practice.
%ationale !! A critical pathway is a healthcare plan de"eloped to pro"ide care with a multidisciplinary, managed
action focus.
&lo'al %ationale: An established code of ethics is one criterion that defines a profession. +thics are principles of
conduct. Codes of ethics for nurses pro"ide a frame of reference for ideal nursing beha"iors that are congruent
with the principles expressed in the Code for )urses. ?uality impro"ement efforts are used to assess and ensure
care is pro"ided and as a means to identify needed changes in care practices. The nurse practice act pro"ides the
standards for an indi"idual state4s stance on the nurse4s scope of practice. A critical pathway is a healthcare plan
de"eloped to pro"ide care with a multidisciplinary, managed action focus.
Client *eed +u':
Learnin( -ut"o.e: (. +xplain the importance of nursing codes and standards as guidelines for clinical nursing
practice.

Question 23
Type: MCSA
A patient tells the nurse, 6$ ha"e an ad"ance directi"e that $ want you to follow.7 3hich of the following will this
document pro"ide for the nurse?
1. the patient4s preferences for health care should the patient become mentally incapacitated
2. a complete plan of care for the patient
. the answers to any care dilemmas for the patient
!. directions regarding when to use uni"ersal precautions for the patient
Corre"t #ns$er:
%ationale 1! An ad"ance directi"e, or li"ing will, is a document in which a patient formally states preferences for
health care in the e"ent that he or she later becomes mentally incapacitated.
%ationale 2! The patient4s care plan is a hospital*based source of information.
%ationale ! ,atient care dilemmas will be decided on a case*by*case basis and do not relate to the information in
this &uestion
%ationale !! $nformation regarding the use of uni"ersal precautions is a hospital*based source of information.
&lo'al %ationale: An ad"ance directi"e, or li"ing will, is a document in which a patient formally states
preferences for health care in the e"ent that he or she later becomes mentally incapacitated. The patient4s care plan
and information regarding the use of uni"ersal precautions are hospital*based sources of information. ,atient care
dilemmas will be decided on a case*by*case basis and do not relate to the information in this &uestion.
Client *eed +u':
practice.

Question 4
Type: MCSA
The nurse is preparing a patient to go home. 3hich of the following s1ills are the most important for the nurse in
order to ade&uately prepare this patient?
1. familiarity with adult learning principles
2. the ability to follow written orders
. the ability to use critical thin1ing
!. the ability to support patient decision ma1ing
Corre"t #ns$er:
%ationale 1! The nurse will function as an educator when preparing a patient for discharge. $n order to do this
ade&uately, the nurse will need to ha"e some le"el of familiarity of adult learning principles to effecti"ely pro"ide
and e"aluate the outcome of patient education.
%ationale 2! 9ollowing written orders considered a basic caregi"er s1ill.
%ationale ! #sing critical thin1ing would be considered a basic caregi"er s1ill.
%ationale !! The ability to support patient decision ma1ing relates to the role of patient ad"ocate.
&lo'al %ationale: The nurse will function as an educator when preparing a patient for discharge. $n order to do
this ade&uately, the nurse will need to ha"e some le"el of familiarity of adult learning principles to effecti"ely
pro"ide and e"aluate the outcome of patient education. 9ollowing written orders and using critical thin1ing would
be considered basic caregi"er s1ills. The ability to support patient decision ma1ing relates to the role of patient
ad"ocate.
Client *eed +u':

Question 1
Type: MCSA
The nurse is preparing to pro"ide patient care information to a group of unlicensed assisti"e personnel. 3hich
type of care deli"ery system is this nurse most li1ely using to pro"ide patient care?
1. team nursing
2. functional nursing
. primary nursing
!. case management
Corre"t #ns$er:
%ationale 1! Team nursing is practiced by teams of healthcare pro"iders with "arious le"els of education,
including unlicensed assisti"e personnel. The concept of team nursing utili%es "ariously educated healthcare team
members. The team wor1s together and pro"ides the care for which they are indi"idually trained.
%ationale 2! 9unctional nursing is not a recogni%ed term.
%ationale ! $n primary nursing, total nursing care is pro"ided by the assigned nurse.
%ationale !! The focus of case management in"ol"es meeting the needs and care of a group of patients, with
concurrent goals of maximi%ed outcomes combined with cost containment.
&lo'al %ationale: Team nursing is practiced by teams of healthcare pro"iders with "arious le"els of education,
including unlicensed assisti"e personnel. The concept of team nursing utili%es "ariously educated healthcare team
members. The team wor1s together and pro"ides the care for which they are indi"idually trained. 9unctional
nursing is not a recogni%ed term. $n primary nursing, total nursing care is pro"ided by the assigned nurse. The
focus of case management in"ol"es meeting the needs and care of a group of patients, with concurrent goals of
maximi%ed outcomes combined with cost containment.
Client *eed +u':

