Lewis's Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems, 5 th
(RN) Edition Test Bank
Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Tyerman: Lewis’s Medical-Surgical Nursing in Canada, 5th Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient with a new diagnosis of pneumonia
and explains to the patient that together they will plan the patient’s
care and set goals for discharge. The patient asks, “How is that
different from what the doctor does?” Which response by the nurse
is most appropriate?
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 data and communicating when
there are problems.”
c. “Nurses perform many of the procedures done by physicians, but nurses are here in
the hospital for a longer time than doctors.”
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 Canadian Nurses Association (CNA) definition of
nursing. Registered nurses are self-regulated health care professionals who work
autonomously and in collaboration with others. RNs enable individuals, families, groups,
communities and populations to achieve their optimal level of health. RNs coordinate health
care, deliver direct services, and support patients in their self-care decisions and actions in
situations of health, illness, injury, and disability in all stages of life. 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.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
2. When caring for patients using evidence-informed practice, which of the following does the
nurse use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the patient outcomes are met
ANS: C
, Lewis's Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems, 5 th
(RN) Edition Test Bank
Evidence-informed nursing practice is a continuous interactive process involving the explicit,
conscientious, and judicious consideration of the best available evidence to provide care. Four
primary elements are: (a) clinical state, setting, and circumstances; (b) patient preferences and
actions; (c) best research evidence, and (d) health care resources. Clinical judgement based on
the nurse’s clinical experience is part of EIP, but clinical decision making also should
incorporate current research and research-based guidelines. Evidence from one clinical
research study does not provide an adequate substantiation for interventions. Evaluation of
patient outcomes is important, but interventions should be based on research from randomized
control studies with a large number of subjects.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
3. Which of the following best explains the nurse’s primary use of the nursing process when
providing care to patients?
a. To explain nursing interventions to other health care professionals
b. As a problem-solving tool to identify and treat patients’ health care needs
c. As a scientific-based process of diagnosing the patient’s health care problems
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
ANS: B
The nursing process is an assertive 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.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
4. The nurse is caring for a critically ill patient in the intensive care unit and plans an every-2-
hour turning schedule to prevent skin breakdown. Which type of nursing function is
demonstrated with this turning schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D
When implementing collaborative nursing actions, the nurse is responsible primarily for
monitoring for complications of acute illness or providing care to prevent or treat
complications. Independent nursing actions are focused on health promotion, illness
prevention, and patient advocacy. A dependent action would require a physician order to
implement. Cooperative nursing functions are not described as one of the formal nursing
functions.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
5. The nurse is caring for a patient who has been admitted to the hospital for surgery and tells
the nurse, “I do not feel right about leaving my children with my neighbour.” Which action
should the nurse take next?
a. Reassure the patient that these feelings are common for parents.
, Lewis's Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems, 5 th
(RN) Edition Test Bank
b. Have the patient call the children to ensure that they are doing well.
c. Call the neighbour to determine whether adequate childcare is being provided.
d. Gather more data about the patient’s feelings about the childcare arrangements.
ANS: D
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.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity
6. The nurse is caring for a patient who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the patient’s left hip. Which of the following is the most
appropriate nursing diagnosis for this patient?
a. Impaired physical mobility related to decrease in muscle control (left-sided
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
protecting tissue integrity
c. Impaired skin integrity related to pressure over bony prominence (impaired
circulation)
d. Ineffective peripheral tissue perfusion related to sedentary lifestyle
ANS: C
The patient’s major problem is the impaired skin integrity as demonstrated by the presence of
a pressure injury. The nurse is able to treat the cause of impaired circulation and pressure over
bony prominence 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 peripheral tissue perfusion, but the impaired skin integrity diagnosis indicates
more clearly what the health problem is.
DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis
MSC: NCLEX: Physiological Integrity
7. The nurse caring for a patient with an infection has a nursing diagnosis of deficient fluid
volume related to excessive fluid loss through normal route (diaphoresis). Which of the
following is an appropriate patient outcome?
a. Patient has a balanced intake and output.
b. Patient’s bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patient’s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid
volume that was identified in the nursing diagnosis statement. The other statements would not
indicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
, Lewis's Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems, 5 th
(RN) Edition Test Bank
8. Which of the following represents a nursing activity that is carried out during the evaluation
phase of the nursing process?
a. Determining if interventions have been effective in meeting patient outcomes.
b. Documenting the nursing care plan in the progress notes in the medical record.
c. Deciding whether the patient’s health problems have been completely resolved.
d. Asking the patient to evaluate whether the nursing care provided was satisfactory.
ANS: A
Evaluation consists of determining whether the desired patient outcomes have been met and
whether the nursing interventions were appropriate. The other responses do not describe the
evaluation phase.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
9. Which of the following would the nurse perform during the assessment phase of the nursing
process?
a. Obtains data with which to diagnose patient problems.
b. Uses patient data to develop priority nursing diagnoses.
c. Teaches interventions to relieve patient health problems.
d. Assists the patient to identify realistic outcomes to health problems.
ANS: A
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.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
10. Which of the following is an example of a correctly written nursing diagnosis statement?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to insufficient sense of control
d. Altered urinary elimination related to urinary tract infection
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes
a patient’s response to a health problem that 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.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
11. Which of the following includes the components required for a complete nursing diagnosis
statement?
a. A problem and the suggested patient goals or outcomes
b. A problem, its cause, and objective data that support the problem
c. A problem with all its possible causes and the planned interventions
d. A problem with its etiology and the signs and symptoms of the problem
