(Osborn) Chapter 42: Learning Outcomes (Number and Title)

[Osborn] chapter 42
Learning Outcomes [Number and Title]

Learning Outcome 1
Evaluate the etiology, incidence, and prevalence of heart
failure.
Learning Outcome 2
Distinguish between systolic and diastolic dysfunction.
Learning Outcome 3
Describe the pathophysiology of heart failure and the
compensatory neurohormonal responses that occur.
Learning Outcome 4
Compare and contrast right-sided versus left-sided symptoms
of heart failure.
Learning Outcome 5
Evaluate the diagnostic work-up used to determine the presence
of heart failure.
Learning Outcome 6
Describe a comprehensive treatment plan including the
medical, device, and surgical components of treatment, using
the multidisciplinary team approach.
Learning Outcome 7
Describe the self-management concepts necessary for patients
with heart failure.
Learning Outcome 8
Compare and contrast potential comorbidities associated with
heart failure.
Learning Outcome 9
Describe components of end-of-life care for end-stage heart
failure.
Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
1. A client with heart failure is given discharge instructions by the nurse. As the client
leaves the hospital, the nurse recognizes that, statistically, this client has a _______
likelihood of readmission within 6 months.
1.
2.
3.
4.
30% to 50%
50% to 75%
0% to 20%
20% to 30%
Correct Answer: 30% to 50%

Rationale: The likelihood of readmission for a client with heart failure within 6 months is
between 30% and 50%. The other answer choices are therefore not correct.
Cognitive Level: Application
Nursing Process: Evaluation
Client Need: Health Promotion and Maintenance
LO: 1

Inc.
2. The nurse knows that the client who is diagnosed with heart failure has a higher
mortality rate. The best way to help decrease the incidence of heart failure is to:
1.
2.
3.
4.
Teach clients about modifiable risk factors.

Teach clients about the higher incidence of sudden cardiac death.
Discuss the higher mortality with the health care provider.
Discuss heart failure statistics at a nursing meeting.
Correct Answer: Teach clients about modifiable risk factors.

Rationale: Modifying a clients risk factors may help to decrease the clients
susceptibility to heart failure. Limiting smoking and cardiotoxic substances, decreasing
the likelihood of cardiac disease, and increasing activity may all help to decrease the
soaring incidence of heart failure in the United States. Discussion with the client about
higher incidence of sudden cardiac death will not impact the incidence of heart failure
unless it scares a client into taking action. Discussion with the health care provider and
nurses about heart failure may help promote awareness of the problem, but will not
impact the client directly.
Nursing Process: Implementation
LO: 1

Inc.
3. A 68-year-old male client is seen in the clinic complaining of fatigue and other
nonspecific, vague symptoms that the nurse believes may be related to heart failure. The
nurse questions the client regarding risk factors for heart disease. Which of the following
could be modifiable risk factors for this client regarding heart failure?
1. Hemoglobin A1C 9.0%
2. Male
3. Father-in-law died from heart disease a year ago
4. Blood pressure 119/78
Correct Answer: Hemoglobin A1C 9.0%
Rationale: Hemoglobin A1C of 9.0% indicates an average blood sugar of 240 mg/dL.
Therefore the client is likely to have undiagnosed diabetes, which is a modifiable risk
factor for heart failure. Being male is a risk factor, but is not modifiable. An in-laws
death from cardiac disease is unrelated to the clients risk factors. Hypertension is a
modifiable risk factor, but the blood pressure of 119/78 is not hypertensive.
Cognitive Level: Analysis
Nursing Process: Assessment
LO: 1

Inc.
4. The nurse is performing an admission assessment on a client who presents to the

emergency department (ED) complaining of poor appetite, bloated abdomen, and
peripheral edema. The nurse recognizes these symptoms as:
1. Right-sided failure.
2. Left-sided failure.
3. Diastolic dysfunction.
4. A myocardial infarction.
Correct Answer: Right-sided failure.
Rationale: Right-sided failure includes symptoms of poor appetite, nausea, vomiting,
bloated abdomen, ascites, and peripheral edema. Left-sided failure symptoms include a
cough, shortness of air, orthopnea, and activity intolerance. Diastolic dysfunction
symptoms are often similar to systolic dysfunction symptoms. A myocardial infarction
(MI) may initially cause the insult to the cardiac system that results in heart failure.
Client Need: Physiological Integrity
LO: 2

Inc.
5. An elderly female client has a left ventricular ejection fraction (LVEF) of 60%. She
complains of activity intolerance, shortness of air, and peripheral edema. The nurse
knows that this clients diagnosis differs from that of another client who has systolic
dysfunction because this clients:
1.
2.
3.
4.
LVEF is within normal limits.

