Test Bank For Understanding Medical-Surgical Nursing, 5th Edition
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Chapter 1. Critical Thinking and the Nursing
Process
Chapter 1. Critical Thinking and the Nursing Process
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. After receiving morning report, which patient should the licensed practical nurse/licensed
vocational nurse (LPN/LVN) assess first?
a. A patient who needs discharge teaching
b. A patient who needs assistance to ambulate
c. A patient who states, “No one cares about me.”
d. A patient who has a temperature of 106°F (41.1°C)
____ 2. During a class discussion, two nursing students demonstrated intellectual courage. What
action did the nursing students perform?
a. Considered being in the other person’s situation
b. Expected proof that the use of restraints is safe
c. Conducted additional research on the use of restraints in patient care
d. Listened to each other’s point of view regarding the use of patient restraints
____ 3. The nursing staff is planning a celebratory dinner and cake for a newly licensed practical
nurse. Which of the new nurse’s human needs is supported by these actions?
a. Self-esteem
b. Physiological
c. Self-actualization
d. Safety and security
____ 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 actions should the nurse take?
a. Reposition the patient.
b. Give the medication in 30 minutes.
c. Notify the registered nurse (RN) or physician.
d. Tell the patient it is too early for pain medication.
____ 5. The nursing instructor is planning a teaching session on critical thinking for students. What
should the instructor say when explaining critical thinking?
Process
Chapter 1. Critical Thinking and the Nursing Process
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. After receiving morning report, which patient should the licensed practical nurse/licensed
vocational nurse (LPN/LVN) assess first?
a. A patient who needs discharge teaching
b. A patient who needs assistance to ambulate
c. A patient who states, “No one cares about me.”
d. A patient who has a temperature of 106°F (41.1°C)
____ 2. During a class discussion, two nursing students demonstrated intellectual courage. What
action did the nursing students perform?
a. Considered being in the other person’s situation
b. Expected proof that the use of restraints is safe
c. Conducted additional research on the use of restraints in patient care
d. Listened to each other’s point of view regarding the use of patient restraints
____ 3. The nursing staff is planning a celebratory dinner and cake for a newly licensed practical
nurse. Which of the new nurse’s human needs is supported by these actions?
a. Self-esteem
b. Physiological
c. Self-actualization
d. Safety and security
____ 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 actions should the nurse take?
a. Reposition the patient.
b. Give the medication in 30 minutes.
c. Notify the registered nurse (RN) or physician.
d. Tell the patient it is too early for pain medication.
____ 5. The nursing instructor is planning a teaching session on critical thinking for students. What
should the instructor say when explaining critical thinking?
Chapter 1. Critical Thinking and the Nursing
Process
Chapter 1. Critical Thinking and the Nursing Process
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. After receiving morning report, which patient should the licensed practical nurse/licensed
vocational nurse (LPN/LVN) assess first?
a. A patient who needs discharge teaching
b. A patient who needs assistance to ambulate
c. A patient who states, “No one cares about me.”
d. A patient who has a temperature of 106°F (41.1°C)
____ 2. During a class discussion, two nursing students demonstrated intellectual courage. What
action did the nursing students perform?
a. Considered being in the other person’s situation
b. Expected proof that the use of restraints is safe
c. Conducted additional research on the use of restraints in patient care
d. Listened to each other’s point of view regarding the use of patient restraints
____ 3. The nursing staff is planning a celebratory dinner and cake for a newly licensed practical
nurse. Which of the new nurse’s human needs is supported by these actions?
a. Self-esteem
b. Physiological
c. Self-actualization
d. Safety and security
____ 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 actions should the nurse take?
a. Reposition the patient.
b. Give the medication in 30 minutes.
c. Notify the registered nurse (RN) or physician.
d. Tell the patient it is too early for pain medication.
____ 5. The nursing instructor is planning a teaching session on critical thinking for students. What
should the instructor say when explaining critical thinking?
Process
Chapter 1. Critical Thinking and the Nursing Process
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. After receiving morning report, which patient should the licensed practical nurse/licensed
vocational nurse (LPN/LVN) assess first?
a. A patient who needs discharge teaching
b. A patient who needs assistance to ambulate
c. A patient who states, “No one cares about me.”
d. A patient who has a temperature of 106°F (41.1°C)
____ 2. During a class discussion, two nursing students demonstrated intellectual courage. What
action did the nursing students perform?
a. Considered being in the other person’s situation
b. Expected proof that the use of restraints is safe
c. Conducted additional research on the use of restraints in patient care
d. Listened to each other’s point of view regarding the use of patient restraints
____ 3. The nursing staff is planning a celebratory dinner and cake for a newly licensed practical
nurse. Which of the new nurse’s human needs is supported by these actions?
a. Self-esteem
b. Physiological
c. Self-actualization
d. Safety and security
____ 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 actions should the nurse take?
a. Reposition the patient.
b. Give the medication in 30 minutes.
c. Notify the registered nurse (RN) or physician.
d. Tell the patient it is too early for pain medication.
____ 5. The nursing instructor is planning a teaching session on critical thinking for students. What
should the instructor say when explaining critical thinking?
a. “Collect data concerning the patient’s problem.”
b. “Think of different ways to help relieve a patient’s problem.”
c. “Determine if an action worked to eliminate a patient problem.”
d. “Use knowledge and skills to make the best decision for patient 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?
a. Patient
b. Nurse manager
c. Patient’s family members
d. Patient’s health care provider (HCP)
____ 7. While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes
serosanguineous drainage on the patient’s dressing. Which statement should the nurse use to
document the finding?
a. “Normal drainage noted.”
b. “Moderate drainage recently noted.”
c. “Scant serosanguineous drainage seen on dressing.”
d. “Pale pink drainage, 2 cm by 1 cm, noted on dressing.”
____ 8. The nurse is caring for a patient who is scheduled for surgery. Which data should the nurse
collect to identify safety and security needs?
a. Meal patterns
b. Sleep patterns
c. Anxiety about surgery
d. Effectiveness of pain medication
____ 9. The nurse is reviewing data collected during patient care. Which data should the nurse
document as objective?
a. Patient is pleasant.
b. Urine output is 300 mL.
c. “It has been a good day.”
d. Patient’s appetite is poor.
____ 10. The nurse is determining diagnoses appropriate for a patient recovering from surgery.
Which nursing diagnoses should the nurse identify as the highest priority for this patient?
a. Acute pain
b. Impaired mobility
b. “Think of different ways to help relieve a patient’s problem.”
c. “Determine if an action worked to eliminate a patient problem.”
d. “Use knowledge and skills to make the best decision for patient 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?
a. Patient
b. Nurse manager
c. Patient’s family members
d. Patient’s health care provider (HCP)
____ 7. While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes
serosanguineous drainage on the patient’s dressing. Which statement should the nurse use to
document the finding?
a. “Normal drainage noted.”
b. “Moderate drainage recently noted.”
c. “Scant serosanguineous drainage seen on dressing.”
d. “Pale pink drainage, 2 cm by 1 cm, noted on dressing.”
____ 8. The nurse is caring for a patient who is scheduled for surgery. Which data should the nurse
collect to identify safety and security needs?
a. Meal patterns
b. Sleep patterns
c. Anxiety about surgery
d. Effectiveness of pain medication
____ 9. The nurse is reviewing data collected during patient care. Which data should the nurse
document as objective?
a. Patient is pleasant.
b. Urine output is 300 mL.
c. “It has been a good day.”
d. Patient’s appetite is poor.
____ 10. The nurse is determining diagnoses appropriate for a patient recovering from surgery.
Which nursing diagnoses should the nurse identify as the highest priority for this patient?
a. Acute pain
b. Impaired mobility
a. “Collect data concerning the patient’s problem.”
b. “Think of different ways to help relieve a patient’s problem.”
c. “Determine if an action worked to eliminate a patient problem.”
d. “Use knowledge and skills to make the best decision for patient 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?
a. Patient
b. Nurse manager
c. Patient’s family members
d. Patient’s health care provider (HCP)
____ 7. While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes
serosanguineous drainage on the patient’s dressing. Which statement should the nurse use to
document the finding?
a. “Normal drainage noted.”
b. “Moderate drainage recently noted.”
c. “Scant serosanguineous drainage seen on dressing.”
d. “Pale pink drainage, 2 cm by 1 cm, noted on dressing.”
____ 8. The nurse is caring for a patient who is scheduled for surgery. Which data should the nurse
collect to identify safety and security needs?
a. Meal patterns
b. Sleep patterns
c. Anxiety about surgery
d. Effectiveness of pain medication
____ 9. The nurse is reviewing data collected during patient care. Which data should the nurse
document as objective?
a. Patient is pleasant.
b. Urine output is 300 mL.
c. “It has been a good day.”
d. Patient’s appetite is poor.
____ 10. The nurse is determining diagnoses appropriate for a patient recovering from surgery.
Which nursing diagnoses should the nurse identify as the highest priority for this patient?
a. Acute pain
b. Impaired mobility
b. “Think of different ways to help relieve a patient’s problem.”
c. “Determine if an action worked to eliminate a patient problem.”
d. “Use knowledge and skills to make the best decision for patient 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?
a. Patient
b. Nurse manager
c. Patient’s family members
d. Patient’s health care provider (HCP)
____ 7. While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes
serosanguineous drainage on the patient’s dressing. Which statement should the nurse use to
document the finding?
a. “Normal drainage noted.”
b. “Moderate drainage recently noted.”
c. “Scant serosanguineous drainage seen on dressing.”
d. “Pale pink drainage, 2 cm by 1 cm, noted on dressing.”
____ 8. The nurse is caring for a patient who is scheduled for surgery. Which data should the nurse
collect to identify safety and security needs?
a. Meal patterns
b. Sleep patterns
c. Anxiety about surgery
d. Effectiveness of pain medication
____ 9. The nurse is reviewing data collected during patient care. Which data should the nurse
document as objective?
a. Patient is pleasant.
b. Urine output is 300 mL.
c. “It has been a good day.”
d. Patient’s appetite is poor.
____ 10. The nurse is determining diagnoses appropriate for a patient recovering from surgery.
Which nursing diagnoses should the nurse identify as the highest priority for this patient?
a. Acute pain
b. Impaired mobility
c. Deficient knowledge
d. Impaired skin integrity
____ 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?
a. Sense of justice
b. Intellectual courage
c. Intellectual empathy
d. Intellectual perseverance
____ 12. The nurse is identifying outcomes for a patient with a Fluid Volume Deficit. Which
outcome should the nurse use to guide the patient’s care?
a. Patient’s fluid intake will be measured daily.
b. Patient’s intake will be 3000 mL daily.
c. Fluids will be at the bedside for the patient.
d. Fluids the patient likes will be at the bedside.