Question 2
Type: MCSA
A nurse has delegated the collection of "ital signs, including blood pressure readings, to two unlicensed assisti"e
personnel. The delegation of this wor1 means the nurse is
1. accountable for the care that was delegated.
2. not responsible for these "ital signs.
. not accountable for these "ital signs.
!. responsible to re*measure all of the "ital signs.
Corre"t #ns$er:
%ationale 1! 3hen the nurse delegates nursing care acti"ities to another person, that person is authori%ed to act in
the place of the nurse, while the nurse retains the accountability for the acti"ities performed.
%ationale 2! The nurse retains responsibility/accountability for the "ital signs.
%ationale ! The nurse is accountable for re"iewing the data collected and ensuring it is done appropriately.
%ationale !! The purpose of delegation is to share tas1s appropriately, not to increase the wor1 load of the
primary nurse.
&lo'al %ationale: 3hen the nurse delegates nursing care acti"ities to another person, that person is authori%ed to
act in the place of the nurse, while the nurse retains the accountability for the acti"ities performed. The nurse
retains responsibility/accountability for the "ital signs. The nurse is accountable for re"iewing the data collected
and ensuring it is done appropriately. The purpose of delegation is to share tas1s appropriately, not increase the
wor1load of the primary nurse.
Client *eed +u':
informatics.

Question
Type: MCSA
The nurse is consulting a critical pathway to help ma1e patient care decisions. 3hich type of care deli"ery model
is this nurse most li1ely using to pro"ide patient care?
1. case management
2. primary nursing
. functional nursing
!. team nursing
Corre"t #ns$er:
%ationale 1! Critical pathways are often used in con;unction with case management models and/or &uality
impro"ement efforts. 0oth critical pathways and case management in"ol"e pro"iding care or o"erseeing care to a
group of patients ha"ing similar diagnoses.
%ationale 2! ,rimary nursing refers to the pro"ision of all nursing care by a single assigned nurse.
%ationale ! 9unctional nursing is not a recogni%ed term.
%ationale !! $n team nursing, the care is pro"ided based upon the education le"el of the team members.
&lo'al %ationale: Critical pathways are often used in con;unction with case management models and/or &uality
impro"ement efforts. 0oth critical pathways and case management in"ol"e pro"iding care or o"erseeing care to a
group of patients ha"ing similar diagnoses. ,rimary nursing refers to the pro"ision of all nursing care by a single
assigned nurse. 9unctional nursing is not a recogni%ed term. $n team nursing, the care is pro"ided based upon the
education le"el of the team members.
Client *eed +u':
informatics.

Question !
Type: MCSA
,atient chart audits pro"ide the nurses with information that impacts the future outcomes of patient care. 3hat
should the nurses do with this information?
1. #se the information to create an action plan to address any negati"e findings.
2. )othing.
. Submit it to the agency4s accrediting body.
!. ,lace it in a file to compare with the next set of audits.
Corre"t #ns$er:
%ationale 1! -ata from chart audits or the result of &uality assurance audits can be used to de"elop a plan of
action to resol"e differences or issues with patient care. The nurses are expected to use the information if it will
ha"e a positi"e impact on the nursing practice.
%ationale 2! 8btaining information and then failing to use it has no useful purpose.
%ationale ! 3hile the accrediting body of an institution may encourage &uality impro"ement acti"ities, there is
no reason to pro"ide the chart audit results.
%ationale !! The nurses are expected to use the information if it will ha"e a positi"e impact on the nursing
practice.
&lo'al %ationale: -ata from chart audits or the result of &uality assurance audits can be used to de"elop a plan of
action to resol"e differences or issues with patient care. The nurses are expected to use the information if it will
ha"e a positi"e impact on the nursing practice. 8btaining information and then failing to use it has no useful
purpose. 3hile the accrediting body of an institution may encourage &uality impro"ement acti"ities, there is no
reason to pro"ide the chart audit results.
Client *eed +u':
informatics.

