Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. When caring for clients 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 client outcomes are met
ANS: C
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)
client 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 client 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
2. Which of the following best explains the nurses’ primary use of the nursing process when
providing care to clients?
a. To explain nursing interventions to other health care professionals
b. As a problem-solving tool to identify and treat clients’ health care needs
c. As a scientific-based process of diagnosing the client’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 clients’ problems. Diagnosis is only one phase of the nursing process. The
primary use of the nursing process is in client care, not to establish nursing theory or
explain nursing interventions to other health care professionals.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
3. The nurse is caring for a critically ill client 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 client 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
4. The nurse is caring for a client 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 client that these feelings are common for parents.
b. Have the client 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 client’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
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the client’s left hip. Which of the following is the most
appropriate nursing diagnosis for this client?
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 tissue perfusion related to sedentary lifestyle
ANS: C
The client’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 altered circulation and pressure
by frequently repositioning the client. Although left-sided weakness is a problem for the
client, the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for
this client, who already has impaired tissue integrity. The client does have ineffective
tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the
health problem is.
DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
volume related to excessive diaphoresis. Which of the following is an appropriate client
outcome?
a. Client has a balanced intake and output.

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Test Bank for Medical-Surgical Nursing in Canada, 4th Edition

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