____ 13. The nurse is caring for a patient with the diagnosis of Fluid Volume Excess. Which
information should the LPN/LVN use to determine if care was effective?
a. Restrict the patient’s fluid intake.
b. Measure the patient’s daily weight.
c. Teach the patient to monitor fluid balance.
d. Discuss the patient’s care plan with the RN.
____ 14. A RN delegates a patient care assignment to the LPN/LVN. Which phase of the nursing
process should the LPN/LVN perform independently?
a. Assessment
b. Planning care
c. Implementation
d. Nursing diagnosis
____ 15. The nurse is caring for a patient with a painful back injury that occurred 6 months ago.
Which three-part nursing diagnosis should the nurse use to guide this patient’s care?
a. Pain as evidenced by herniated lumbar disk
b. Acute pain related to inability to sit as evidenced by muscle spasms
c. Chronic pain related to muscle spasms as evidenced by patient pain rating of 8 and difficulty
d. Impaired skin integrity
____ 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?
a. Sense of justice
b. Intellectual courage
c. Intellectual empathy
d. Intellectual perseverance
____ 12. The nurse is identifying outcomes for a patient with a Fluid Volume Deficit. Which
outcome should the nurse use to guide the patient’s care?
a. Patient’s fluid intake will be measured daily.
b. Patient’s intake will be 3000 mL daily.
c. Fluids will be at the bedside for the patient.
d. Fluids the patient likes will be at the bedside.
____ 13. The nurse is caring for a patient with the diagnosis of Fluid Volume Excess. Which
information should the LPN/LVN use to determine if care was effective?
a. Restrict the patient’s fluid intake.
b. Measure the patient’s daily weight.
c. Teach the patient to monitor fluid balance.
d. Discuss the patient’s care plan with the RN.
____ 14. A RN delegates a patient care assignment to the LPN/LVN. Which phase of the nursing
process should the LPN/LVN perform independently?
a. Assessment
b. Planning care
c. Implementation
d. Nursing diagnosis
____ 15. The nurse is caring for a patient with a painful back injury that occurred 6 months ago.
Which three-part nursing diagnosis should the nurse use to guide this patient’s care?
a. Pain as evidenced by herniated lumbar disk
b. Acute pain related to inability to sit as evidenced by muscle spasms
c. Chronic pain related to muscle spasms as evidenced by patient pain rating of 8 and difficulty
walking
d. Acute pain related to patient pain rating of 6 as evidenced by muscle spasms and nerve
compression
____ 16. The RN implements an intervention to improve a patient’s appetite. After implementing the
intervention for two meals, the LPN/LVN notes no improvement in the patient’s eating. What action
should the LPN/LVN take?
a. Develop a new plan of care.
b. Revise the patient outcome to one that is achievable.
c. Collaborate on a new nursing diagnosis with the RN.
d. Provide data to the RN to assist in evaluation of the plan.
____ 17. During morning report, the LPN/LVN is assigned a group of patients. Which patient should
the LPN/LVN see first?
a. A patient scheduled for magnetic resonance imaging (MRI) due to back pain
b. A patient reporting constipation and stomach cramps
c. A 2-day postsurgical patient reporting pain at a level of 6
d. A patient with pneumonia who is short of breath and anxious
____ 18. The LPN/LVN is reviewing a patient’s list of nursing diagnoses. Which diagnoses should
the LPN/LVN identify as a priority for this patient?
a. Anxiety
b. Constipation
c. Deficient fluid volume
d. Ineffective airway clearance
____ 19. The nurse is using the nursing process when caring for a patient. In which order should the
nurse implement this process?
a. Nursing diagnosis, intervention, rationale, evaluation, planning
b. Data collection, intervention, nursing diagnosis, rationale, evaluation
c. Assessment, nursing diagnosis, planning, implementation, evaluation
d. Data collection, evaluation, nursing diagnosis, implementation, rationale
____ 20. The nurse is determining a patient’s problems. What step of the nursing process is the nurse
performing?
a. Assessment
b. Outcome planning
c. Nursing diagnosis
d. Acute pain related to patient pain rating of 6 as evidenced by muscle spasms and nerve
compression
____ 16. The RN implements an intervention to improve a patient’s appetite. After implementing the
intervention for two meals, the LPN/LVN notes no improvement in the patient’s eating. What action
should the LPN/LVN take?
a. Develop a new plan of care.
b. Revise the patient outcome to one that is achievable.
c. Collaborate on a new nursing diagnosis with the RN.
d. Provide data to the RN to assist in evaluation of the plan.
____ 17. During morning report, the LPN/LVN is assigned a group of patients. Which patient should
the LPN/LVN see first?
a. A patient scheduled for magnetic resonance imaging (MRI) due to back pain
b. A patient reporting constipation and stomach cramps
c. A 2-day postsurgical patient reporting pain at a level of 6
d. A patient with pneumonia who is short of breath and anxious
____ 18. The LPN/LVN is reviewing a patient’s list of nursing diagnoses. Which diagnoses should
the LPN/LVN identify as a priority for this patient?
a. Anxiety
b. Constipation
c. Deficient fluid volume
d. Ineffective airway clearance
____ 19. The nurse is using the nursing process when caring for a patient. In which order should the
nurse implement this process?
a. Nursing diagnosis, intervention, rationale, evaluation, planning
b. Data collection, intervention, nursing diagnosis, rationale, evaluation
c. Assessment, nursing diagnosis, planning, implementation, evaluation
d. Data collection, evaluation, nursing diagnosis, implementation, rationale
____ 20. The nurse is determining a patient’s problems. What step of the nursing process is the nurse
performing?
a. Assessment
b. Outcome planning
c. Nursing diagnosis
d. Nursing intervention
____ 21. The nurse is preparing to determine if a patient is meeting planned outcomes. What
measurable information should the nurse use to make this determination?
a. P-E-S format
b. Objective observations
c. Subjective terminology
d. Open-ended time frames
____ 22. The nurse is planning a patient’s care based on Maslow’s hierarchy of needs. Which human
need should the nurse identify as requiring his or her immediate attention?
a. Heart rate 38 and irregular
b. Plans to return to college in a year
c. Needs walker adjusted to safely ambulate
d. Desire to learn how to self-inject medication
____ 23. While being taught to apply a topical medication, the patient begins to vomit. Which action
should the nurse take to meet the patient’s human needs?
a. Provide a clean gown before resuming the teaching.
b. Position an emesis basin for patient use while teaching.
c. Provide medication prescribed for nausea and vomiting.
d. Wait for the vomiting to stop and begin the teaching session again.
____ 24. The nurse approaches a person in a restaurant who appears to be experiencing respiratory
distress. Which action should the nurse perform first?
a. Diagnose the problem.
b. Help the person lie down.
c. Gather data from other people.
d. Collect data about the person’s condition.
____ 25. The nurse identifies the diagnosis Fluid Volume Overload as appropriate for a patient with
heart failure. Which collected data should the nurse use to provide evidence for this diagnosis?
a. Skin warm to the touch
b. Oriented to person only
c. Respiratory rate 20 and shallow
d. +3 pitting edema of both feet and ankles
____ 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?
____ 21. The nurse is preparing to determine if a patient is meeting planned outcomes. What
measurable information should the nurse use to make this determination?
a. P-E-S format
b. Objective observations
c. Subjective terminology
d. Open-ended time frames
____ 22. The nurse is planning a patient’s care based on Maslow’s hierarchy of needs. Which human
need should the nurse identify as requiring his or her immediate attention?
a. Heart rate 38 and irregular
b. Plans to return to college in a year
c. Needs walker adjusted to safely ambulate
d. Desire to learn how to self-inject medication
____ 23. While being taught to apply a topical medication, the patient begins to vomit. Which action
should the nurse take to meet the patient’s human needs?
a. Provide a clean gown before resuming the teaching.
b. Position an emesis basin for patient use while teaching.
c. Provide medication prescribed for nausea and vomiting.
d. Wait for the vomiting to stop and begin the teaching session again.
____ 24. The nurse approaches a person in a restaurant who appears to be experiencing respiratory
distress. Which action should the nurse perform first?
a. Diagnose the problem.
b. Help the person lie down.
c. Gather data from other people.
d. Collect data about the person’s condition.
____ 25. The nurse identifies the diagnosis Fluid Volume Overload as appropriate for a patient with
heart failure. Which collected data should the nurse use to provide evidence for this diagnosis?
a. Skin warm to the touch
b. Oriented to person only
c. Respiratory rate 20 and shallow
d. +3 pitting edema of both feet and ankles
____ 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?
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a. The patient will have less heartburn.
b. The patient will sleep through the night.
c. The patient’s esophageal burning will resolve 30 minutes after taking oral antacids.
d. The patient will state that burning only occurs when eating foods high in acid content.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 27. After collecting data the nurse identifies diagnoses to guide the patient’s care. Which
diagnoses did the nurse document correctly? (Select all that apply.)
a. Diabetes
b. Acute pain
c. Pancreatitis
d. Activity intolerance
e. Impaired physical mobility
____ 28. A patient with a family history of diabetes is experiencing high blood glucose levels,
confusion, an unsteady gait, and dehydration. Which nursing diagnoses should the nurse identify as
appropriate for this patient’s care? (Select all that apply.)
a. Diabetes
b. Dehydration
c. Risk for falls
d. Hyperglycemia
e. Deficient fluid volume
____ 29. The nurse identifies the diagnosis Potential for Ineffective Gas Exchange as appropriate for
a patient with pneumonia. Which independent nursing actions should the nurse plan for this problem?
(Select all that apply.)
a. Apply oxygen, 2 liters, per nasal cannula.
b. Turn and reposition in bed every 2 hours.
c. Coach to deep breathe and cough every hour.
d. Administer intramuscular antibiotic medication.
e. Encourage to drink 240 mL of fluid every 2 hours.
____ 30. The nurse finishes collecting data on a patient with injuries from a motor vehicle crash.
Which data should the nurse document as objective? (Select all that apply.)
a. Patient in no acute distress
b. “I can’t believe I wrecked my car.”
b. The patient will sleep through the night.
c. The patient’s esophageal burning will resolve 30 minutes after taking oral antacids.
d. The patient will state that burning only occurs when eating foods high in acid content.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 27. After collecting data the nurse identifies diagnoses to guide the patient’s care. Which
diagnoses did the nurse document correctly? (Select all that apply.)
a. Diabetes
b. Acute pain
c. Pancreatitis
d. Activity intolerance
e. Impaired physical mobility
____ 28. A patient with a family history of diabetes is experiencing high blood glucose levels,
confusion, an unsteady gait, and dehydration. Which nursing diagnoses should the nurse identify as
appropriate for this patient’s care? (Select all that apply.)
a. Diabetes
b. Dehydration
c. Risk for falls
d. Hyperglycemia
e. Deficient fluid volume
____ 29. The nurse identifies the diagnosis Potential for Ineffective Gas Exchange as appropriate for
a patient with pneumonia. Which independent nursing actions should the nurse plan for this problem?
