Test Bank Understanding Medical Surgical Nursing 6th Edition Williams
Table of Contents Chapter 1. Critical Thinking and the Nursing Process
... [Show More] ................................ ...................... 2 Chapter 2. Evidence-Based Practice ................................ ................................ .... 23 Chapter 3. Issues in Nursing Practice ................................ ................................ ... 36 Chapter 4. Cultural Influences on Nursing Care................................ ........................... 53 Chapter 5. Complementary and Alternative Modalities ................................ .................... 66 Chapter 6. Nursing Care of Patients With Fluid, Electrolytes, and Acid-Base Imbalances ........................ 78 Chapter 7. Nursing Care of Patients Receiving Intravenous Therapy ................................ ......... 95 Chapter 8. Nursing Care of Patients With Infections................................ ...................... 106 Chapter 9. Nursing Care of Patients in Shock ................................ ........................... 124 Chapter 10. Nursing Care of Patients in Pain................................ ............................ 141 Chapter 11. Nursing Care of Patients With Cancer ................................ ....................... 159 Chapter 12. Nursing Care of Patients Having Surgery ................................ .................... 176 Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response ........... 195 Chapter 14. Developmental Considerations and Chronic Illness in the Nursing Care of Adults .................. 206 Chapter 15. Nursing Care of Older Adult Patients................................ ........................ 218 Chapter 16. Patient Care Settings ................................ ................................ ..... 234 Chapter 17. Nursing Care of Patients at the End of Life ................................ ................... 247 Chapter 18. Immune System Function, Assessment, and Therapeutic Measures .............................. 261 Chapter 19. Nursing Care of Patients With Immune Disorders ................................ ............. 274 Chapter 20. Nursing Care of Patients With HIV Disease and AIDS ................................ .......... 293 Chapter 21. Cardiovascular System Function, Assessment, and Therapeutic Measures ......................... 308 Chapter 22. Nursing Care of Patients With Hypertension ................................ ................. 327 Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders ... 345 Chapter 24. Nursing Care of Patients With Occlusive Cardiovascular Disorders ............................... 371 Chapter 25. Nursing Care of Patients With Cardiac Dysrhythmias ................................ .......... 390 Chapter 26. Nursing Care of Patients With Heart Failure................................ .................. 407 Chapter 27. Hematological and Lymphatic System Function, Assessment, and Therapeutic Measures ............ 421 Chapter 28. Nursing Care of Patients With Hematological and Lymphatic Disorders........................... 432 Chapter 29. Respiratory System Function, Assessment, and Therapeutic Measures............................ 453 Chapter 30. Nursing Care of Patients With Upper Respiratory Tract Disorders ............................... 476 Chapter 31. Nursing Care of Patients With Lower Respiratory Tract Disorders ............................... 491 Chapter 32. Gastrointestinal, Hepatobiliary, and Pancreatic Systems Function, Assessment, and Therapeutic ..... 510 Measures ................................ ................................ ......................... 510 Chapter 33. Nursing Care of Patients With Upper Gastrointestinal Disorders................................ . 526 Chapter 34. Nursing Care of Patients With Lower Gastrointestinal Disorders ................................ 541 Chapter 35. Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders ....................... 561 Chapter 36. Urinary System Function, Assessment, and Therapeutic Measures ............................... 574 Chapter 37. Nursing Care of Patients With Disorders of the Urinary System ................................ . 588
1 | P a g eChapter 38. Endocrine System Function and Assessment ................................ ................. 601
Chapter 39. Nursing Care of Patients With Endocrine Disorders ................................ ........... 614
Chapter 40. Nursing Care of Patients With Disorders of the Endocrine Pancreas.............................. 630
Chapter 41. Genitourinary and Reproductive System Function and Assessment .............................. 647
Chapter 42. Nursing Care of Women With Reproductive System Disorders ................................ .. 660
Chapter 43. Nursing Care of Male Patients With Genitourinary Disorders ................................ ... 672
Chapter 44. Nursing Care of Patients With Sexually Transmitted Infections ................................ .. 690
Chapter 45. Musculoskeletal Function and Assessment ................................ ................... 702
Chapter 46. Nursing Care of Patients With Musculoskeletal and Connective Tissue Disorders................... 715
Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures ............................ 728
Chapter 48. Nursing Care of Patients With Central Nervous System Disorders................................ 742
Chapter 49. Nursing Care of Patients With Cerebrovascular Disorders ................................ ...... 756
Chapter 50. Nursing Care of Patients With Peripheral Nervous System Disorders ............................. 770
Chapter 51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing ............. 783
Chapter 52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing............................ 799
Chapter 53. Integumentary System Function, Assessment, and Therapeutic Measures ......................... 815
Chapter 54. Nursing Care of Patients With Skin Disorders ................................ ................ 828
Chapter 55. Nursing Care of Patients With Burns ................................ ........................ 842
Chapter 1. Critical Thinking and the Nursing Process
MULTIPLE CHOICE
1. The nurse is caring for a group of patients on a medical-surgical unit. Which patient should
the licensed practical nurse/licensed vocational nurse (LPN/LVN) assess first?