LVEF is low.
Symptoms are unique to diastolic dysfunction.
Symptoms are unique to systolic dysfunction.
Correct Answer: LVEF is within normal limits.

Rationale: Diastolic dysfunction is diagnosed based upon a clients LVEF being normal
and the client exhibiting clinical symptoms of heart failure. This client is an elderly
female, which is typical of diastolic dysfunction. In systolic dysfunction, the LVEF is
low, with the client exhibiting clinical symptoms of heart failure. Systolic and diastolic
dysfunctions tend to have similar symptoms.
LO: 2

Inc.
6. A client has been diagnosed with left-sided heart failure. The nurse collects the
following data: peripheral edema, abdominal bloating, bradycardia, bilateral crackles,
weight loss, and a cough. Which of the data would be indicative of left-sided heart
failure?
1. Cough
2. Bradycardia
3. Abdominal bloating
4. Weight loss
Correct Answer: Cough
Rationale: A cough and bilateral crackles would be indicative of left-sided heart failure.
Peripheral edema and abdominal bloating would be indicators of right-sided heart failure.
Tachycardia would be a symptom of heart failure, not bradycardia. Weight loss could be a
symptom of right-sided heart failure, since these clients report loss of appetite. However,
there is usually enough fluid gain to mask any actual nutritional deficits.
LO: 2

Inc.
7. A client with heart failure has orthopnea, tachycardia, fatigue, and activity intolerance.
The nurse instructs the client that these symptoms are a result of the clients:
1. Inherent compensatory mechanisms trying to maintain a good blood pressure
and oxygenation.
2. Inability to cope with the bodys changing health.
3. Inability to follow instructions.
4. Inherent compensatory mechanisms that are malfunctioning.
Correct Answer: Inherent compensatory mechanisms trying to maintain a good blood
pressure and oxygenation.
Rationale: The clients compensatory mechanisms attempt initially to compensate for the
failing blood pressure and oxygen levels. At the outset, these mechanisms are able to
keep up with the bodys demands. However, long term, they create bigger problems. The
clients symptoms are not a result of the clients inability to cope with the bodys
changing health or to follow instructions, since the client has no power over the
compensatory mechanisms. The clients inherent compensatory mechanisms are not
malfunctioning, but instead continue to attempt to maintain homeostasis.
LO: 3

Inc.
8. The nurse notes that one of her clients is more anxious than usual. The client states, I
dont understand how I can still be alive when my heart has failed. The nurses most
appropriate response is:
1. It must be very confusing. Heart failure doesnt mean your heart has quit, just
that it no longer is as efficient as it once was. You have internal mechanisms that
work to try to keep your blood pressure from falling, but eventually these
mechanisms work against the hearts ability to pump blood easily.
2. It seems like you are upset. Would you like for me to call the health care
provider to explain this to you?
3. Heart failure is pretty complicated. It means the heart is failing to work.
4. Heart failure is a common problem in the United States. Many people have it.
They all have problems such as yours.
Correct Answer: It must be very confusing. Heart failure doesnt mean your heart has
quit, just that it no longer is as efficient as it once was. You have internal mechanisms that
work to try to keep your blood pressure from falling, but eventually these mechanisms
work against the hearts ability to pump blood easily.
Rationale: An explanation that helps alleviate the clients concerns may be helpful.
Contacting the health care provider is not necessary, since the nurse should know how to
respond to this question. Answering with Heart failure is pretty complicated. It means
the heart is failing to work does not provide the client with enough information. Sharing
with the client that heart failure is a common problem doesnt help the client understand
the heart issue any better.
Client Need: Psychosocial Integrity
LO: 3

Inc.
9. Which of the following nursing diagnoses is most appropriate for the client with acute
systolic heart failure?
1. Excess Fluid Volume
2. Disturbed Body Image
3. Imbalanced Nutrition: more than body requirements
4. Ineffective Airway Clearance
Correct Answer: Excess Fluid Volume
Rationale: The client with acute systolic heart failure will have excess fluid volume. If
there is an imbalance in nutrition, it is more likely to be less than body requirements.
Ineffective airway clearance is not applicable, since these clients do not have issues with
clearing the airway as much as issues with impaired gas exchange. It is not common for
the client to have disturbed body image related to heart failure.
Nursing Process: Diagnosis
LO: 3

Inc.
10. Reflecting upon the clients other symptoms and past history, the nurse determines the
client likely has right-sided heart failure when the client:
1.
2.
3.
4.
Consumes 5% of meals and complains of nausea.

