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Chapter 02: Critical Thinking and the Nursing Process
deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition
MULTIPLE CHOICE
1. Which foundational behavior is necessary for effective critical thinking?
a. Unshakable beliefs and values
b. An open attitude
c. An ability to disregard evidence inconsistent with set goals
d. An ability to recognize the perfect solution
ANS: B
An open attitude not clouded by unshakable beliefs and values or preset goals allows the
application of critical thinking. Acceptance that there may not be a perfect solution leaves the
field open to new ideas.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 16, Box 2- OBJ: 2 (theory) TOP: Factors Influencing Critical Thinking KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance
2. Which fundamental belief underscores the basis of the nursing process?
a. Recognition that basic needs must be met by the individual without assistance.
b. Acknowledgment that patients and families appreciate an efficient health care
system that functions without their input.
c. A focus on disease control as the most important aspect of patient care.
d. Recognition that all people have worth and dignity.
ANS: D
The nursing process is based on the belief that all people have worth and dignity. Patient-
centered care that is applied to all aspects of the patient’s health, and is not just disease
oriented, is appreciated by the family and patient. Holistic care approach can support the
patient to meet basic needs.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 5 (theory) TOP: Basic Beliefs Pertinent to the Nursing Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
3. The nurse is assessing a new patient who complains of his chest feeling tight. The patient
displays a temperature of 100° F and an oxygen saturation of 89%, and expectorates frothy
mucus. Which finding is an example of subjective data?
a. Temperature
b. Oxygen saturation
c. Frothy mucus
d. Chest tightness
ANS: D
Subjective data is information given by the patient that cannot be measured otherwise. The
other data are considered objective data. Objective data are pieces of information that can be
measured by the examiner. The nurse should avoid making judgments or conclusions when
obtaining data.
PTS: 1 DIF: Cognitive Level: Application REF: 18 OBJ: 8 (clinical) TOP: Assessment Data KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
4. The nurse is caring for a newly admitted patient who is describing his recent symptoms to the
nurse. This scenario is an example of which type of source?
a. Primary
b. Objective
c. Secondary
d. Complete
ANS: A
The patient is the primary source of information. Objective refers to a type of data obtained by
the nurse that is measured or can be verified through assessment techniques, secondary
information is obtained from relatives or significant others, and information is not necessarily
complete when the patient is the source.
PTS: 1 DIF: Cognitive Level: Application REF: 19 OBJ: 8 (clinical) TOP: Sources of Information KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
5. The nurse is performing an intake interview on a new resident to the long-term care facility.
The nurse detects the odor of acetone from the patient’s breath. Which term accurately
describes this assessment?
a. Inspection
b. Observation
c. Auscultation
d. Olfaction
ANS: D
Olfaction is an assessment method of smells. Inspection and observation use the sense of
vision. Auscultation refers to use of the sense of hearing.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 20 OBJ: 9 (clinical) TOP: Olfaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
6. During a morning assessment, the nurse observes that the patient displays significant edema of
both feet and ankles. Which statement best documents these findings?
a. Pitting edema present in both feet and ankles
b. Edema in both feet and ankles approximately 4 mm deep
c. 4 mm pitting edema quickly resolving
c. “Hemoglobin levels and blood sugar levels are closely related.”
d. “The HbA1c tells if you have type 1 or type 2 diabetes.”
ANS: B
HbA1c evaluates the average blood glucose level for the last 2 to 3 months. By explaining the
purpose of the common laboratory test (HgbA1c) and its relationship to diabetes, the nurse
answers the patient’s question and clearly communicates relevant data.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 25, 27 OBJ: 8 (clinical) TOP: Diagnostic Studies KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
10. The nurse is caring for a patient with the problem statement/nursing diagnosis of Risk for
Impaired Skin Integrity Related to Immobility. Which goal/outcome statement best correlates
with this diagnosis?
a. The patient will sit in chair at bedside for 15 minutes after each meal.
b. The nurse will assist the patient to chair every shift.
c. The nurse will assess skin and record condition every shift.
d. The patient will change positions frequently.