1. A patient with a blood glucose of 42 mg/dL
2. A patient who reports a pain level of 2
3. A patient who has just received a diagnosis of cancer
4. A patient who has a respiratory rate of 22
ANS: 1
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human
needs. Pages: 6–7
Heading: Prioritize Care
Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Client Need: SECE—Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1 This patient has a dangerously low blood glucose level and requires immediate
intervention.
2 This patient will need to be assessed, but is not as high a priority.
3 According to Maslow, psychosocial needs are not as high of a priority as
physiological needs.
2 | P a g e4 A respiratory rate of 22 is within normal range.
PTS: 1
CON: Patient-Centered Care
2. The LPN/LVN enters the room of a patient who is angry and yells, “I asked 5 minutes ago for
my pain medication. I’m going to call the CEO of the hospital if you don’t get it for me now.”
Which statement by the nurse demonstrates intellectual empathy?
1. “We are short-staffed today, so it will take me longer to meet your needs.”
2. “I am sorry you had to wait, I know you must be in a lot of pain.”
3. “I had another patient who had severe pain, and I had to get to them first.”
4. “I will get you the number for the CEO, but he is aware of how busy we are.”
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 2. Describe attitudes and skills that promote good critical thinking Page: 2
Heading: Intellectual Empathy
Integrated Process: Communication and
Documentation Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1 This statement does not consider an individual’s situation.
2 This statement demonstrates intellectual empathy by considering this patient’s
situation and will likely alleviate the patient’s anger.
3 This statement does not consider a patient’s situation and does not demonstrate
intellectual empathy.
4 This statement addresses the patient’s statement of wanting to call the CEO, but
does not demonstrate intellectual empathy by considering the patient’s situation.
PTS: 1
CON: Communication
3. The nurse is collecting data on a patient. Which data are described as subjective?
1. Respiratory rate of 26 per minute
2. Patient report of shortness of breath
3. Coarse lung sounds bilaterally
4. Cough producing green sputum
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 5. Differentiate between objective and subjective data. Page: 4
Heading: Subjective Data
Integrated Process: Communication and
Documentation Client Need: Communication and
Documentation Cognitive Level: Application (Applying)
Concept: Communication
Difficulty: Moderate
Feedback
3 | P a g e1 Respiratory rate of 26 per minute is an example of objective data.
2 A patient reporting symptoms to the nurse is an example of subjective data.
3 Coarse lung sounds is an example of objective data.
4 A productive cough is an example of objective data.
PTS: 1
CON: Communication
4. A patient with a newly fractured femur reports a pain level of 8/10 and analgesic medication
is not due for another 50 minutes. Which action should the nurse take first?
1. Reposition the patient.
2. Give the medication in 30 minutes.
3. Notify the registered nurse (RN) or physician.
4. Tell the patient it is too early for pain medication.
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using
the nursing process.
Page: 3
Heading: Clinical Judgement
Integrated Process: Clinical Problem-solving Process (Nursing
Process) Client Need: SECE—Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 The patient who has a fractured femur is having acute pain. Repositioning a
patient with a new fracture is not likely to relieve pain.
2 Giving the medication before the prescribed time is beyond the nurse’s scope of
practice.
3 The patient should not have to wait for pain relief, so the LPN should inform the
RN or physician so new pain relief orders can be obtained.
4 The nurse needs to do more than expect the patient to wait for pain relief.
PTS: 1
CON: Patient-Centered Care
5. The nurse is prioritizing care based on Maslow hierarchy of needs. Which need does the
nurse identify as having the highest priority?