Question 5
Type: MCSA
A graduate nurse is attending a seminar regarding the role of the nurse as a patient ad"ocate. After the session, the
students engage in a discussion. 3hich of the following statements by the graduate nurse indicates the need for
further education?
1. 6,atient ad"ocates ha"e the authority to ma1e decisions for the patient.7
2. 60eing a patient ad"ocate entails ma1ing efforts to impro"e patient outcomes.7
. 6,ro"iding education to the patient and family is a 1ey way to be a positi"e patient ad"ocate.7
!. 6Communicating patient needs to the members of the healthcare team is a role of the patient ad"ocate.7
Corre"t #ns$er:
%ationale 1! The nurse who ser"es as a patient ad"ocate may assist and support the patient in decision ma1ing.
The nurse cannot ma1e decisions for the patient.
%ationale 2! This is an element of being a successful patient ad"ocate.
%ationale ! This is an element of being a successful patient ad"ocate.
%ationale !! This is an element of being a successful patient ad"ocate.
&lo'al %ationale: The nurse who ser"es as a patient ad"ocate may assist and support the patient in decision
ma1ing. The nurse cannot ma1e decisions for the patient. The remaining answer choices are elements of being a
successful patient ad"ocate.
Client *eed +u':

Question 0
Type: MCSA
Core competencies in nursing are essential to meet the challenges of upcoming patient populations and expanding
technologies to pro"ide safe and effecti"e nursing care. All of the following choices are parts of core
competencies. Choose the best description that designates the competency of providing patient centered-care.
1. -esign and test inter"entions to change processes and systems of care, with the ob;ecti"e of impro"ing &uality.
2. Communicate, manage 1nowledge, decrease error, and support. -ecision*ma1ing Acritical thin1ingB using
information technology.
. $dentify, respect and communicate patient4s differences, "alues, preferences, and expressed needs.
!. Clarify roles and responsibilities of team members, collaborating and integrating care.
5. #se organi%ational systems to report near misses and errors.
Corre"t #ns$er: (
%ationale 1! The nurse uses critical thin1ing to collect and interpret information, consider the patient4s needs, and
determine appropriate inter"entions. 8ption is under the competency of applying quality improvement.
%ationale 2! The nurse uses critical thin1ing to collect and interpret information, consider the patient4s needs, and
determine appropriate inter"entions. 8ption 2 is under the competency of using informatics.
%ationale ! The nurse uses "riti"al thinkin( to "olle"t and interpret infor.ation, "onsider the patient8s
needs, and deter.ine appropriate inter)entions.
%ationale !! The nurse uses "riti"al thinkin( to "olle"t and interpret infor.ation, "onsider the patient8s
needs, and deter.ine appropriate inter)entions. -ption ! is under the working in interdisciplinary teams
and -ption 5 is under promoting safety.
%ationale 5! The nurse uses "riti"al thinkin( to "olle"t and interpret infor.ation, "onsider the patient8s
needs, and deter.ine appropriate inter)entions. -ption 5 is under promoting safety.
&lo'al %ationale: The nurse uses critical thin1ing to collect and interpret information, consider the patient4s
needs, and determine appropriate inter"entions. 8ption is under the competency of applying quality
improvement. 8ption 2 is under the competency of using informatics, 8ption < is under the working in
interdisciplinary teams and 8ption 2 is under promoting safety.
Client *eed: ,hysiological $ntegrity
Client *eed +u': 0asic Care and Comfort
care, work in interdisciplinary teams, use evidence-based practice, apply quality improvement, promote safety,
and use informatics.