(Select all that apply.)
a. Apply oxygen, 2 liters, per nasal cannula.
b. Turn and reposition in bed every 2 hours.
c. Coach to deep breathe and cough every hour.
d. Administer intramuscular antibiotic medication.
e. Encourage to drink 240 mL of fluid every 2 hours.
____ 30. The nurse finishes collecting data on a patient with injuries from a motor vehicle crash.
Which data should the nurse document as objective? (Select all that apply.)
a. Patient in no acute distress
b. “I can’t believe I wrecked my car.”
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c. Complains of pain when moving arms
d. Oxygen saturation level 92% on room air
e. Mid-forehead wound 3 cm long, oozing blood
Other
31. A patient with a history of respiratory disease is recovering from total hip replacement surgery. In
which order should the nurse address the patient’s diagnoses? (Place in order from 1 to 4.)
A. _____ Acute pain related to surgery
B. _____ Risk for injury related to unsteady gait
C. _____ Deficient knowledge related to use of a walker
D. _____ Impaired gas exchange related to compromised respiratory system
32. The nurse is caring for a patient recovering from a stroke. Use the nursing process to order the
observations made or actions performed while caring for this patient (A–E).
A. Hand grasp absent left hand
B. Alteration in Cerebral Perfusion
C. The patient flexed left thumb and index finger.
D. Coached to squeeze rubber ball placed in left hand.
E. The patient will be able to self-feed using left hand.
Chapter 1. Critical Thinking and the Nursing Process
Answer Section
MULTIPLE CHOICE
1. ANS: D
D. According to Maslow, humans’ basic physiological needs have the highest priority, and these
patients’ health problems should be addressed first. Life-threatening needs are ranked first; health-
threatening needs are second; and health-promoting needs are last. The elevated temperature has the
greatest urgency. A, B, and C are not as high priority.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
2. ANS: D
D. Intellectual courage is looking at other points of view. A. Intellectual empathy allows a person to
d. Oxygen saturation level 92% on room air
e. Mid-forehead wound 3 cm long, oozing blood
Other
31. A patient with a history of respiratory disease is recovering from total hip replacement surgery. In
which order should the nurse address the patient’s diagnoses? (Place in order from 1 to 4.)
A. _____ Acute pain related to surgery
B. _____ Risk for injury related to unsteady gait
C. _____ Deficient knowledge related to use of a walker
D. _____ Impaired gas exchange related to compromised respiratory system
32. The nurse is caring for a patient recovering from a stroke. Use the nursing process to order the
observations made or actions performed while caring for this patient (A–E).
A. Hand grasp absent left hand
B. Alteration in Cerebral Perfusion
C. The patient flexed left thumb and index finger.
D. Coached to squeeze rubber ball placed in left hand.
E. The patient will be able to self-feed using left hand.
Chapter 1. Critical Thinking and the Nursing Process
Answer Section
MULTIPLE CHOICE
1. ANS: D
D. According to Maslow, humans’ basic physiological needs have the highest priority, and these
patients’ health problems should be addressed first. Life-threatening needs are ranked first; health-
threatening needs are second; and health-promoting needs are last. The elevated temperature has the
greatest urgency. A, B, and C are not as high priority.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
2. ANS: D
D. Intellectual courage is looking at other points of view. A. Intellectual empathy allows a person to
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consider another’s situation. B. Intellectual integrity is seeking the same level of proof for
comparable items. C. Intellectual perseverance is continuing to search for evidence about a concern.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care| Cognitive Level:
Application
3. ANS: A
A. Recognizing a person’s accomplishments enhances self-esteem. B. C. D. The staff’s actions are
not meeting physiological, self-actualization, or safety and security needs of the new nurse.
PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity
4. ANS: C
C. The patient should not have to wait for pain relief. The LPN should inform the RN or physician,
so new pain relief orders can be obtained. A. The patient who has a fractured femur is experiencing
acute pain. Repositioning a patient with a new fracture is not likely to relieve pain. B. Giving the
medication before the prescribed time is beyond the nurse’s scope of practice. D. The nurse needs to
do more than expect the patient to wait for pain relief.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
5. ANS: D
D. Critical thinking is using knowledge and skills to make the best decisions possible in patient care
situations. A. Collecting data describes assessment. B. Thinking of different ways to help a patient
with a problem is planning. C. Determining if an action worked to eliminate a patient problem is
evaluation.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
6. ANS: A
A. Planning care and setting goals are actions performed with the patient. The patient must be in
agreement with the plan for it to be successful in meeting the desired outcomes. B. The nurse
manager may or may not be aware of the patient’s care needs. C. The patient’s family may or may
comparable items. C. Intellectual perseverance is continuing to search for evidence about a concern.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care| Cognitive Level:
Application
3. ANS: A
A. Recognizing a person’s accomplishments enhances self-esteem. B. C. D. The staff’s actions are
not meeting physiological, self-actualization, or safety and security needs of the new nurse.
PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity
4. ANS: C
C. The patient should not have to wait for pain relief. The LPN should inform the RN or physician,
so new pain relief orders can be obtained. A. The patient who has a fractured femur is experiencing
acute pain. Repositioning a patient with a new fracture is not likely to relieve pain. B. Giving the
medication before the prescribed time is beyond the nurse’s scope of practice. D. The nurse needs to
do more than expect the patient to wait for pain relief.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
5. ANS: D
D. Critical thinking is using knowledge and skills to make the best decisions possible in patient care
situations. A. Collecting data describes assessment. B. Thinking of different ways to help a patient
with a problem is planning. C. Determining if an action worked to eliminate a patient problem is
evaluation.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
6. ANS: A
A. Planning care and setting goals are actions performed with the patient. The patient must be in
agreement with the plan for it to be successful in meeting the desired outcomes. B. The nurse
manager may or may not be aware of the patient’s care needs. C. The patient’s family may or may
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not be aware of the patient’s care needs. D. The focus of nursing care is different from that of the
HCP.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
7. ANS: D
D. Objective data are pieces of factual information obtained through physical assessment and
diagnostic tests observable or knowable through the five senses. The nurse should document exactly
what is seen. A. B. C. These statements are interpretations of the data and use words that have vague
meanings, which should be avoided when documenting.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
8. ANS: C
C. A threat to a person’s safety and security, such as surgery, creates anxiety. The patient’s anxiety
level will help the nurse plan care to meet safety and security needs. A, B, and D describe data used
to support the patient’s physiological needs.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
9. ANS: B
B. Objective data are factual information such as the volume of urine output. A. This is an opinion
that the nurse has about the patient’s behavior and is too vague to document as objective data. C.
This statement is in quotations, so it is something that the patient subjectively stated. D. This is an
opinion the nurse has about the patient’s appetite and is too vague to document as objective data.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
10. ANS: A
A. Using Maslow’s hierarchy, pain is the highest priority nursing diagnosis for a postoperative
patient. B. D. These diagnoses would be equally important after the patient’s pain is addressed,
HCP.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
7. ANS: D
D. Objective data are pieces of factual information obtained through physical assessment and
diagnostic tests observable or knowable through the five senses. The nurse should document exactly
what is seen. A. B. C. These statements are interpretations of the data and use words that have vague
meanings, which should be avoided when documenting.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
8. ANS: C
C. A threat to a person’s safety and security, such as surgery, creates anxiety. The patient’s anxiety
level will help the nurse plan care to meet safety and security needs. A, B, and D describe data used
to support the patient’s physiological needs.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
9. ANS: B
B. Objective data are factual information such as the volume of urine output. A. This is an opinion
that the nurse has about the patient’s behavior and is too vague to document as objective data. C.
This statement is in quotations, so it is something that the patient subjectively stated. D. This is an
opinion the nurse has about the patient’s appetite and is too vague to document as objective data.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
10. ANS: A
A. Using Maslow’s hierarchy, pain is the highest priority nursing diagnosis for a postoperative
patient. B. D. These diagnoses would be equally important after the patient’s pain is addressed,
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because they focus on physiological needs. C. This diagnosis can be addressed at a later time once
physiological needs have been met.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
11. ANS: D
D. Intellectual perseverance is not giving up. A. A sense of justice examines motives when making
decisions. B. Intellectual courage looks at other points of view, even when the nurse does not agree
with them. C. Intellectual empathy understands how another person feels when making decisions.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
12. ANS: B
B. This outcome provides objective measurable data. A. C. D. These statements are nursing actions.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
13. ANS: B
B. To evaluate the effectiveness of the plan of care and the actions implemented, the nurse must
assess the outcome for the patient’s nursing diagnosis and determine if the outcome has been
achieved or if revisions are needed. For this patient, a change in weight is an objective measurement
for determining if interventions to address Fluid Volume Excess have been effective. A. Restricting
fluid intake is an action. Evaluation is required to determine patient outcome and effective care. C.
Teaching the patient to monitor fluid balance is an intervention and will not help determine the
effectiveness of care. D. Although discussing the plan of care with the RN is relevant to the patient’s
care, it will not help determine effectiveness of care provided.
PTS: 1 DIF: Difficult
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
14. ANS: C
C. The LPN/LVN independently provides direct patient care. A. B. D. The LPN/LVN assists the RN
physiological needs have been met.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
11. ANS: D
D. Intellectual perseverance is not giving up. A. A sense of justice examines motives when making
decisions. B. Intellectual courage looks at other points of view, even when the nurse does not agree
with them. C. Intellectual empathy understands how another person feels when making decisions.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
12. ANS: B
B. This outcome provides objective measurable data. A. C. D. These statements are nursing actions.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
13. ANS: B
B. To evaluate the effectiveness of the plan of care and the actions implemented, the nurse must
assess the outcome for the patient’s nursing diagnosis and determine if the outcome has been
achieved or if revisions are needed. For this patient, a change in weight is an objective measurement
for determining if interventions to address Fluid Volume Excess have been effective. A. Restricting
fluid intake is an action. Evaluation is required to determine patient outcome and effective care. C.
Teaching the patient to monitor fluid balance is an intervention and will not help determine the
effectiveness of care. D. Although discussing the plan of care with the RN is relevant to the patient’s
care, it will not help determine effectiveness of care provided.