1. Job-related stress
2. Feeling of loneliness
3. Pain level of 9 on 0-to-10 scale
4. Lack of confidence
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human
needs Page: 7
Heading: Prioritize Care
Integrated Process: Caring
Client Need: SECE – Coordinated Care
Cognitive Level: Application [Applying]
4 | P a g eConcept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 Job-related stress falls under safety according to Maslow and is addressed after
physiological needs.
2 According to Maslow, loneliness is addressed under social needs following
physiological and safety.
3 Pain is a physiological need and is the highest priority.
4 Lack of confidence falls under esteem according to Maslow and is addressed
following physiological, safety, and social needs.
PTS: 1
CON: Patient-Centered Care
6. The nurse is planning care and setting goals for a newly admitted patient. Who should the
nurse include when conducting these nursing actions?
1. Patient
2. Nurse manager
3. Hospital chaplain
4. Patient’s health care provider (HCP)
ANS: 1
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse is using
the nursing process.
Page: 6
Heading: Prioritize Care
Integrated Process: Communication and
Documentation Client Need: SECE—Management of
Care
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1 Planning care and setting goals is an action performed with the patient. The
patient must be in agreement with the plan for it to be successful in meeting
the desired outcomes.
2 The nurse manager may or may not be aware of the patient’s care needs.
3 The hospital chaplain may not be aware of the patient’s needs.
4 The focus of nursing care is different from that of the HCP.
PTS: 1
CON: Communication
7. While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes
serosanguineous drainage on the dressing. Which statement should the nurse use to
document this finding?
1. “Normal drainage noted.”
2. “Moderate drainage recently noted.”
3. “Scant serosanguineous drainage seen on dressing.”
4. “Pale pink drainage 2 cm by 1 cm noted on dressing.”
ANS: 4
5 | P a g eChapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 6.
Document subjective and objective data.
Page: 5
Heading: Documentation of Data
Integrated Process: Communication and
Documentation Client Need: PHYS—Physiological
Adaptation Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1 These statements are interpretations of the data and use words that have vague
meanings, which should be avoided when documenting.
2 These statements are interpretations of the data and use words that have vague
meanings, which should be avoided when documenting.
3 These statements are interpretations of the data and use words that have vague
meanings, which should be avoided when documenting.
4 Objective data are pieces of factual information obtained through physical
assessment and diagnostic tests that are observable or knowable through
the five senses. The nurse should document exactly what is seen.
PTS: 1
CON: Communication
8. The nurse is caring for a patient using the nursing process. Which step should the nurse take
first?
1. Implementation
2. Planning
3. Nursing diagnosis
4. Assessment
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using
the nursing process.
Page: 4
Heading: Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 The steps of the nursing process are data collection/assessment, nursing
diagnosis, planning, implementation, and evaluation.
2 The steps of the nursing process are data collection/assessment, nursing
diagnosis, planning, implementation, and evaluation.
3 The steps of the nursing process are data collection/assessment, nursing
diagnosis, planning, implementation, and evaluation.
6 | P a g e4 Assessment, or data collection, is the first step in the nursing process and is
used to evaluate a patient’s condition before providing care. The other steps,
in order, are nursing diagnosis, planning, implementation, and evaluation.
PTS: 1
CON: Patient-Centered Care
9. The nurse is administering morphine to a patient reporting a pain level of 8 on a 0-to10
scale. This describes which step of the nursing process?
1. Assessment
2. Nursing diagnosis
3. Implementation
4. Evaluation
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using
the nursing process.
Page: 8
Heading: Identify Interventions
Integrated Process: Clinical Problem-Solving Process (Nursing
Process) Client Need: SECE – Coordination of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 Administering medication does not describe assessment.
2 Administering medication does not describe nursing diagnosis.
3 Administering medication describes the implementation process, since an
action is being taken to help the patient meet a desired outcome.
4 Administering medication does not describe the evaluation phase of the nursing
process.
PTS: 1
CON: Patient-Centered Care
10. The nurse is developing an outcome for a patient with exacerbation of asthma. Which is the
most appropriate outcome for this patient?
1. The patient will not experience shortness of breath.
2. The patient will have a respiratory rate of 16 to 20 per minute.
3. The patient will ambulate without reporting shortness of breath.
4. The patient will not require use of an inhaler.
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 8
Heading: Establish Outcomes
Integrated Process: Clinical Problem-solving (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
7 | P a g eFeedback
1 This is a vague outcome and is not measurable.
2 This is a measurable outcome and is not vague.
3 This is a vague outcome and is not measurable.
8 | P a g e4 This is a vague outcome and is not measurable.