Question 1
Type: MCMA
Choose the &uestions or results which would best represents di"ergent thin1ing on the part of a nurse doing an
initial inta1e assessment for a patient complaining of pain in his or her bac1.
1. 6Tell me about your dietary practices.7
2. 63hen did the pain start and can you tell me on a scale of *', with ' being the worst, what your pain rating
is now?7
. The nurse notes a cluster of blisters on patient4s scapula.
!. 63hen is the last time you had a physical?7
5. 6-oes your eyesight affect your ability to see the insulin that you are ta1ing?7
Corre"t #ns$er: 2,(,2
%ationale 1! 6Tell me about your dietary practices.7 )ormal data are helpful but may not change the care the
nurse pro"ides.
%ationale 2! 63hen did the pain start and can you tell me on a scale of *', with ' being the worst, what your
pain rating is now?7 -i"ergent thin1ing is the ability to weigh the importance of information. This means that
when the nurse collects data from a patient, he or she can sort out the data that are rele"ant for care from the data
that is not rele"ant.
%ationale ! The nurse notes a cluster of blisters on patient4s scapula. -i"ergent thin1ing is the ability to weigh
the importance of information. This means that when the nurse collects data from a patient, he or she can sort out
the data that are rele"ant for care from the data that is not rele"ant.
%ationale !! 63hen is the last time you had a physical?7 )ormal data are helpful but may not change the care the
nurse pro"ides.
%ationale 5! 6-oes your eyesight affect your ability to see the insulin that you are ta1ing?7 -i"ergent thin1ing is
the ability to weigh the importance of information. This means that when the nurse collects data from a patient, he
or she can sort out the data that are rele"ant for care from the data that is not rele"ant.
&lo'al %ationale: -i"ergent thin1ing is the ability to weigh the importance of information. This means that when
the nurse collects data from a patient, he or she can sort out the data that are rele"ant for care from the data that is
not rele"ant. )ormal data are helpful but may not change the care the nurse pro"ides.
Client *eed +u':

Question 2
Type: S+?
Arrange in order the steps the nurse would ta1e to create a fo"used assess.ent for a patient with type $$ diabetes.
+tandard Te/t: Clic1 and drag the options below to mo"e them up or down.
Choi"e 1. )urse notes patient is reluctant to draw up insulin in syringe.
Choi"e 2. )urse assesses what the patient already 1nows.
Choi"e . )urse has patient practice drawing up insulin.
Choi"e !. )urse calls in diabetic educator.
Choi"e 5. )urse notes patient is not aware of differences of hypo* and hyperglycemia.
Corre"t #ns$er: (,,2,<,2
%ationale 1!
%ationale 2!
%ationale !
%ationale !!
%ationale 5!
&lo'al %ationale: 9ocused assessments are ongoing and continuous. -ata is used to e"aluate nursing actions and
ma1e decisions about whether to continue or change inter"entions to meet outcomes. Assessments also pro"ide
structure for documenting nursing care, enable responses to a disease process or treatment, and to identify new
problems AAlfaro*.e9e"re, 2''CB.
Client *eed +u': ,harmacological and ,arenteral Therapies

Question 3
Type: MCSA
+"aluate the following scenarios and choose the one that best describes an ethical nursing dilemma.
1. A 2'*year*old male patient comes in the hospital with an opportunistic disease and has =$D. =e is sexually
irresponsible and is sleeping with two girls and does not want this information gi"en out.
2. >ou are a charge nurse and the patient ratio is greater than 2!.
. >ou are assigned to a cardiac unit but are not capable of interpreting +E@ results. >ou ta1e the assignment
anyway.
!. >ou drop the patient4s medication on the floor but gi"e it to the patient anyway.
5. A co*wor1er has hung the wrong antibiotic on the patient. >ou find the error.
Corre"t #ns$er:
%ationale 1! A dile..a is a choice between two unpleasant, ethically troubling alternati"es. )urses who pro"ide
medical*surgical nursing care face dilemmas almost daily. Many commonly experienced dilemmas in"ol"e
confidentiality, patient rights, and issues of dying and death.
%ationale 2! The rest of the ans$ers 2, , !, and 5 do not fall under the definition of dilemma, although they are
"iolating standards of care, codes of ethics and standards of practice.
%ationale ! The rest of the ans$ers 2, , !, and 5 do not fall under the definition of dilemma, although they are
%ationale !! The rest of the ans$ers 2, , !, and 5 do not fall under the definition of dilemma, although they are
%ationale 5! The rest of the ans$ers 2, , !, and 5 do not fall under the definition of dilemma, although they are
&lo'al %ationale: A dile..a is a choice between two unpleasant, ethically troubling alternati"es. )urses who
pro"ide medical*surgical nursing care face dilemmas almost daily. Many commonly experienced dilemmas
in"ol"e confidentiality, patient rights, and issues of dying and death. The rest of the ans$ers 2, , !, and 5 do not
fall under the definition of dilemma, although they are "iolating standards of care, codes of ethics, and standards
of practice.
Co(niti)e Le)el: +"aluating
Client *eed: ,sychosocial $ntegrity
Client *eed +u':
practice.