PTS: 1 DIF: Difficult
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
14. ANS: C
C. The LPN/LVN independently provides direct patient care. A. B. D. The LPN/LVN assists the RN
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with collecting data, formulating nursing diagnoses, determining outcomes, and planning care to
meet patient needs.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
15. ANS: C
C. “Chronic pain related to muscle spasms as evidenced by patient pain rating of 8 and difficulty
walking” uses the three-part, or Problem, Etiology, and Signs/Symptoms, system with measurable
data as evidence. This best guides the nurse’s care and evaluation of the outcome. A. This statement
includes a medical diagnosis. B. D. There is not enough measurable evidence for these nursing
diagnosis statements.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Basic Care and Comfort | Cognitive Level: Application
16. ANS: D
D. The role of the LPN/LVN includes data collection and assisting in evaluating outcomes. The
LPN/LVN should provide new data to the RN, so they can revise the plan of care together. A. B. This
is not done independently. C. A new diagnosis may be appropriate, but is not carried out
independently of the RN.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
17. ANS: D
D. Using Maslow’s hierarchy of needs and considering which patient problems are life-threatening,
shortness of breath is most important. A. B. C. Problems of pain, constipation, and scheduled tests
are all important, but not immediately life-threatening.
PTS: 1 DIF: Difficult
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
18. ANS: D
D. Ineffective airway clearance is the highest priority, because it can be life-threatening. B. C. These
meet patient needs.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
15. ANS: C
C. “Chronic pain related to muscle spasms as evidenced by patient pain rating of 8 and difficulty
walking” uses the three-part, or Problem, Etiology, and Signs/Symptoms, system with measurable
data as evidence. This best guides the nurse’s care and evaluation of the outcome. A. This statement
includes a medical diagnosis. B. D. There is not enough measurable evidence for these nursing
diagnosis statements.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Basic Care and Comfort | Cognitive Level: Application
16. ANS: D
D. The role of the LPN/LVN includes data collection and assisting in evaluating outcomes. The
LPN/LVN should provide new data to the RN, so they can revise the plan of care together. A. B. This
is not done independently. C. A new diagnosis may be appropriate, but is not carried out
independently of the RN.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
17. ANS: D
D. Using Maslow’s hierarchy of needs and considering which patient problems are life-threatening,
shortness of breath is most important. A. B. C. Problems of pain, constipation, and scheduled tests
are all important, but not immediately life-threatening.
PTS: 1 DIF: Difficult
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
18. ANS: D
D. Ineffective airway clearance is the highest priority, because it can be life-threatening. B. C. These
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diagnoses are important; however they are not immediately life-threatening. A. Anxiety is the lowest
priority, because physiological needs must be addressed first.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
19. ANS: C
C. The nurse should implement the steps of the nursing process by beginning with assessment,
formulating nursing diagnoses, planning care, implementing care, and then evaluating care. A. B. D.
These lists do not implement the steps of the nursing process in appropriate order. Rationale is not a
step in the nursing process.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
20. ANS: C
C. A nursing diagnosis is a clinical judgment about individual, family, or community response to
actual or potential health problems or life processes. Nursing diagnoses are standardized labels that
make an identified problem understandable to all nurses. A. Assessment is the collection of data used
to identify patient problems. B. Outcome planning occurs after a patient’s problems have been
identified. D. Interventions are provided after the problems, plan, and outcome have been identified.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
21. ANS: B
B. Measurable means that an outcome can be observed or is objective. It should not be vague or open
to interpretation. A. Problem-Etiology-Symptoms (PES) format refers to nursing diagnoses, not
outcomes measurement. C. Subjective terminology is the use of patient statements to support
objective data. D. Open-ended time frames do not help with measurement.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
priority, because physiological needs must be addressed first.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
19. ANS: C
C. The nurse should implement the steps of the nursing process by beginning with assessment,
formulating nursing diagnoses, planning care, implementing care, and then evaluating care. A. B. D.
These lists do not implement the steps of the nursing process in appropriate order. Rationale is not a
step in the nursing process.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
20. ANS: C
C. A nursing diagnosis is a clinical judgment about individual, family, or community response to
actual or potential health problems or life processes. Nursing diagnoses are standardized labels that
make an identified problem understandable to all nurses. A. Assessment is the collection of data used
to identify patient problems. B. Outcome planning occurs after a patient’s problems have been
identified. D. Interventions are provided after the problems, plan, and outcome have been identified.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
21. ANS: B
B. Measurable means that an outcome can be observed or is objective. It should not be vague or open
to interpretation. A. Problem-Etiology-Symptoms (PES) format refers to nursing diagnoses, not
outcomes measurement. C. Subjective terminology is the use of patient statements to support
objective data. D. Open-ended time frames do not help with measurement.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
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22. ANS: A
A. According to Maslow, basic needs or physiological needs must be met first. A heart rate of 38 and
irregular is a physiological need. C. Safety and security needs are met after physiological needs have
been satisfied. Safe ambulation would be addressed next. D. Self-esteem needs are met after safety
and security needs have been addressed. The desire to be independent with medication injections can
be addressed after safety and security needs. B. Planning to return to college is an example of self-
actualization, which is a need that can be addressed last.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
23. ANS: C
C. Basic physiological needs must be met first. Since the patient is vomiting, the nurse should
provide the medication prescribed for nausea and vomiting. A. B. D. 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 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
24. ANS: D
D. The first step in the nursing process is to collect data, and the patient should come first. C. The
nurse can collect data from other people if necessary. A. Diagnosing the problem would occur after
collecting data. B. Helping the person lie down is implementing an action to address the problem.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
25. ANS: D
D. Collected data that the nurse should use as evidence for the diagnosis are signs and symptoms
related to the diagnosis. For Fluid Volume Overload, edema would be used as evidence that the
patient’s tissue is accumulating extra fluid. A. Skin warm to the touch is an opinion. B. Oriented to
person only is objective data; however, it does not apply to the nursing diagnosis. C. Respiratory rate
20 and shallow is objective data; however, it does not apply to the nursing diagnosis.
A. According to Maslow, basic needs or physiological needs must be met first. A heart rate of 38 and
irregular is a physiological need. C. Safety and security needs are met after physiological needs have
been satisfied. Safe ambulation would be addressed next. D. Self-esteem needs are met after safety
and security needs have been addressed. The desire to be independent with medication injections can
be addressed after safety and security needs. B. Planning to return to college is an example of self-
actualization, which is a need that can be addressed last.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
23. ANS: C
C. Basic physiological needs must be met first. Since the patient is vomiting, the nurse should
provide the medication prescribed for nausea and vomiting. A. B. D. 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 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
24. ANS: D
D. The first step in the nursing process is to collect data, and the patient should come first. C. The
nurse can collect data from other people if necessary. A. Diagnosing the problem would occur after
collecting data. B. Helping the person lie down is implementing an action to address the problem.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
25. ANS: D
D. Collected data that the nurse should use as evidence for the diagnosis are signs and symptoms
related to the diagnosis. For Fluid Volume Overload, edema would be used as evidence that the
patient’s tissue is accumulating extra fluid. A. Skin warm to the touch is an opinion. B. Oriented to
person only is objective data; however, it does not apply to the nursing diagnosis. C. Respiratory rate
20 and shallow is objective data; however, it does not apply to the nursing diagnosis.
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PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
26. ANS: C
C. Outcomes should be measurable and realistic for the patient; they should include an appropriate
time frame for achievement. A. Outcomes should not be vague or open to interpretation, with the use
of subjective words such as “normal,” “large,” “small,” or “moderate.” B. Sleeping through the night
may or may not be associated with the patient’s problem. D. Stating that the burning only occurs
when eating foods high in acid content is a patient observation that could be used for subjective data
collection.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
MULTIPLE RESPONSE
27. ANS: B, D, E
B. D. E. Acute Pain, Activity Intolerance, and Impaired Physical Mobility are nursing diagnoses. A.
C. Diabetes and Pancreatitis are medical diagnoses.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
28. ANS: C, E
C. E. Deficient fluid volume and Risk for falls are nursing diagnoses related to the patient’s
symptoms and condition. A. B. D. Diabetes, Dehydration, and Hyperglycemia are medical problems.
The nurse assists with medical diagnoses; however, the nurse does not diagnose and treat medical
problems.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
29. ANS: B, C, E
B. C. E. Independent nursing actions are those that can be implemented without an HCP’s order. A.
D. Interventions that need an HCP’s order include administering oxygen and medication. These are
collaborative interventions.
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
26. ANS: C
C. Outcomes should be measurable and realistic for the patient; they should include an appropriate
time frame for achievement. A. Outcomes should not be vague or open to interpretation, with the use
of subjective words such as “normal,” “large,” “small,” or “moderate.” B. Sleeping through the night
may or may not be associated with the patient’s problem. D. Stating that the burning only occurs
when eating foods high in acid content is a patient observation that could be used for subjective data
collection.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
MULTIPLE RESPONSE
27. ANS: B, D, E
B. D. E. Acute Pain, Activity Intolerance, and Impaired Physical Mobility are nursing diagnoses. A.
C. Diabetes and Pancreatitis are medical diagnoses.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
28. ANS: C, E
C. E. Deficient fluid volume and Risk for falls are nursing diagnoses related to the patient’s
symptoms and condition. A. B. D. Diabetes, Dehydration, and Hyperglycemia are medical problems.
The nurse assists with medical diagnoses; however, the nurse does not diagnose and treat medical
problems.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
29. ANS: B, C, E
B. C. E. Independent nursing actions are those that can be implemented without an HCP’s order. A.
D. Interventions that need an HCP’s order include administering oxygen and medication. These are
collaborative interventions.
Loading page 15...