PTS: 1
CON: Patient-Centered Care
11. The nurse suspects a patient is experiencing adverse effects to a newly prescribed
antihypertensive medication. After being informed that the effects are expected, the nurse
remains concerned and conducts an Internet search on the patient’s manifestations. Which
critical thinking behavior did the nurse implement?
1. Sense of justice
2. Intellectual courage
3. Intellectual empathy
4. Intellectual perseverance
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 2. Describe attitudes and skills that promote critical thinking. Page: 2
Heading: Intellectual
Perseverance Integrated Process:
Caring
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 A sense of justice examines motives when making decisions.
2 Intellectual courage looks at other points of view, even when the nurse does
not agree with them.
3 Intellectual empathy understands how another person feels when making
decisions.
4 Intellectual perseverance is not giving up.
PTS: 1
CON: Patient-Centered Care
12. The nurse is identifying outcomes for a patient with fluid volume deficit. Which outcome should
the nurse use to guide this patient’s care?
1. Patient’s intake will be measured daily.
2. Patient’s intake will be 3,000 mL daily.
3. Fluids will be at the bedside for the patient.
4. Fluids the patient likes will be at the bedside.
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 7
Heading: Establish Outcomes
Integrated Process: Clinical Problem-solving (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered
Care Difficulty: Moderate
9 | P a g eFeedback
1 These statements are nursing actions.
2 This outcome provides objective measurable data.
3 These statements are nursing actions.
10 | P a g e4 These statements are nursing actions.
PTS: 1
CON: Patient-Centered Care
13. The nurse is formulating nursing diagnoses for a patient with chronic obstructive pulmonary
disease (COPD). Which diagnosis is of the highest priority?
1. Activity intolerance
2. Impaired gas exchange
3. Risk for injury
4. Deficient knowledge
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human
needs. Page: 6
Heading: Prioritize Care
Integrated Process: Clinical Problem-solving (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1 Although activity intolerance is a nursing diagnosis for a patient with COPD, it is
not the highest priority.
2 Impaired gas exchange is the highest priority according to Maslow.
3 A risk for diagnosis is not a priority because the patient is only at risk for the
problem, it is not an actual problem as of yet.
4 According to Maslow, deficient knowledge is not a priority.
PTS: 1
CON: Patient-Centered Care
14. An RN delegates a patient care assignment to the LPN/LVN. Which phase of the nursing
process should the LPN/LVN perform independently?
1. Assessment
2. Planning care
3. Implementation
4. Nursing diagnosis
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in
using the nursing process.
Page: 22
Heading: Role of the Licensed Practical Nurse/Licensed Vocational Nurse
Integrated Process: Clinical Problem-Solving (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
11 | P a g e1 The LPN/LVN assists the RN with collecting data, formulating nursing
diagnoses, and in determining outcomes and planning care to meet
patient needs.
2 The LPN/LVN assists the RN with collecting data, formulating nursing
diagnoses, and in determining outcomes and planning care to meet
patient needs.
3 The LPN/LVN independently provides direct patient care.
4 The LPN/LVN assists the RN with collecting data, formulating nursing
diagnoses, and in determining outcomes and planning care to meet
patient needs.
PTS: 1
CON: Patient-Centered Care
15. The LPN/LVN is reviewing a care plan for a patient who underwent abdominal surgery 2
hours ago and has a priority nursing diagnosis of acute pain. Which intervention should
the nurse implement first?
1. Teach the patient how to splint the abdomen when coughing.
2. Assist the patient with early ambulation.
3. Encourage the patient to increase fluid intake.
4. Administer hydromorphone (Dilaudid) per order as needed for pain.
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human
needs. Page: 6
Heading: Prioritize Care
Integrated Process: Clinical Problem-solving Process (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1 Splinting is important, but if the patient is in pain, he or she will not likely retain
information.
2 Early ambulation is important, but does not address the diagnosis of acute pain.
3 The patient may need to increase fluid intake, but this is not a priority
intervention.
4 The patient has a nursing diagnosis of acute pain; this intervention should be
implemented first.
PTS: 1
CON: Patient-Centered Care
16. Which critical thinking trait is demonstrated when the LPN/LVN is unsure of how to
perform a dressing change and asks the RN for assistance?
1. Intellectual courage
2. Intellectual integrity
3. Intellectual humility
4. Intellectual empathy
ANS: 3
12 | P a g eChapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 2. Describe attitudes and skills that promote good critical thinking.