Admits to anxiety over learning the new medication regimen.
Has trouble concentrating on the conversation.
Is dyspneic with activity.
Correct Answer: Consumes 5% of meals and complains of nausea.

Rationale: Poor appetite and complaints of nausea and vomiting correspond to right-sided
heart failure. Dyspnea with activity is more commonly associated with left-sided heart
failure. Anxiety over new medications and difficulty concentrating on the conversation
are not likely related to heart failure, but could be symptoms of depression.
LO: 4

Inc.
11. The client has been diagnosed with heart failure. The nurse is asked if the clients
symptoms are more likely right or left heart failure. Which of the following symptoms
would indicate left-sided heart failure?
1.
2.
3.
4.
Respiration of 36 per minute

Right upper quadrant pain
Dependent edema
Anasarca
Correct Answer: Respirations of 36 per minute

Rationale: The client with left-sided heart failure has pulmonary involvement and
therefore will be tachypneic. Right upper quadrant pain, dependent edema, and anasarca
are all symptoms of right-sided heart failure.
Nursing Process: Diagnosis
LO: 4

Inc.
12. A client with left-sided heart failure is admitted to the unit. Which item is a priority
assessment upon arrival?
1.
2.
3.
4.
Airway and oxygenation status

Neurological status
Abdominal assessment
Presence of peripheral edema
Correct Answer: Airway and oxygenation status

Rationale: The client with left-sided failure will exhibit symptoms of a respiratory nature.
The priority assessment for this client would be the airway and oxygenation status. The
neurological status will decline as the lack of oxygenation progresses. An abdominal
assessment and presence of peripheral edema will be included in the assessment, but are
more common in right-sided failure than in left-sided failure.
LO: 4

Inc.
13. The nurse is assessing a client who has been admitted with heart failure. The nurse
anticipates which of the following lab tests to be ordered to validate the severity of the
diagnosis?
1.
2.
3.
4.
BNP
CBC
Troponin
Lipid panel
Correct Answer: BNP

Rationale: A BNP, renal function, and liver function studies may provide an indication of
the severity of the heart failure. CBC, troponin, and lipid panel may give an indication of
the etiology of this clients heart failure.
LO: 5

Inc.
14. A client is admitted with heart failure. The nurse establishes a nursing diagnosis of
decreased cardiac output related to ventricular dysfunction. Which one of the following
parameters might the nurse establish to measure the clients outcome?
1.
2.
3.
4.
PCWP 612 mmHg

CO 23 L/min
BP 100/48
Daily weight same as the day before
Correct Answer: PCWP 612 mmHg

Rationale: The overall desired outcome is to achieve an adequate cardiac output. The
only parameter that is within normal limits is the PCWP of 612 mmHg. The CO and BP
are both low, which would indicate the cardiac output is still low. The daily weight would
need to be lower than the previous day to show continued weight loss.
LO: 5

Inc.
15. The client may have several diagnostic tests completed to assist with the diagnosis of
heart failure. Which of the following diagnostic studies would rule out heart failure being
present?
1. BNP 50 pg/mL
2. Hemoglobin 10g/dl
3. Sodium 148 mEq/L
4. Normal EKG
Correct Answer: BNP 50pg/mL
Rationale: A BNP within normal limits will rule out heart failure. An elevated BNP is
indicative of heart failure, but will often only be one indicator of heart failure.
Hemoglobin of 10 gm/dl is low, and heart failure clients will often have anemia. Sodium
level is slightly high. The EKG results are normal. However, the low hemoglobin, a
sodium slightly high, and a normal EKG cannot rule heart failure in or out.
LO: 5

Inc.
16. A client with heart failure will be undergoing the insertion of a pacemaker. The nurse
is providing instructions preoperatively regarding the clients length of stay following the
procedure. On which of the following will the nurse instruct the client?
1. Following the procedure and recovery, the client may expect to stay at the hospital
up to 24 hours, but often the stay is less.
2. Following the procedure, the client may expect to go home immediately.
3. Following the procedure, the client will be required to stay in the hospital up to 2
days.
4. Following the procedure, the client will be required to stay in the hospital up to a
week.
Correct Answer: Following the procedure and recovery, the client may expect to stay at
the hospital up to 24 hours, but often the stay is less.
Rationale: The client is usually kept in the facility overnight and released pending followup tests to ensure the leads and pacemaker are functioning. Only the client who
experiences unforeseen complications could expect a longer length of stay.
LO: 6