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
30. ANS: D, E
D. E. Data that can be observed are objective. Objective data would include an oxygen saturation
level of 92% on room air and a wound on the forehead, 3 cm in length and oozing blood. A. The
“patient in no acute distress” is an opinion about the patient’s status. B. A direct patient quote is
subjective data. C. Complaining of pain when moving arms needs additional information to be
objective such as the patient’s pain rating on a scale of 1 to 10 and the exact location of the arm pain.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
OTHER
31. ANS:
D, A, B, C
D. In a nursing plan of care, the patient’s most urgent problem is listed first. According to Maslow’s
hierarchy of human needs, this usually involves a physiological need, such as oxygen or water,
because these are life-sustaining needs. If several physiological needs are present, life-threatening
needs are ranked first; health-threatening needs are second; and health-promoting needs, although
important, are last. In this case, Ineffective Gas Exchange is potentially life-threatening and would be
first. A. Acute Pain is the next most urgent need. B. Risk for Injury is less critical than pain, because
it is a potential problem rather than an actual problem. C. Deficient Knowledge comes last, because it
is health- promoting and is considered psychosocial rather than physical/physiological.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
32. ANS:
A, B, E, D, C
A. Assessed data is the absence of a left hand grasp. B. The nursing diagnosis that would be
associated with the absence of a hand grasp would be Alteration in Cerebral Perfusion. E. The goal of
nursing care would be for the patient to self-feed using the left hand. D. Coaching to squeeze a
rubber ball in the left hand is an intervention to improve left hand function. C. The patient flexing the
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
30. ANS: D, E
D. E. Data that can be observed are objective. Objective data would include an oxygen saturation
level of 92% on room air and a wound on the forehead, 3 cm in length and oozing blood. A. The
“patient in no acute distress” is an opinion about the patient’s status. B. A direct patient quote is
subjective data. C. Complaining of pain when moving arms needs additional information to be
objective such as the patient’s pain rating on a scale of 1 to 10 and the exact location of the arm pain.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
OTHER
31. ANS:
D, A, B, C
D. In a nursing plan of care, the patient’s most urgent problem is listed first. According to Maslow’s
hierarchy of human needs, this usually involves a physiological need, such as oxygen or water,
because these are life-sustaining needs. If several physiological needs are present, life-threatening
needs are ranked first; health-threatening needs are second; and health-promoting needs, although
important, are last. In this case, Ineffective Gas Exchange is potentially life-threatening and would be
first. A. Acute Pain is the next most urgent need. B. Risk for Injury is less critical than pain, because
it is a potential problem rather than an actual problem. C. Deficient Knowledge comes last, because it
is health- promoting and is considered psychosocial rather than physical/physiological.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application
32. ANS:
A, B, E, D, C
A. Assessed data is the absence of a left hand grasp. B. The nursing diagnosis that would be
associated with the absence of a hand grasp would be Alteration in Cerebral Perfusion. E. The goal of
nursing care would be for the patient to self-feed using the left hand. D. Coaching to squeeze a
rubber ball in the left hand is an intervention to improve left hand function. C. The patient flexing the
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left thumb and index finger evaluates the success of the intervention of squeezing a rubber ball in the
left hand.
PTS: 1 DIF: Difficult
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
Chapter 2. Evidence-Based Practice
Chapter 2. Evidence-Based Practice
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse working in a radiation oncology department wants to reduce the incidence of skin
breakdown in patients who receive beam radiation. Which question should the nurse use to guide a
literature search about this topic?
a. How often do patients with beam radiation experience skin breakdown?
b. Why do patients who get radiation beam therapy have skin breakdown?
c. What nursing interventions minimize the occurrence of skin breakdown in patients receiving beam
radiation?
d. How does our rate of skin breakdown in patients receiving beam radiation compare to other
institutions in the city?
____ 2. The nurse who works on a medical-surgical unit reads an article about a research study
regarding nursing care in the intensive care unit (ICU) and decreased nosocomial infections. Which
action should the nurse take in exploring this research topic?’
a. Institute a pilot study utilizing the outlined nursing care.
b. Discuss the research with the chief of nursing at the institution.
c. Do a journal search and look for similar studies related to non-ICU patients.
d. Take the article to the nurse manger in the ICU and suggest a new policy be developed.
____ 3. A licensed practical nurse (LPN) working on the pediatric floor is interested in improving
patient outcomes for children with asthma. Which clinical question would best guide the nurse’s next
steps?
a. How many patients with asthma have a pet dog or cat?
b. What is the monthly admission rate of patients with asthma to the unit?
c. What patient education materials are available to address effective management of asthma in
pediatric patients?
left hand.
PTS: 1 DIF: Difficult
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis
Chapter 2. Evidence-Based Practice
Chapter 2. Evidence-Based Practice
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse working in a radiation oncology department wants to reduce the incidence of skin
breakdown in patients who receive beam radiation. Which question should the nurse use to guide a
literature search about this topic?
a. How often do patients with beam radiation experience skin breakdown?
b. Why do patients who get radiation beam therapy have skin breakdown?
c. What nursing interventions minimize the occurrence of skin breakdown in patients receiving beam
radiation?
d. How does our rate of skin breakdown in patients receiving beam radiation compare to other
institutions in the city?
____ 2. The nurse who works on a medical-surgical unit reads an article about a research study
regarding nursing care in the intensive care unit (ICU) and decreased nosocomial infections. Which
action should the nurse take in exploring this research topic?’
a. Institute a pilot study utilizing the outlined nursing care.
b. Discuss the research with the chief of nursing at the institution.
c. Do a journal search and look for similar studies related to non-ICU patients.
d. Take the article to the nurse manger in the ICU and suggest a new policy be developed.
____ 3. A licensed practical nurse (LPN) working on the pediatric floor is interested in improving
patient outcomes for children with asthma. Which clinical question would best guide the nurse’s next
steps?
a. How many patients with asthma have a pet dog or cat?
b. What is the monthly admission rate of patients with asthma to the unit?
c. What patient education materials are available to address effective management of asthma in
pediatric patients?
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d. How has the occurrence rate of asthma in children under the age of 5 changed since the hospital
instituted a no smoking policy for the hospital grounds?
____ 4. The nurse is preparing to give oral care to a patient receiving tube feedings. Which approach
should the nurse use to provide care that is based on EBP?
a. Use a soft toothbrush and toothpaste to brush the teeth.
b. Have the patient use swish-and-swallow Nystatin twice a day.
c. Increase oral suctioning to every 2 hours using toothette suction devices.
d. Use mouthwash and toothettes to swab the teeth and mouth three times a day.
____ 5. The nurse is planning to review a research article for applicability to EBP. Which acronym
should the nurse use to guide this review?
a. RIGHT
b. MYWAY
c. ASKMME
d. ASKWHY
____ 6. The nurse working on the burn unit is interested in understanding the rate of renal
compromise with a burn. Which step should the nurse take first?
a. Complete a literature review.
b. Work with a medical librarian to identify key words.
c. Develop a clinical question that can guide further research.
d. Join the policy and procedure committee to evaluate care in the hospital.
____ 7. A nursing committee developed an evidence-based intervention that it would like to initiate
institute-wide. Which step should the committee take to implement the intervention?
a. Conduct a small pilot study involving the proposed change.
b. Ask the charge nurse to propose the change to administration.
c. Poll the nursing staff to determine its attitude toward change.
d. Invite nursing experts in the city to review the proposed change.
____ 8. The nurse is researching evidence to address a clinical problem. Which evidence should the
nurse focus as being the highest level supporting practice?
a. Evidence obtained from quasi-experimental research studies
b. Evidence from a systematic review of all relevant randomized clinical trials
c. Evidence from the opinion of authorities and/or reports of expert committees
d. Evidence obtained from at least one well-designed randomized controlled trial
____ 9. A nursing student asks the registered nurse (RN) preceptor why EBP is important. How
instituted a no smoking policy for the hospital grounds?
____ 4. The nurse is preparing to give oral care to a patient receiving tube feedings. Which approach
should the nurse use to provide care that is based on EBP?
a. Use a soft toothbrush and toothpaste to brush the teeth.
b. Have the patient use swish-and-swallow Nystatin twice a day.
c. Increase oral suctioning to every 2 hours using toothette suction devices.
d. Use mouthwash and toothettes to swab the teeth and mouth three times a day.
____ 5. The nurse is planning to review a research article for applicability to EBP. Which acronym
should the nurse use to guide this review?
a. RIGHT
b. MYWAY
c. ASKMME
d. ASKWHY
____ 6. The nurse working on the burn unit is interested in understanding the rate of renal
compromise with a burn. Which step should the nurse take first?
a. Complete a literature review.
b. Work with a medical librarian to identify key words.
c. Develop a clinical question that can guide further research.
d. Join the policy and procedure committee to evaluate care in the hospital.
____ 7. A nursing committee developed an evidence-based intervention that it would like to initiate
institute-wide. Which step should the committee take to implement the intervention?
a. Conduct a small pilot study involving the proposed change.
b. Ask the charge nurse to propose the change to administration.
c. Poll the nursing staff to determine its attitude toward change.
d. Invite nursing experts in the city to review the proposed change.
____ 8. The nurse is researching evidence to address a clinical problem. Which evidence should the
nurse focus as being the highest level supporting practice?
a. Evidence obtained from quasi-experimental research studies
b. Evidence from a systematic review of all relevant randomized clinical trials
c. Evidence from the opinion of authorities and/or reports of expert committees
d. Evidence obtained from at least one well-designed randomized controlled trial
____ 9. A nursing student asks the registered nurse (RN) preceptor why EBP is important. How
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should the nurse respond to the student?
a. “EBP makes nursing more professional.”
b. “EBP helps ensure we can demand more pay.”
c. “EBP helps validate the difference nurses really make.”
d. “EBP guides nursing decisions to optimize effective care.”
____ 10. The nurse is reviewing a proposal for changing the type of needleless systems currently
used to administer intravenous (IV) medications in the hospital. Which part of the proposal most
effectively supports the proposed change?
a. A pilot study is planned.
b. Two cases of staff injury related to needle sticks have occurred in the past 3 years.
c. A single randomized clinical trial is cited as evidence to support the new policy.
d. The supporting evidence includes research conducted at an outpatient hematology center.
____ 11. The staff development instructor is preparing a presentation on EBP for the nursing staff.
Which should the instructor include as being the most important reason for using EBP?
a. Saves money
b. Optimizes care
c. Reduces staff error
d. Improves access to care
____ 12. The nurse is researching articles prior to determining the best practice for providing an
aspect of patient care. On what type of article should the nurse focus when researching best practice?
a. Expert opinion
b. Systematic review
c. Traditional practice
d. Quasi-experimental studies
____ 13. The nurse wants to find research studies on infection rates as they relate to specific hand
washing products. Where should the nurse search for these articles?
a. Medline
b. PubMed
c. CINAHL
d. Cochrane Reviews
____ 14. The nurse researcher is designing a study using the quasi-experimental approach. What type
of data will the nurse obtain from this study design?
a. Uncontrolled results
a. “EBP makes nursing more professional.”
b. “EBP helps ensure we can demand more pay.”
c. “EBP helps validate the difference nurses really make.”
d. “EBP guides nursing decisions to optimize effective care.”
____ 10. The nurse is reviewing a proposal for changing the type of needleless systems currently
used to administer intravenous (IV) medications in the hospital. Which part of the proposal most
effectively supports the proposed change?
a. A pilot study is planned.
b. Two cases of staff injury related to needle sticks have occurred in the past 3 years.
c. A single randomized clinical trial is cited as evidence to support the new policy.
d. The supporting evidence includes research conducted at an outpatient hematology center.