ANS: A
The goal/outcome statement is directed at the etiology and should be patient oriented. The
statement should be realistic and measurable and reflect what the patient will do.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 24 OBJ: 11 (clinical) TOP: Goals KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
11. The nurse who has recently moved from Louisiana to Texas is uncertain about the LPN/LVN’s
role in applying the nursing process. Which source is most appropriate source for the nurse to
consult?
a. Hospital policies
b. The Texas State Board of Nursing
c. Rules and regulations of the Louisiana Nurse Practice Act
d. The National Association of Practical Nurse Education and Service
ANS: B
Each state has different guidelines for areas of care planning, intravenous therapy, teaching,
and delegation. The Texas State Board of Nursing is the most reliable source.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory) TOP: Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
12. The nurse adds a nursing order to the care plan related to a patient with a problem
statement/nursing diagnosis of altered nutrition/ Nutrition: Less Than Body Requirements
Related to Nausea and Vomiting. Which nursing order should the nurse include in the plan of
care?
a. Medicate with an antiemetic before each meal.
b. Offer crackers and iced drink before each meal.
c. Change diet to clear liquids.
d. Give nothing by mouth until nausea subsides.
ANS: B
Offering crackers and iced drinks are within the scope of nursing; the other options would
require a medical order to complete.
PTS: 1 DIF: Cognitive Level: Application REF: 18 OBJ: 11 (clinical) TOP: Nursing Orders KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
13. After evaluating the nursing care plan, the nurse finds lack of progress toward the goal. What
action should the nurse take next?
a. Create a more accessible goal.
b. Revise the nursing interventions.
c. Change the problem statement/nursing diagnosis.
d. Use a new evaluation plan.
ANS: B
When lack of progress to reach the goal is seen on evaluation, the interventions are reviewed
and/or revised.
PTS: 1 DIF: Cognitive Level: Application REF: 26 OBJ: 10 (clinical) TOP: Evaluation KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
14. During an intake interview, the nurse observes the patient grimacing and holding his hand over
his stomach. The patient previously denied having any pain. What action should the nurse take
next?
a. Examine the history closely for etiology of pain.
b. Ask the patient if he is experiencing abdominal pain.
c. Record that patient seems to be having abdominal discomfort.
d. Physically examine the patient’s abdomen.
ANS: B
The nurse should try to resolve any incongruence between body language and verbal
responses.
PTS: 1 DIF: Cognitive Level: Application REF: 20, Box 2- OBJ: 7 (clinical) TOP: Patient Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
15. While conducting an admission interview, the nurse questions the patient about pain. The
patient responds, “No. I’m pretty wobbly.” Which action should the nurse take next?
a. Repeat the question about pain.
b. Ask the patient to clarify his meaning.
c. Record that the patient denied pain.
d. Record that the patient stated he was wobbly.
d. A specifically worded medical diagnosis
ANS: C
A complete problem statement/nursing diagnosis must have a NANDA stem, etiology, and
signs and symptoms (etiology) of the problem.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 23 OBJ: 4 (theory) TOP: Nursing Diagnosis KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
19. Which statement explains the reason for inclusion of potential problems in the nursing care
plan?
a. To alert nursing staff to prevent potential complications.
b. To remind the family of potential problems.
c. To broaden the assessment of the caregiver.
d. To educate the patient to aspects of her health.
ANS: A
Addressing potential problems prevents complications by early action rather than waiting for a
problem to materialize.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 23 OBJ: 7 (clinical) TOP: Potential Health Problems KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
20. The nurse is completing the medication reconciliation form for a patient. Which information is
most important for the nurse to include?
a. The patient reports taking Ginkgo biloba daily for the last 6 months.
b. The patient reports having high hematocrit levels during his last hospital stay.
c. The patient reports he has been diabetic for 10 years.
d. The patient reports having a recent infection.