Inc.
17. A client is sent home on lisinopril (Zestril). The nurse has educated the heart failure
client on the actions of this medication. Which of the following best describes what the
nurse instructed?
1. Lisinopril is an ACE inhibitor medication. This medication will lower the blood
pressure and decrease the fluid in the body. The client may notice a cough.
2. Lisinopril is an ACE inhibitor medication that will lower the clients heart rate
and blood pressure. The client should observe closely for angioedema.
3. Lisinopril is a beta-blocking drug that will lower the clients heart rate and blood
pressure. The client should observe closely for symptoms of worsening heart
failure.
4. Lisinopril is a beta-blocker drug that will increase the pumping ability of the
heart. The client should observe closely for orthostatic hypotension.
Correct Answer: Lisinopril is an ACE inhibitor medication. This medication will lower
the blood pressure and decrease the fluid in the body. The client may notice a cough.
Rationale: ACE inhibitor medications act by preventing vasoconstriction, thus allowing
vasodilation. Since ACE inhibitors also interrupt the bodys ability to conserve sodium,
the net result is fluid loss. Lisinopril does not impact the heart rate. Angioedema and a
cough are side effects of ACE inhibitors. Angioedema should be reported to the health
care provider immediately. Lisinopril is not a beta-blocker drug and does not impact the
pumping ability of the heart. Lisinopril will not create worsening heart failure symptoms
as beta blocker can. Lisinopril can create orthostatic hypotension, so the client should be
advised to rise slowly.
LO: 6

Inc.
18. A client preparing for discharge asks the nurse about an appropriate diet. Which of the
following replies is best?
1. I will be reviewing your discharge plans with you, but I would also like to
ask the dietitian to come visit with you to help finalize your diet.
2. I am glad you asked. The health care provider will be discussing the diet with
you.
3. A special diet is important for you. Let me tell you about it in detail.
4. The pharmacist will be talking with the physician. They will let the dietitian
know what is best for you.
Correct Answer: I will be reviewing your discharge plans with you, but I would also
like to ask the dietitian to come visit with you to help finalize your diet.
Rationale: Each client has special needs for discharge planning. A multidisciplinary team
approach is important for the success of the client in managing the disease process at
home. The client should be referred to a dietitian for any special instructions related to
heart failure. While the physician is important in the health care team, the most
appropriate person to discuss the details of the diet is the dietitian, not the physician.
LO: 6

Inc.
19. The client has been instructed in the MAWDS system. Which one of the following
instructions is not included in the MAWDS method?
1.
2.
3.
4.
Avoid large crowds.

Check your pulse before taking digoxin (Lanoxin) each day.
You should rest periodically throughout the day.
Check your weight daily.
Correct Answer: Avoid large crowds.

Rationale: MAWDS stands for medication, activity, weight, diet, and symptoms.
Avoiding large crowds is not a typical instruction for a heart failure client and does not fit
with the MAWDS acronym. Checking a pulse before digoxin (medication), resting
periodically throughout the day (activity), and checking daily weights (weights) are all
part of the MAWDS method.
LO: 7

Inc.
20. The nurse recognizes that the heart failure client does not understand discharge
instructions when the client states:
1.
2.
3.
4.
I will have my spouse pick up my new medications in a few days.

I will eat a low-sodium diet.
I will contact the health care provider if I begin gaining weight.
I will increase my activity a little every day.
Correct Answer: I will have my spouse pick up my new medications in a few days.
Rationale: It is important that the client has the medication each and every day. Waiting
for a few days to pick up the medication will not be effective and could demonstrate a
misunderstanding of discharge instructions. Eating a low-sodium diet, increasing activity
slowly, and notification of a health care provider should there be weight gain all indicate
understanding.
LO: 7

Inc.
21. A client with heart failure does not have a scale to weigh on at home. What other
methods might the client be instructed to use until a scale can be purchased?
1. Instruct the client to see if his or her same belt or shoes are tighter every day.
2. Have the client observe if he or she feels heavier while wearing the same clothing
every day.
3. Suggest the client come to the health department every other week to weigh.
4. Have the client notice if his or her rings are tighter.
Correct Answer: Instruct the client to see if his or her same belt or shoes are tighter every
day.
Rationale: A heart failure client who is gaining fluid will have his or her belt or shoes get
tighter. However, the best method of measuring fluid build-up is with a scale, and the
client should be so instructed. A client will not be able to gauge feeling heavier.
Weighing at the health department every other week is not frequent enough. A client
should be advised to weigh daily and at the same time each day. A clients rings may get
tighter, but this can also be impacted by other activities and temperature.
LO: 7

Inc.
22. A diabetic client received instructions from the nurse discussing ways to minimize the
any further damage to the heart from heart failure. The client understands the instructions
when the client states the following:
1.
2.
3.
4.
I will keep my hemoglobin A1C less than 6.4.