____ 11. The staff development instructor is preparing a presentation on EBP for the nursing staff.
Which should the instructor include as being the most important reason for using EBP?
a. Saves money
b. Optimizes care
c. Reduces staff error
d. Improves access to care
____ 12. The nurse is researching articles prior to determining the best practice for providing an
aspect of patient care. On what type of article should the nurse focus when researching best practice?
a. Expert opinion
b. Systematic review
c. Traditional practice
d. Quasi-experimental studies
____ 13. The nurse wants to find research studies on infection rates as they relate to specific hand
washing products. Where should the nurse search for these articles?
a. Medline
b. PubMed
c. CINAHL
d. Cochrane Reviews
____ 14. The nurse researcher is designing a study using the quasi-experimental approach. What type
of data will the nurse obtain from this study design?
a. Uncontrolled results
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b. Outcome tracking over 10 years
c. Controlled comorbid conditions
d. Modifiable and non-modifiable risk factors
____ 15. The nurse is planning to evaluate care provided to a patient. Which step should the nurse
take to learn if the best possible care is being provided?
a. Measure outcomes.
b. Review the literature.
c. Construct a burning clinical question.
d. Determine the validity of clinical research.
____ 16. After completing all of the steps in the research process, the nurse identifies a positive
response to a new intervention for foot ulcer care. Which step in EBP should the nurse perform now?
a. Publish and share the results of the study.
b. Complete a cost-benefit analysis of the results.
c. Evaluate the validity of related research studies.
d. Conduct a pilot project using the proposed intervention.
____ 17. The nurse is using Level II research when planning best practices for skin care. Which type
of evidence is the nurse using?
a. Cochrane Review
b. A quasi-experimental study
c. Joanna Briggs Best Practice Review
d. A randomized controlled trial (RCT)
____ 18. While reviewing a patient care assignment with unlicensed assistive personnel (UAP), the
nurse explains the reason for turning and repositioning a patient every 2 hours. Why did the nursing
include this information?
a. Ensures that evidence-based care is provided
b. Guarantees that the patient will receive morning care
c. Helps UAP focus on the action being performed
d. Helps UAP with time management of tasks to complete
____ 19. Prior to administering a prescribed medication to a patient, the nurse talks with the health
care provider (HCP) regarding expected effects and then contacts the pharmacist to review the
guidelines for administration. Which Quality and Safety Education for Nurses (QSEN) focus is the
nurse demonstrating?
a. Informatics
c. Controlled comorbid conditions
d. Modifiable and non-modifiable risk factors
____ 15. The nurse is planning to evaluate care provided to a patient. Which step should the nurse
take to learn if the best possible care is being provided?
a. Measure outcomes.
b. Review the literature.
c. Construct a burning clinical question.
d. Determine the validity of clinical research.
____ 16. After completing all of the steps in the research process, the nurse identifies a positive
response to a new intervention for foot ulcer care. Which step in EBP should the nurse perform now?
a. Publish and share the results of the study.
b. Complete a cost-benefit analysis of the results.
c. Evaluate the validity of related research studies.
d. Conduct a pilot project using the proposed intervention.
____ 17. The nurse is using Level II research when planning best practices for skin care. Which type
of evidence is the nurse using?
a. Cochrane Review
b. A quasi-experimental study
c. Joanna Briggs Best Practice Review
d. A randomized controlled trial (RCT)
____ 18. While reviewing a patient care assignment with unlicensed assistive personnel (UAP), the
nurse explains the reason for turning and repositioning a patient every 2 hours. Why did the nursing
include this information?
a. Ensures that evidence-based care is provided
b. Guarantees that the patient will receive morning care
c. Helps UAP focus on the action being performed
d. Helps UAP with time management of tasks to complete
____ 19. Prior to administering a prescribed medication to a patient, the nurse talks with the health
care provider (HCP) regarding expected effects and then contacts the pharmacist to review the
guidelines for administration. Which Quality and Safety Education for Nurses (QSEN) focus is the
nurse demonstrating?
a. Informatics
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b. Patient-centered care
c. Quality improvement
d. Teamwork and collaboration
____ 20. The nurse identifies an intervention that has been proven to enhance patient safety. What
should the nurse do before implementing this intervention?
a. Analyze the intervention to determine if it is appropriate for the patient.
b. Ask the charge nurse if the intervention can be implemented.
c. Find out if the patient wants the intervention to be performed.
d. Conduct a pilot study to see if the intervention works on the care area.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. The nurse is implementing dependent interventions when providing patient care. Which
actions are dependent nursing interventions? (Select all that apply.)
a. Low sodium soft diet
b. Music therapy as desired
c. Bathroom privileges as tolerated
d. Give Tylenol 650 mg orally every 4 hours prn pain
e. Wet-to-moist dressing changes every 6 hours while awake
____ 22. The nurse is planning a quasi-experimental study. Which criteria support the nurse’s
approach? (Select all that apply.)
a. 28 volunteer patients who agree to try a new type of mouthwash
b. An experimental group and a control group each with 225 patients
c. 14 individuals on a medical unit who complete the same questionnaire
d. Tracking of pneumonia rates for all patients receiving artificial tube feedings
e. Identification of oral flora in nursing home patients who receive artificial feedings
____ 23. The nurse is working with a committee to determine EBP approaches for patient care.
Which steps will the committee members include when determining EBP? (Select all that apply.)
a. Evaluate the change.
b. Measure the outcome.
c. Ask the nursing experts.
d. Manipulate current practice.
e. Search for the best available evidence.
____ 24. The nurse is considering the importance of safety when providing patient care. At which
c. Quality improvement
d. Teamwork and collaboration
____ 20. The nurse identifies an intervention that has been proven to enhance patient safety. What
should the nurse do before implementing this intervention?
a. Analyze the intervention to determine if it is appropriate for the patient.
b. Ask the charge nurse if the intervention can be implemented.
c. Find out if the patient wants the intervention to be performed.
d. Conduct a pilot study to see if the intervention works on the care area.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. The nurse is implementing dependent interventions when providing patient care. Which
actions are dependent nursing interventions? (Select all that apply.)
a. Low sodium soft diet
b. Music therapy as desired
c. Bathroom privileges as tolerated
d. Give Tylenol 650 mg orally every 4 hours prn pain
e. Wet-to-moist dressing changes every 6 hours while awake
____ 22. The nurse is planning a quasi-experimental study. Which criteria support the nurse’s
approach? (Select all that apply.)
a. 28 volunteer patients who agree to try a new type of mouthwash
b. An experimental group and a control group each with 225 patients
c. 14 individuals on a medical unit who complete the same questionnaire
d. Tracking of pneumonia rates for all patients receiving artificial tube feedings
e. Identification of oral flora in nursing home patients who receive artificial feedings
____ 23. The nurse is working with a committee to determine EBP approaches for patient care.
Which steps will the committee members include when determining EBP? (Select all that apply.)
a. Evaluate the change.
b. Measure the outcome.
c. Ask the nursing experts.
d. Manipulate current practice.
e. Search for the best available evidence.
____ 24. The nurse is considering the importance of safety when providing patient care. At which
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times should the nurse be particularly alert for safety hazards? (Select all that apply.)
a. When providing patient medications
b. When identifying a patient for a treatment
c. When washing hands after providing care
d. When stocking the supply room with linens
e. When raising the side rails on a patient’s bed
____ 25. The nurse is implementing the QSEN focus of patient-centered care. Which nursing actions
support this focus? (Select all that apply.)
a. Individualize interventions.
b. Schedule interventions to meet the patient’s needs.
c. Evaluate interventions for applicability to the patient.
d. Scan prescribed medications using the bar-coding system.
e. Document responses to treatment in the electronic medical record.
Chapter 2. Evidence-Based Practice
Answer Section
MULTIPLE CHOICE
1. ANS: C
Asking a burning clinical question is the first step in the evidence-based practice (EBP) process. It is
important to include related factors in the question and to focus on nursing interventions and care. In
this situation, the nurse should focus on nursing care that may reduce the occurrence of skin
breakdown for the specific patient population of interest. A. B. The frequency of skin breakdown and
why patients develop skin breakdown does not help identify ways to prevent skin breakdown. D.
Information on statistics from other organizations will not help the nurse identify ways to prevent
skin breakdown.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
2. ANS: C
Clinical reality can be very different from research situations. It could be unsafe to apply research
findings in an environment that differs from the one in the study, so the next step would be to
identify current research related to the current population. A. A pilot study would be premature. B.
a. When providing patient medications
b. When identifying a patient for a treatment
c. When washing hands after providing care
d. When stocking the supply room with linens
e. When raising the side rails on a patient’s bed
____ 25. The nurse is implementing the QSEN focus of patient-centered care. Which nursing actions
support this focus? (Select all that apply.)
a. Individualize interventions.
b. Schedule interventions to meet the patient’s needs.
c. Evaluate interventions for applicability to the patient.
d. Scan prescribed medications using the bar-coding system.
e. Document responses to treatment in the electronic medical record.
Chapter 2. Evidence-Based Practice
Answer Section
MULTIPLE CHOICE
1. ANS: C
Asking a burning clinical question is the first step in the evidence-based practice (EBP) process. It is
important to include related factors in the question and to focus on nursing interventions and care. In
this situation, the nurse should focus on nursing care that may reduce the occurrence of skin
breakdown for the specific patient population of interest. A. B. The frequency of skin breakdown and
why patients develop skin breakdown does not help identify ways to prevent skin breakdown. D.
Information on statistics from other organizations will not help the nurse identify ways to prevent
skin breakdown.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
2. ANS: C
Clinical reality can be very different from research situations. It could be unsafe to apply research
findings in an environment that differs from the one in the study, so the next step would be to
identify current research related to the current population. A. A pilot study would be premature. B.
Loading page 22...
Discussing the research with the chief of nursing would not help explore the topic. D. Taking the
article to the head nurse in the ICU would not help with the issue of nosocomial infections on the
medical-surgical unit.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive
Level: Application
3. ANS: C
Asking a burning clinical question is the first step in the EBP process. It is important to include
related factors in the question and to focus on nursing interventions and care. For this scenario, the
nurse would focus on nursing care that affects patient outcomes for the specific patient population of
interest. Patient education is a critical component of nursing care. A. B. D. Information about pets,
admission rates of patients with asthma, and asthma occurrence since the implementation of a no
smoking policy will not help improve patient outcomes for children with asthma.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
4. ANS: D
Evidence-based information shows the use of toothbrushes for oral care is much more effective than
foam swabs in removing plaque from the teeth. B. Swish-and swallow Nystatin is a medication that
treats oral thrush and is not routinely used to provide oral care. C. Oral suctioning is not an approach
to provide oral care. D. Toothettes are not an effective mechanism for providing oral care.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Basic Care and Comfort | Cognitive Level: Application
5. ANS: C
An acronym that can be used to recall the steps of the evidence-based process is ASKMME: Ask,
Search, Think, Measure, Make It Happen, and Evaluate. A. B. D. RIGHT, MYWAY, and ASKWHY
are not acronyms used to recall the steps of the evidence-based process.