Question !4
Type: MCMA
A nurse has met a patient who can pro"ide season passes for the upcoming football season at a discounted price.
The nurse offers to pro"ide home care for one wee1 in exchange for the discounted tic1ets as a present to her
boyfriend. The nurse is in "iolation of which standardAsB?
1. =$,,A
2. A)A standards
. professional boundaries
!. state nurse practice acts
5. standards pertinent to specific hospital protocols
Corre"t #ns$er: (,<
%ationale 1! Answer is a "iolation of patient confidentiality.
%ationale 2! Answer 2 is a "iolation of ethics in the A)A Standards of Care and would not apply here.
%ationale ! ,rofessional boundaries are the borders between the "ulnerability of the patient and the power of the
nurse.
%ationale !! ,rofessional boundaries are the borders between the "ulnerability of the patient and the power of the
nurse.
%ationale 5! =ospital protocols are not specified in the &uestion: howe"er, the nurse4s action "iolates a
professional boundary.
&lo'al %ationale: ,rofessional boundaries are the borders between the "ulnerability of the patient and the power
of the nurse. Answer is a "iolation of patient confidentiality and 2 is a "iolation of ethics in the A)A Standards
of Care and would not apply here.
Client *eed +u':
practice.

Question !1
Type: MCSA
)urse .ynn has been in the profession for o"er ' years. 3hen students come on the medical*surgical unit, .ynn
is often grumpy, mean, and non*compliant when it comes to helping the students stating, 6$ had to pay my dues,
they must pay theirs.7 She does not want the students on the floor and is often obstructi"e in ha"ing them gain
experiences or sharing insights that may benefit them. )urse .ynn is guilty of "iolating which standard?
1. $C) Code of +thics
2. A)A Standards of ,ractice
. A)A Code of +thics
!. state practice acts
5. A,)A Code of +thics
Corre"t #ns$er: 2
%ationale 1! The $C) Code of +thics for )urses A2''FB helps guide nurses in setting priorities, ma1ing
;udgments, and ta1ing action when they face ethical dilemmas in clinical practice.
%ationale 2! Collegiality, from the A)A Standards of ,ractice! The registered nurse interacts with and contributes
to the professional de"elopment of peers and colleagues.
%ationale ! 5esponse ( deals with the standards of self*care, collaboration and association in"ol"ement.
%ationale !! 5esponse < deals with the laws to define the scope of nursing in each state
%ationale 5! 5esponse 2 has to do with the American ,sychiatric )urse Association.
&lo'al %ationale: Collegiality, from the A)A Standards of ,ractice! The registered nurse interacts with and
contributes to the professional de"elopment of peers and colleagues. 8ption! The $C) Code of +thics for )urses
A2''FB helps guide nurses in setting priorities, ma1ing ;udgments, and ta1ing action when they face ethical
dilemmas in clinical practice. 8ption ( deals with the standards of self*care, collaboration and association
in"ol"ement. 8ption < deals with the laws to define the scope of nursing in each state and 8ption 2 has to do with
the American ,sychiatric )urse Association.
Client *eed +u':
practice.

Question !2
Type: MCSA
The nurse attends multidisciplinary meetings to discuss the plan of care for a trauma patient who has been
transferred to the medical*surgical unit. $n this role the nurse is acting in the role of which of the following?
1. caregi"er
2. team leader
. delegate
!. ad"ocate
5. manager
Corre"t #ns$er: <
%ationale 1! The caregi"er role does not fit the description of ad"ocate abo"e. The caregi"er wor1s independently
and collaborati"ely with the patient.
%ationale 2! Team leaders and delegates are nurses who are participating in roles of leadership in that they
manage time, people, resources, and the en"ironment to ensure that staff is able to pro"ide the proper care to
children.
%ationale ! Team leaders and delegates are nurses who are participating in roles of leadership in that they
manage time, people, resources, and the en"ironment to ensure that staff is able to pro"ide the proper care to
children.
%ationale !! The nurse as ad"ocate will attend meetings with others on the healthcare team so that the ad"ocate is
able to mediate between the patient and other persons on the team such as the physician, social wor1er, and case
manager.
%ationale 5! A manager4s role is to o"ersee the operation of their perspecti"e nursing floors. They must be aware
of daily acti"ities and the roles and &uality assurances needed to implement safe and effecti"e patient care.
&lo'al %ationale: The nurse as ad"ocate will attend meetings with others on the healthcare team so that the
ad"ocate is able to mediate between the patient and other persons on the team such as the physician, social
wor1er, and case manager.