Page: 2
Heading: Intellectual Humility
Integrated Process: Communication and
Documentation Client Need: Psychosocial Integrity
Cognitive Level: Comprehension (Understanding)
Concept: Communication
Difficulty: Moderate
Feedback
1 Intellectual courage allows the nurse to look at other points of view even if he
or she does not agree.
2 Intellectual integrity is holding oneself to the same level of standards one
expects others to meet.
3 The LPN/LVN is demonstrating intellectual humility, which is having the ability
to ask for assistance when he or she is unsure.
4 Intellectual empathy allows the nurse to put himself or herself in the patient’s
shoes.
PTS: 1
CON: Communication
17. During morning report, the LPN/LPN is assigned a group of patients. Which patient should the
LPN/LPN see first?
1. A patient scheduled for magnetic resonance imaging (MRI) due to back pain
2. A patient reporting constipation and stomach cramps
3. A 2-day postsurgical patient reporting pain at a level of 6
4. A patient with pneumonia who is short of breath and anxious
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human
needs. Page: 3
Heading: Prioritize Care
Integrated Process: Clinical Problem-solving Process (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1 The patient’s problems of pain, constipation, and scheduled tests are all
important but are not immediately life threatening.
2 The patient’s problems of pain, constipation, and scheduled tests are all
important but are not immediately life threatening.
3 The patient’s problems of pain, constipation, and scheduled tests are all
important but are not immediately life threatening.
4 Using Maslow hierarchy of needs and considering which patient problems are life
threatening, shortness of breath is most important.
PTS: 1
13 | P a g e
CON: Patient-Centered Care18. The LPN/LVN asks a patient who received 2 mg of Morphine IV 30 minutes ago to rate his or
her pain. This describes which step of the nursing process?
1. Assessment
2. Planning
3. Implementation
4. Evaluation
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 8
Heading: Evaluation of Outcomes
Integrated Process: Clinical Problem-solving Process (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 The assessment process would be conducted prior to administering the
Morphine.
2 This does not describe the planning phase of the nursing process.
3 The implementation phase of the nursing process is the administration of
Morphine.
4 Asking the patient if the Morphine was effective by asking him or her to rate
the pain describes the evaluation phase of the nursing process.
PTS: 1
CON: Patient-Centered Care
19. The LPN/LVN is assisting the RN in planning interventions for a patient. Which is an
example of a collaborative action?
1. Administering a medication
2. Giving a back rub
3. Assessing a patient
4. Teaching relaxation techniques
ANS: 1
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 6
Heading: Nursing Diagnosis
Integrated Process: Clinical Problem-solving Process (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 Administering a medication requires an order from the HCP, which makes this a
collaborative action.
2 Giving a back rub is an independent nursing action.
3 Assessing a patient is an example of an independent nursing action.
14 | P a g e4 Teaching relaxation techniques is an example of an independent nursing action.
PTS: 1
CON: Patient-Centered Care
20. The LPN/LVN is reviewing nursing diagnoses for a patient. Which diagnosis should the
nurse report to the RN as incorrect?
1. Risk for injury
2. Heart failure
3. Ineffective gas exchange
4. Activity intolerance
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in
using the nursing process.
Page: 6
Heading: Nursing Diagnosis
Integrated Process: Clinical Problem-solving Process (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 Risk for injury is a nursing diagnosis and does not require correction.
2 Heart failure is a medical diagnosis and requires correction.
3 Ineffective gas exchange is a nursing diagnosis and does not require correction.
4 Activity intolerance is a nursing diagnosis and does not require correction.
PTS: 1
CON: Patient-Centered Care
21. The LPN/LVN is caring for a group of patients. Which patient should the nurse assess first?
1. A patient with an oxygen saturation level of 96% on room air
2. A patient who has a blood pressure of 208/114 mm Hg
3. A patient who reports a pain level of 7 on a scale of 0 to 10
4. A patient with a temperature of 100.2°F
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human
needs. Page: 7
Heading: Prioritize Care
Integrated Process: Clinical Problem-solving Process (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1 An oxygen saturation of 96% is not too concerning. This is not the highest
priority.
2 A blood pressure of 208/114 mm Hg is very high and should be addressed
immediately. This patient should be seen first.
15 | P a g e3 This patient is in pain and should be seen, but is not as high of a priority as the
patient with hypertension.