PTS: 1 DIF: Easy
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
article to the head nurse in the ICU would not help with the issue of nosocomial infections on the
medical-surgical unit.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive
Level: Application
3. ANS: C
Asking a burning clinical question is the first step in the EBP process. It is important to include
related factors in the question and to focus on nursing interventions and care. For this scenario, the
nurse would focus on nursing care that affects patient outcomes for the specific patient population of
interest. Patient education is a critical component of nursing care. A. B. D. Information about pets,
admission rates of patients with asthma, and asthma occurrence since the implementation of a no
smoking policy will not help improve patient outcomes for children with asthma.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
4. ANS: D
Evidence-based information shows the use of toothbrushes for oral care is much more effective than
foam swabs in removing plaque from the teeth. B. Swish-and swallow Nystatin is a medication that
treats oral thrush and is not routinely used to provide oral care. C. Oral suctioning is not an approach
to provide oral care. D. Toothettes are not an effective mechanism for providing oral care.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Basic Care and Comfort | Cognitive Level: Application
5. ANS: C
An acronym that can be used to recall the steps of the evidence-based process is ASKMME: Ask,
Search, Think, Measure, Make It Happen, and Evaluate. A. B. D. RIGHT, MYWAY, and ASKWHY
are not acronyms used to recall the steps of the evidence-based process.
PTS: 1 DIF: Easy
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
Loading page 23...
6. ANS: C
Asking a burning clinical question is the first step in the EBP process. A. B. Conducting a literature
search and working with a medical librarian to identify key words would be done after the clinical
question is formulated. D. Evaluating the impact of care or changes in care is the last step in the EBP
process.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
7. ANS: A
Usually a small pilot study within the institution is done before any institute-wide change in practice
is made. B. The charge nurse will not have the evidence needed to propose the change to
administration. C. Polling the nursing staff is not going to help with implementing the change. D.
Nursing experts might not have the information needed to determine if the change is appropriate
within the organization.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
8. ANS: B
Level I is the best evidence and is an analysis of many well-conducted, randomized, controlled trials.
It is a systematic review of studies. D. Level II evidence is obtained from at least one well-designed
randomized controlled trial. A. Level III is evidence obtained from quasi-experimental research
studies. C. Level IV is evidence from the opinion of authorities and/or reports of expert committees.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
9. ANS: D
Evidence-based nursing practice is much more than just evaluating research studies to determine
what results to apply to nursing practice. Evidence-based nursing practice is a systematic process that
utilizes current evidence to make decisions about the care of patients, including evaluation of quality
and applicability of existing research, patient preferences, costs, clinical expertise, and clinical
Asking a burning clinical question is the first step in the EBP process. A. B. Conducting a literature
search and working with a medical librarian to identify key words would be done after the clinical
question is formulated. D. Evaluating the impact of care or changes in care is the last step in the EBP
process.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
7. ANS: A
Usually a small pilot study within the institution is done before any institute-wide change in practice
is made. B. The charge nurse will not have the evidence needed to propose the change to
administration. C. Polling the nursing staff is not going to help with implementing the change. D.
Nursing experts might not have the information needed to determine if the change is appropriate
within the organization.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
8. ANS: B
Level I is the best evidence and is an analysis of many well-conducted, randomized, controlled trials.
It is a systematic review of studies. D. Level II evidence is obtained from at least one well-designed
randomized controlled trial. A. Level III is evidence obtained from quasi-experimental research
studies. C. Level IV is evidence from the opinion of authorities and/or reports of expert committees.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
9. ANS: D
Evidence-based nursing practice is much more than just evaluating research studies to determine
what results to apply to nursing practice. Evidence-based nursing practice is a systematic process that
utilizes current evidence to make decisions about the care of patients, including evaluation of quality
and applicability of existing research, patient preferences, costs, clinical expertise, and clinical
Loading page 24...
settings. A. B. EBP is not used to support professionalism in nursing or as a mechanism to increase
nurses’ salaries. C. EBP also is not used to validate the importance of nursing care.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
10. ANS: A
A small pilot study is typically done before an institute-wide change is made. B. This would not be a
statistically significant number to support the need for change. C. More evidence or evidence of a
higher level would better support the proposed change. D. It is important to consider the context in
which the evidence will be used, and research involving a population similar to that of the nurse’s
institution is helpful.
PTS: 1 DIF: Difficult
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
11. ANS: B
The use of EBP allows nurses to give patients the best care possible, which is the goal of all caring
nurses. It is considered the gold standard for nursing care. A. C. EBP does not necessarily save
money or reduce staff errors. D. EBP does not influence access to health care.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
12. ANS: B
Systematic review, or Level I evidence, is the best evidence; it is an analysis of several well-
conducted, randomized, controlled trials. A. Expert opinion is Level IV evidence, which is
considered the weakest evidence. C. Traditional practice is not a type of evidence for EBP analysis.
D. Quasi-experimental studies are considered Level III evidence, because these studies do not control
factors that could falsely change the results and are less predictive of the effectiveness of nursing
care.
nurses’ salaries. C. EBP also is not used to validate the importance of nursing care.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
10. ANS: A
A small pilot study is typically done before an institute-wide change is made. B. This would not be a
statistically significant number to support the need for change. C. More evidence or evidence of a
higher level would better support the proposed change. D. It is important to consider the context in
which the evidence will be used, and research involving a population similar to that of the nurse’s
institution is helpful.
PTS: 1 DIF: Difficult
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
11. ANS: B
The use of EBP allows nurses to give patients the best care possible, which is the goal of all caring
nurses. It is considered the gold standard for nursing care. A. C. EBP does not necessarily save
money or reduce staff errors. D. EBP does not influence access to health care.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
12. ANS: B
Systematic review, or Level I evidence, is the best evidence; it is an analysis of several well-
conducted, randomized, controlled trials. A. Expert opinion is Level IV evidence, which is
considered the weakest evidence. C. Traditional practice is not a type of evidence for EBP analysis.
D. Quasi-experimental studies are considered Level III evidence, because these studies do not control
factors that could falsely change the results and are less predictive of the effectiveness of nursing
care.
Loading page 25...
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
13. ANS: C
The only database specific to nursing is CINAHL. CINAHL is available through school libraries and
hospital libraries. A. B. Medline and PubMed are the same resource and are used for medical
literature. D. Cochrane Reviews focus on reviews of nursing literature.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive
Level: Application
14. ANS: A
Quasi-experimental research studies do not control for factors that could falsely change results and as
such, are less predictive of the effectiveness of nursing care. B. Outcome tracking over 10 years is a
longitudinal study design, however, does not explain the type of data that will be obtained. C.
Control of comorbid conditions describes a Level II design study. D. Modifiable and non-modifiable
risk factors would not be identified through a quasi-experimental approach, because the variables or
factors are not controlled.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
15. ANS: A
Nurses will know from measured outcomes that they are giving the best care possible based on the
evidence available at the time. B. Reviewing the literature helps with planning care. C. Constructing
a burning question is used to identify the best possible practice for care. D. Determining the validity
of clinical research is used to analyze research studies for best practices.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
16. ANS: A
The steps of EBP are Ask, Search, Think, Measure, Make It Happen, and Evaluate. Since the nurse
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
13. ANS: C
The only database specific to nursing is CINAHL. CINAHL is available through school libraries and
hospital libraries. A. B. Medline and PubMed are the same resource and are used for medical
literature. D. Cochrane Reviews focus on reviews of nursing literature.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive
Level: Application
14. ANS: A
Quasi-experimental research studies do not control for factors that could falsely change results and as
such, are less predictive of the effectiveness of nursing care. B. Outcome tracking over 10 years is a
longitudinal study design, however, does not explain the type of data that will be obtained. C.
Control of comorbid conditions describes a Level II design study. D. Modifiable and non-modifiable
risk factors would not be identified through a quasi-experimental approach, because the variables or
factors are not controlled.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
15. ANS: A
Nurses will know from measured outcomes that they are giving the best care possible based on the
evidence available at the time. B. Reviewing the literature helps with planning care. C. Constructing
a burning question is used to identify the best possible practice for care. D. Determining the validity
of clinical research is used to analyze research studies for best practices.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
16. ANS: A
The steps of EBP are Ask, Search, Think, Measure, Make It Happen, and Evaluate. Since the nurse
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completed Ask, Search, Think, and Measure, the next step is Make It Happen. B. A cost-benefit
analysis should have been completed already. C. Related research studies should have been validated
already. D. A pilot project should have been completed already.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Physiological Integrity | Cognitive Level:
Application
17. ANS: D
A randomized controlled trial is considered Level II evidence. A. C. The Cochrane Review and
Joanna Briggs Best Practices Review are considered Level I evidence. B. A quasi-experimental study
is considered Level III evidence.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
18. ANS: A
Evidence-based care should be given at all times if possible and in all settings where nursing care is
given. A way to ensure that evidence-based care is provided is to explain why the care should be
given at the time the care is delegated. B. C. D. Explaining the reason for the care is not done to
guarantee that the patient will receive morning care, help the UAP focus on actions, or help with time
management.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
19. ANS: D
Discussing expected effects of a prescribed medication with an HCP and reviewing guidelines for
administration of the medication with the pharmacist demonstrate teamwork and collaboration. A.
Informatics is the management of patient confidential information. B. Patient-centered care is
creating an individualized plan of care for a patient. C. Quality improvement is a process to improve
patient care.
analysis should have been completed already. C. Related research studies should have been validated
already. D. A pilot project should have been completed already.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Physiological Integrity | Cognitive Level:
Application
17. ANS: D
A randomized controlled trial is considered Level II evidence. A. C. The Cochrane Review and
Joanna Briggs Best Practices Review are considered Level I evidence. B. A quasi-experimental study
is considered Level III evidence.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
18. ANS: A
Evidence-based care should be given at all times if possible and in all settings where nursing care is
given. A way to ensure that evidence-based care is provided is to explain why the care should be
given at the time the care is delegated. B. C. D. Explaining the reason for the care is not done to
guarantee that the patient will receive morning care, help the UAP focus on actions, or help with time
management.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
19. ANS: D
Discussing expected effects of a prescribed medication with an HCP and reviewing guidelines for
administration of the medication with the pharmacist demonstrate teamwork and collaboration. A.
Informatics is the management of patient confidential information. B. Patient-centered care is
creating an individualized plan of care for a patient. C. Quality improvement is a process to improve
patient care.
Loading page 27...
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
20. ANS: A
It takes critical thinking to use safety interventions at the right times and in the right circumstances.