Question !
Type: MCMA
To ensure the &uality and safety of patient care the nurse must understand the following concepts.
1. training, experience and competence of each member of the healthcare team
2. monitor care pro"ided and gi"e constructi"e e"aluation
. ensure &uality and safety that patients recei"e
!. the demographics of the patient
5. the number of pre"ious hospitali%ations and satisfaction scores
Corre"t #ns$er: ,2,(
%ationale 1! All nurses must be prepared to understand, ta1e seriously, and participate in &uality and safety
impro"ement strategies, which include training, experience, monitoring of care and &uality and safety assurance.
%ationale 2! All nurses must be prepared to understand, ta1e seriously, and participate in &uality and safety
%ationale ! All nurses must be prepared to understand, ta1e seriously, and participate in &uality and safety
%ationale !! $nformation specific to the geographic region or the patient may ha"e some impact on care but does
not generally pertain to the concepts.
%ationale 5! $nformation specific to the geographic region or the patient may ha"e some impact on care but does
not generally pertain to the concepts.
&lo'al %ationale: All nurses must be prepared to understand, ta1e seriously, and participate in &uality and safety
$nformation specific to the geographic region or the patient may ha"e some impact on care but do not generally
pertain to the concepts.
Client *eed +u':

Question !!
Type: MCSA
A nurse would li1e to do a research pro;ect that determines that patients are able to wal1 to the be"erage "ending
machine and ha"e choices that fulfill their needs. This research pro;ect is
1. "alid but not realistic.
2. not "alid and not pertinent.
. a nice idea and should be explored further.
!. realistic but not "alid.
5. does not contribute to patient care and therefore is not a good research pro;ect.
Corre"t #ns$er: 2
%ationale 1! To be rele"ant, nursing research must ha"e a goal to impro"e the care that nurses pro"ide patients.
This means that all nurses must consider the researcher role to be integral to nursing practice. Dalidity, pertinence,
and an interesting idea ha"e nothing to do with impro"ing patient care.
%ationale ! To be rele"ant, nursing research must ha"e a goal to impro"e the care that nurses pro"ide patients.
%ationale !! 5ealistic attempts to do research are based on the need to promote patient care in nursing practice.
This means that all nurses must consider the researcher role to be integral to nursing practice.
&lo'al %ationale: To be rele"ant, nursing research must ha"e a goal to impro"e the care that nurses pro"ide
patients. This means that all nurses must consider the researcher role to be integral to nursing practice. Dalidity,
pertinence, and an interesting idea ha"e nothing to do with impro"ing patient care. 3e are spea1ing to the
outcome of the study and the rationale for the attempt. 5ealistic attempts to do research are based on the need to
promote patient care in nursing practice.

Question !5
Type: S+?
,ut the process of ma1ing a nursing diagnosis in the correct order.
+tandard Te/t: Clic1 and drag the options below to mo"e them up or down.
Choi"e 1. Choose the standardi%ed problem label.
Choi"e 2. -raw conclusions about the present health status.
Choi"e . Compare data to standards and norms.
Choi"e !. Cluster clues to loo1 for patterns and relationships.
Choi"e 5. $dentify the problem.
Corre"t #ns$er: 2,(,,2,<
%ationale 1!
%ationale 2!
%ationale !
%ationale !!
%ationale 5!
&lo'al %ationale: The nurse analy%es assessment data to support appropriate nursing diagnoses. -uring
analy%ing, the nurse organi%es or categori%es data so that it can be used to identify actual or potential health
problems.


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LeMone/Burke/Bauldoff, Medical-Surgical Nursing 5th Edition Test Bank

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