Lewis Medical-Surgical Nursing in Canada 4th Edition – Test Bank
Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Lewis: Medical Surgical Nursing in Canada, 4th Canadian Edition
ring in Ca
MULTIPLE CHOKE
Test Bank
1. The nurse is caring for a client with a new diagnosis of pneumonia and explains to the client that together they will plan the client’s care and set goals for discharge. The client asks, “How is that different from what the doctor does?” Which response by the nurse is most appropriate?
“The role of the nurse is to administer medications and other treatments prescribed by your doctor”
“The nurse’s job is to help the doctor by collecting data and communicating when there are problems.”
“Nurses perform many of the procedures done by physicians, but nurses are here in the hospital for a longer time than doctors.”
4. “In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health”
ANS: D
This response is consistent with the Canadian Nurses Association (CNA) definition of nursing. Registered nurses are self-regulated health care professionals who work autonomously and in collaboration with others. RNs enable individual, famides, groups, communities and populations to achieve their optimal level of health. RNs coordinate health care, deliver direct services, and support clients in their self-care decisions and actions in situations of health, illness, injury, and disability in all stages of life. The other responses describe some of the dependent and collaborative functions of the nursing sole but do not accurately describe the surse’s role in the health care system
DO: Cognitive Level Companion
TOP: Narning Prin
MSC: NCLEX Safe and Effective Creat
2. When caring for clients using evidence-informed practice, which of the following does the
Clinical judgement based on experience
Evidence from a clinical research shady
The best available evidence to guide clinical expertise
4. Evaluation of data showing that the client outcomes are met
ANS: C
Evidence-informed nursing practice is a continuous interactive process involving the explicit conscientious, and judicious consideration of the best available evidence to provide case. Four primary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and actions (c) best research evidence, and (6) health care resources. Clinical judgement based on the nurse’s clinical experience is part of EIP, but clinical decision making also should incorporate current research and research-based guidelines. Evidence from one clinical research stady does not provide an adequate substantiation for interventions. Evaluation of client outcomes is important, but interventions should be based on research from randomized control studies with a large number of subjects.
DIF: Cognitive Levom
TOP Nomination Processing
MSC: NCLEX: SendEffective Care Ev
3. Which of the following best explains the surses primary use of the nursing process when providing care to clients?
To explain suring interventions to other health care professionals
As a problem-solving tool to identify and treat clients’ health care needs
As a scientific-based process of diagnosing the client’s health care problems
4. To establish mursing theory that incorporates the biopsychosocial nature of humans
ANS: B
The nursing process is an assertive problem-solving approach to the identification and treatment of clients problems. Diagnous is only one phase of the nursing process. The primary use of the nursing process is in client care, not to establish nursing theory of explain nursing interventions to other health care professionals.
DO: Cogative Levom
TOP Nursing Propion
MSC: NCLEX Safe and Effective Care Eve
4. The nurse is caring for a critically ill client in the intensive care unit and plans an every-2-hour turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated with this turning schedule?
Dependent
Cooperative
Independent
4. Collaborative
ANS: D
When implementing collaborativesursing actions, the nurse is responsible primarily for monitoring for complications of acute illness or providing care to prevent or treat complications. Independent nursing actions are focused on health promotion, illness prevention, and client advocacy. A dependent action would require a physician order to implement. Cooperative sursing functions are not described as one of the formal nursing functions.
DIF: Cogative Level Application
TOP: Nursing Proc
MSC: NCLEX: Safe and Cre
5. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the nurse, “I do not feel right about leaving my children with my neighbour. Which action should the move take next?
Reassure the client that these feelings are common for parents
Have the client call the children to ensure that they are doing well
Call the neighbour to determine whether adequate childcare is being grovided
4. Gather move data about the client’s feelings about the childcare arrangements
ANS: D
Since a complete assessment is necessary in order to identify a problem and choose an appropriate intervention, the nurse’s first action should be to obtain more information. The other actions may be appropriate, but more assessment is needed befoor the best intervention can be chosen
DIF Cotive Level Application
TOP Ning Process: A
MSC: NCLEX: Prychosocial Integrity
6. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and assesses a pressure injury on the client’s left hip. Which of the following is the most appropriate nursing diagnosis for this client?
Impaired physical mobility related to decrease in muscle control (left-sided paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about protecting tissue integrity
Impaired skin integrity related to pressure over bony prominence (impaired circulation)
4. Ineffective peripheral tissue perfusion related to sedentary lifestyle
ANS: C
The client’s major problem is the impaired skin integrity as demonstrated by the presence of a pressure injury. The nurse is able to treat the cause of impaired circulation and pressure over bony prominence by frequently repositioning the client. Although left-sided weakness is a problem for the client, the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this client, who already has impaired tissue integrity. The client does have ineffective peripheral tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Application
TOP: Nursing Proces: Diagnosis
MSC: NCLEX: Physiological Integrity
7. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid volume related to excessive fluid loss through normal route (diaphoresis). Which of the following is an appropriate client outcome?
Client has a balanced intake and output
b. Client’s bedding is changed when it becomes damg.
c. Client understands the need for increased fluid intake.
4. Client’s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficientid volume that was identified in the nursing diagnosis statement. The other statements would not indicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Application
TOP Ning Proces: Planning
MSC: NCLEX: Physiological Integrity
Which of the following represents a nursing activity that is carried out during the evaluation phase of the nursing process?
Determining if interventions have been effective in meeting client outcomes.
b. Documenting the nursing care plan in the progress notes in the medical record.
<Deciding whether the client’s health problems have been completely resolved.
4. Asking the client to evaluate whether the nursing care provided was satisfactory.
ANS: A
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