Using them appropriately helps provide safer care with fewer errors. A. The nurse does not need to
ask for permission to use a safety intervention. C. The patient will most likely want all safety
interventions to be used. D. A pilot study does not need to be conducted before implementing a
safety intervention.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
MULTIPLE RESPONSE
21. ANS: A, C, D, E
Dependent nursing interventions are those delegated by a physician. B is an independent nursing
intervention that does not require a physician’s order.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Basic Care and Comfort | Cognitive Level: Analysis
22. ANS: A, C, D, E
Quasi-experimental studies do not control factors that could falsely change the results and as such,
are less predictive of the effectiveness of nursing care. No control exists if there is only one group
being tracked or if patients are collected on a volunteer basis. B. The use of an experimental group
and a control group describes a randomized controlled trial study.
PTS: 1 DIF: Difficult
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
23. ANS: A, B
The steps in the EBP process are Ask, Search, Think, Measure, Make It Happen, and Evaluate. An
acronym to remember these steps is ASKMME. C. D. Asking nursing experts and manipulating
current practice are not steps in the EBP process.
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
20. ANS: A
It takes critical thinking to use safety interventions at the right times and in the right circumstances.
Using them appropriately helps provide safer care with fewer errors. A. The nurse does not need to
ask for permission to use a safety intervention. C. The patient will most likely want all safety
interventions to be used. D. A pilot study does not need to be conducted before implementing a
safety intervention.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
MULTIPLE RESPONSE
21. ANS: A, C, D, E
Dependent nursing interventions are those delegated by a physician. B is an independent nursing
intervention that does not require a physician’s order.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Basic Care and Comfort | Cognitive Level: Analysis
22. ANS: A, C, D, E
Quasi-experimental studies do not control factors that could falsely change the results and as such,
are less predictive of the effectiveness of nursing care. No control exists if there is only one group
being tracked or if patients are collected on a volunteer basis. B. The use of an experimental group
and a control group describes a randomized controlled trial study.
PTS: 1 DIF: Difficult
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
23. ANS: A, B
The steps in the EBP process are Ask, Search, Think, Measure, Make It Happen, and Evaluate. An
acronym to remember these steps is ASKMME. C. D. Asking nursing experts and manipulating
current practice are not steps in the EBP process.
Loading page 28...
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
24. ANS: A, B, C, E
Safety goals increase awareness and understanding of patient safety. They address administering
medications safely, identifying patients correctly, identifying operative sites correctly, improving
communication, reducing fall injuries, and reducing the risk of infection. D. Safety goals would not
be applicable while stocking a supply room with linens.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive
Level: Application
25. ANS: A, B, C
A. When collaborating on the development of nursing care plans, it is important to individualize
interventions to provide patient-centered care. B. As nursing interventions are performed, they should
meet the patient’s preferred schedules. C. Nurses should always evaluate each suggested intervention
to see if it fits the patient. D. E. Scanning medication using a bar-coding system and documenting in
the electronic medical record are actions that support the focus of informatics.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
Chapter 3. Issues in Nursing Practice
Chapter 3. Issues in Nursing Practice
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. After working a 12-hour shift, the nurse is asked to work part of the next shift due to short
staffing. Which obligation to work should the nurse use to guide the response to this request?
a. Justice
b. Welfare
c. Moral
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Application
24. ANS: A, B, C, E
Safety goals increase awareness and understanding of patient safety. They address administering
medications safely, identifying patients correctly, identifying operative sites correctly, improving
communication, reducing fall injuries, and reducing the risk of infection. D. Safety goals would not
be applicable while stocking a supply room with linens.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Safety and Infection Control | Cognitive
Level: Application
25. ANS: A, B, C
A. When collaborating on the development of nursing care plans, it is important to individualize
interventions to provide patient-centered care. B. As nursing interventions are performed, they should
meet the patient’s preferred schedules. C. Nurses should always evaluate each suggested intervention
to see if it fits the patient. D. E. Scanning medication using a bar-coding system and documenting in
the electronic medical record are actions that support the focus of informatics.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level:
Analysis
Chapter 3. Issues in Nursing Practice
Chapter 3. Issues in Nursing Practice
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. After working a 12-hour shift, the nurse is asked to work part of the next shift due to short
staffing. Which obligation to work should the nurse use to guide the response to this request?
a. Justice
b. Welfare
c. Moral
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d. Legal
____ 2. The family of a patient who has been diagnosed with cancer does not want the patient to be
told about the diagnosis. The patient asks the nurse, “Do I have cancer?” Which ethical principles
should the nurse consider when resolving this situation?
a. Autonomy and veracity
b. Beneficence and justice
c. Welfare rights and moral obligations
d. Nonmaleficence and legal obligations
____ 3. A patient tells the nurse that the Patient’s Bill of Rights gives patients the legal right to read
their medical information. Which of these responses would be appropriate for the nurse to make?
a. “I’ll ask your physician if you can read the record.”
b. ”Are you concerned about the care you are receiving?”
c. ”I’ll stay here with you while you read it in case you have any questions.”
d. ”Let me check with the charge nurse first.”
____ 4. The nurse assigned to care for a patient who has HIV accepts the patient assignment despite
believing that the patient’s condition is a punishment from God. With which ethical principle is this
nurse’s behavior associated?
a. Justice
b. Veracity
c. Beneficence
d. Nonmaleficence
____ 5. While planning patient care, the nurse considers what needs to be done to limit any liability.
Which action should the nurse take to minimize liability when providing patient care?
a. Ensure patients’ rights.
b. Follow verbal orders.
c. Follow directions exactly as given.
d. Verify employer’s liability insurance.
____ 6. A patient is identified to participate in a new drug study, but does not understand the drug or
the study. Which ethical principle should the nurse use to prevent the patient from participating in the
study?
a. Veracity
b. Autonomy
c. Nonmaleficence
____ 2. The family of a patient who has been diagnosed with cancer does not want the patient to be
told about the diagnosis. The patient asks the nurse, “Do I have cancer?” Which ethical principles
should the nurse consider when resolving this situation?
a. Autonomy and veracity
b. Beneficence and justice
c. Welfare rights and moral obligations
d. Nonmaleficence and legal obligations
____ 3. A patient tells the nurse that the Patient’s Bill of Rights gives patients the legal right to read
their medical information. Which of these responses would be appropriate for the nurse to make?
a. “I’ll ask your physician if you can read the record.”
b. ”Are you concerned about the care you are receiving?”
c. ”I’ll stay here with you while you read it in case you have any questions.”
d. ”Let me check with the charge nurse first.”
____ 4. The nurse assigned to care for a patient who has HIV accepts the patient assignment despite
believing that the patient’s condition is a punishment from God. With which ethical principle is this
nurse’s behavior associated?
a. Justice
b. Veracity
c. Beneficence
d. Nonmaleficence
____ 5. While planning patient care, the nurse considers what needs to be done to limit any liability.
Which action should the nurse take to minimize liability when providing patient care?
a. Ensure patients’ rights.
b. Follow verbal orders.
c. Follow directions exactly as given.
d. Verify employer’s liability insurance.
____ 6. A patient is identified to participate in a new drug study, but does not understand the drug or
the study. Which ethical principle should the nurse use to prevent the patient from participating in the
study?
a. Veracity
b. Autonomy
c. Nonmaleficence
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d. Standard of Best Interest
____ 7. The nurse educator is preparing a seminar that focuses on the impact of technology on
patient care. Which effect of technology on ethical decision making should the educator include in
this seminar?
a. Ethical situations remain similar to what they have always been in health care.
b. Nurses have fewer ethical decisions, because computers now make many decisions.
c. Ethical dilemmas have become more complex owing to technologies that prolong life.
d. Nurses can postpone ethical decisions, because technology allows patients to live longer.
____ 8. The nurse is concerned about a patient’s ability to make decisions about a proposed treatment
plan. Which patient characteristic is causing the nurse to have this concern?
a. Lower socioeconomic status
b. Authoritarian family relationship
c. Past experience with hospitalization
d. Lack of information about treatment
____ 9. A patient has a living will and gives it to the nurse to follow. The patient says, “Do not tell
my family about the living will.” Which action should the nurse take?
a. Send a copy of the living will to medical records.
b. Assure the patient that the nurse will not tell anyone.
c. Encourage the patient to discuss the living will with the family.
d. Return the living will to the patient until the family is informed.
____ 10. The nurse is caring for an 80-year-old patient. Which statement made by the nurse conveys
dignity and respect to the patient?
a. “Honey, I have your medications.”
b. “I have your medications for you, dear.”
c. “I have your medications for you.”
d. “It’s time for us to take our medications.”
____ 11. The charge nurse is concerned that an HCP is breaching a patient’s confidentiality. What
did the charge nurse observe to come to this conclusion?
a. A physician asking a nurse if a friend has cancer
b. Use of patient initials on nurse’s assignment worksheet
c. A nurse asking an unknown physician for identification
d. A nurse reviewing charts of assigned patients for orders
____ 12. The nurse is reviewing information on the state board of nursing website prior to renewing
____ 7. The nurse educator is preparing a seminar that focuses on the impact of technology on
patient care. Which effect of technology on ethical decision making should the educator include in
this seminar?
a. Ethical situations remain similar to what they have always been in health care.
b. Nurses have fewer ethical decisions, because computers now make many decisions.
c. Ethical dilemmas have become more complex owing to technologies that prolong life.
d. Nurses can postpone ethical decisions, because technology allows patients to live longer.
____ 8. The nurse is concerned about a patient’s ability to make decisions about a proposed treatment
plan. Which patient characteristic is causing the nurse to have this concern?
a. Lower socioeconomic status
b. Authoritarian family relationship
c. Past experience with hospitalization
d. Lack of information about treatment
____ 9. A patient has a living will and gives it to the nurse to follow. The patient says, “Do not tell
my family about the living will.” Which action should the nurse take?
a. Send a copy of the living will to medical records.
b. Assure the patient that the nurse will not tell anyone.
c. Encourage the patient to discuss the living will with the family.
d. Return the living will to the patient until the family is informed.
____ 10. The nurse is caring for an 80-year-old patient. Which statement made by the nurse conveys
dignity and respect to the patient?
a. “Honey, I have your medications.”
b. “I have your medications for you, dear.”
c. “I have your medications for you.”
d. “It’s time for us to take our medications.”
____ 11. The charge nurse is concerned that an HCP is breaching a patient’s confidentiality. What
did the charge nurse observe to come to this conclusion?
a. A physician asking a nurse if a friend has cancer
b. Use of patient initials on nurse’s assignment worksheet
c. A nurse asking an unknown physician for identification
d. A nurse reviewing charts of assigned patients for orders
____ 12. The nurse is reviewing information on the state board of nursing website prior to renewing
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