ANS: A
As part of the medication reconciliation form, all home medications (including herbal
preparations like Gingko biloba ) are listed and reviewed by the provider, pharmacist, and
nurses. The information gathered during the completion of this form may impact care that the
patient will receive. Abnormal lab work and history of chronic or acute illnesses are important
components of the patient’s history but should not be part of the medication reconciliation
form.
PTS: 1 DIF: Cognitive Level: Application REF: 20 OBJ: 7 (clinical) TOP: Alternative Medicine KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
21. The LPN/LVN adheres to facility policy regarding core measures by performing which
interventions during patient care?
a. Administering the ordered amount of insulin to a patient with type 1 diabetes.
b. Performing a thorough patient assessment upon admission to the health care
facility.
c. Documenting accurately and at appropriate intervals in the patient’s record.
d. Providing patient teaching regarding proper diet for the patient diagnosed with
renal failure.
ANS: A
Core measures are interventions that are based on scientifically researched, evidence-based
standards of care, and are used to treat the majority of patients with a specific illness that often
develops complications. Insulin administration for diabetics is evidence-based researched
practice. The remaining options are good practice but are not considered core measures.
PTS: 1 DIF: Cognitive Level: Analysis REF: 25 OBJ: 4 (theory) TOP: Core Measures KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care
22. The nurse is caring for a patient with pneumonia who complains of shortness of breath.
Further assessment reveals an oxygen saturation of 89% on room air, 28 respirations/min with
bilateral crackles in lung bases, blood pressure of 160/94, and a pulse rate of 102 beats/min.
Which nursing diagnosis is priority for this patient?
a. Activity Intolerance
b. Impaired Gas Exchange
c. Ineffective Cardiopulmonary Tissue Perfusion
d. Self-Care Deficit: Bathing and Hygiene
ANS: B
While all nursing diagnoses may apply to this patient, impaired gas exchange is the highest
priority because this is the underlying problem for the other nursing diagnoses, as well as
physiologically the highest priority.
PTS: 1 DIF: Cognitive Level: Analysis REF: 23 OBJ: 11 (clinical) TOP: Nursing Diagnosis KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Management of Care MULTIPLE RESPONSE
23. The nurse explains to the nursing student that the application of critical thinking to patient
care involves which factor(s)? ( Select all that apply. )
a. Identification of a patient problem
b. Setting priorities
c. Concentrating on the patient rather than family needs
d. Use of logic and intuition
e. Expansion of thought beyond the obvious
ANS: A, B, D, E
Critical thinking as applied to nursing care requires setting priorities of patient problems and
needs by using logic and intuition. Inclusion of the family in the care makes the approach
family oriented. Critical thinking should go beyond the obvious.
26. The nursing student demonstrates knowledge of the proper use of the ___________ when
determining that it is safe to administer meperidine (Demerol) and promethazine (Phenergan)
together.
ANS:
Medication Reconciliation Form
The Medication Reconciliation Form tracks all medications the patient is taking as prescribed
by different physicians and can identify overdoses or drugs that are not compatible.
PTS: 1 DIF: Cognitive Level: Application REF: 20 OBJ: 8 (clinical) TOP: Medication Reconciliation Form KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
27. Shortness of breath due to emphysema would be a major component of the _________ care
plan.
ANS:
interdisciplinary
An interdisciplinary care plan involves all members of the health care team and is based on the
medical diagnosis rather than a problem statement/nursing diagnosis.
PTS: 1 DIF: Cognitive Level: Application REF: 26 OBJ: 8 (clinical) TOP: Interdisciplinary Care Plan KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance MATCHING
Place the steps of the nursing process in their proper sequence.
a. Evaluation
b. Assessment
c. Implementation
d. Planning
e. Problem statement/nursing diagnosis
28. Step 1
29. Step 2
30. Step 3
31. Step 4
32. Step 5
- ANS: B PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory) TOP: Applying the Nursing Process KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- ANS: E PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory) TOP: Applying the Nursing Process
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- ANS: D PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory) TOP: Applying the Nursing Process KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- ANS: C PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory) TOP: Applying the Nursing Process KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- ANS: A PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory) TOP: Applying the Nursing Process KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