4 This patient has a low-grade temperature, which is not a priority.
PTS: 1
CON: Patient-Centered Care
22. The LPN/LVN is caring for a patient who begins to exhibit shortness of breath and chest
pain. Which action should the nurse take first?
1. Administer medication as ordered.
2. Notify the RN.
3. Document the findings in the chart.
4. Reposition the patient.
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human
needs. Page: 3
Heading: Prioritize Care
Integrated Process: Clinical Problem-solving Process (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1 The nurse will likely need to administer medication, but should first notify the
RN of the patient’s condition.
2 The LPN/LVN should notify the RN immediately of the change in the patient’s
status.
3 The nurse will document the findings in the chart, but should first notify the RN.
4 Repositioning the patient may not help in this situation; the LPN/LVN should
first notify the RN.
PTS: 1
CON: Patient-Centered Care
23. While teaching how to apply a topical medication the patient begins to vomit. Which action
should the nurse take to meet the patient’s human needs?
1. Provide a clean gown before resuming the teaching.
2. Position an emesis basin for patient use while teaching.
3. Administer medication prescribed for nausea and vomiting.
4. Wait for the vomiting to stop and begin the teaching session again.
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human
needs. Page: 7
Heading: Prioritize Care
Integrated Process: Clinical Problem-solving Process (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
16 | P a g eFeedback
1 These actions do not take the patient’s physiological needs into
consideration. The patient will not be able to achieve a higher level of the
hierarchy before basic physiological needs are met.
2 These actions do not take the patient’s physiological needs into consideration.
The patient will not be able to achieve a higher level of the hierarchy before
basic physiological needs are met.
3 Basic physiological needs must be met first. Since the patient is vomiting, the
nurse should provide the medication that is prescribed for nausea and vomiting.
4 These actions do not take the patient’s physiological needs into consideration.
The patient will not be able to achieve a higher level of the hierarchy before
basic physiological needs are met.
PTS: 1
CON: Patient-Centered Care
24. A nurse approaches a person in a restaurant who appears to be experiencing respiratory
distress. Which action should the nurse perform first?
1. Diagnose the problem.
2. Assist the person to lie down.
3. Gather data from other people.
4. Collect data about the person’s condition.
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing
process. Page: 7 Heading: Subjective Data
Integrated Process: Clinical Problem-solving Process (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Application (Applying)
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 Diagnosing the problem would occur after collecting data.
2 Assisting the person to lie down is implementing an action to address the
problem.
3 The nurse can collect data from other people if necessary.
4 The first step in the nursing process is to collect data, and the patient should
come first.
PTS: 1
CON: Patient-Centered Care
25. The nurse is reviewing nursing diagnoses. Which is an example of a correctly written
nursing diagnosis?
1. Acute pain related to tissue trauma as evidenced by facial grimacing and rating pain
at a level of 9 on a 0-to-10 scale
2. Pain related to appendicitis as evidenced by moaning and guarding
3. Acute pain related to guarding abdomen and rating pain at a level of 9 on a 0-to10
scale
4. Pain as evidenced by status postsurgical procedure
ANS: 1
17 | P a g eChapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 6
Heading: Nursing Diagnosis
Integrated Process: Clinical Problem-solving Process (Nursing
Process) Client Need: SECE: Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
18 | P a g e1 This is a well-written three-part nursing diagnosis that includes the etiology and signs and symptoms.
2 This is a medical diagnosis, not a nursing diagnosis. 3 This nursing diagnosis is missing correct etiology. 4 This is a medical diagnosis and is also missing correct signs and symptoms.
PTS: 1 CON: Patient-Centered Care
26. After identifying nursing diagnoses the nurse plans outcomes for a patient with gastroesophageal reflux disease. Which outcome should the nurse use to evaluate this patient’s care? 1. The patient will have less heartburn. 2. The patient will sleep through the night. 3. The patient’s esophageal burning will resolve 30 minutes after taking oral antacids. 4. The patient will state that burning only occurs when eating foods high in acid content.
ANS: 3 Chapter: Chapter 1 Critical Thinking and the Nursing Process Objective: 3. Describe the thinking that occurs in each step of the nursing process. Page: 8 Heading: Nursing Diagnosis Integrated Process: Clinical Problem-solving Process (Nursing Process) Client Need: SECE: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Moderate
Feedback
1 Outcomes should not be vague or open to interpretation, and should use subjective words such as normal, large, small, or moderate.
2 Sleeping through the night may or may not be associated with the patient’s problem.
3 Outcomes should be measurable [Show Less]