I will take a daily walk.
I will follow a diet.
I will weight myself every day.
Correct Answer: I will keep my hemoglobin A1C less than 6.4.

Rationale: Keeping the blood sugar under control is the best way for a diabetic client with
heart failure to minimize any further damage to the heart. The other answer options are
all instructions to decrease exacerbation of heart failure.
LO: 8

Inc.
23. The client who has hypertension and heart failure might expect to be discharged on
which of the following medications?
1.
2.
3.
4.
ACE inhibitors
Digoxin (Lanoxin)
Antidysrhythmics
Anticoagulants
Correct Answer: ACE inhibitors

Rationale: The client who has both hypertension and heart failure can expect to be taking
ACE inhibitors, which impact both diseases. Digoxin is not a first-line option for a client
with both hypertension and heart failure, but is often used for heart failure alone.
Antidysrhythmics and anticoagulants are not used to treat heart failure or hypertension
unless there are other underlying comorbidities.
LO: 8

Inc.
24. A client with diabetes and heart failure can expect better outcomes from heart failure
in which of the following situations?
1. Hemoglobin A1C is 5.8%.
2. Fingerstick blood sugar is 155.
3. Hemoglobin is 14 g/dl.
4. Creatinine is 2.2 mg/dl.
Correct Answer: Hemoglobin A1C is 5.8%.
Rationale: The client who maintains strict glycemic control as evidenced by the
hemoglobin A1C being < 6% will have better heart failure outcomes. A fingerstick blood
sugar of 155 is not glycemic control and is a one-time result, whereas the hemoglobin
A1C is an average of the blood sugar over a 3-month time frame. The hemoglobin plays
no role in long-term mortality of heart failure. A creatinine of 2.2 mg/dl is high and could
indicate renal involvement.
LO: 8

Inc.
25. A client is on hospice with a diagnosis of end-stage heart failure. The family wants to
know what the goals of treatment will be. The hospice nurse relates to them that the
primary goal of treatment is tp:
1.
2.
3.
4.
Provide comfort and reduce any distressing respiratory symptoms.

Provide significant pain medications.
Keep the client out of the hospital.
Provide information to the family.
Correct Answer: To provide comfort and reduce any distressing respiratory symptoms.
Rationale: The goals of care are to provide comfort measures and reduce or eliminate any
primary symptoms that may be distressing, such as respiratory distress. The treatment
plan is not to cure the illness. Pain medications may be provided in the course of this
plan. Attempts to keep the client out of the hospital will be a goal if the client desires to
stay at home. Communication with the family and client is important to the overall plan
of care.
LO: 9

Inc.
26. The nurse has explained the seriousness of a clients condition to the family. The
family understands that which one of the following problems most increases the mortality
for their loved one with terminal heart failure?
1.
2.
3.
4.
Other serious comorbidities

Age
Positive mental attitude
Taking ACE inhibitors
Correct Answer: 1Other serious comorbidities

Rationale: Many corresponding factors impact the poor prognosis of the heart failure
client. Among them are other serious comorbidities. Age, positive mental attitude, and on
the use of ACE inhibitors do not add to the poor prognosis.
Nursing Process: Planning
LO: 9

Inc.
27. A client who has heart failure is asking about end of life. The priority for the nurses
discussion with the client is to:
1. Be as honest as possible about the progression of the disease and the support
needed.
2. Tell the client that nursing staff might be available if needed, but that family will
need to help provide client support.
3. Have the health care provider discuss end-of-life topics with the client.
4. Reassure the client that the chances for survival are good.
Correct Answer: Be as honest as possible about the progression of the disease and the
support needed.
Rationale: The heart failure client who is nearing the end of life will need honest
discussions regarding the progression of the disease and the support needed and
available. Telling the client that nursing staff might be available, but family will need to
provide support is not completely honest and likely is not helpful. The health care
provider will be involved in end-of-life discussions, but the nurse as a client advocate can
certainly discuss the end-of-life options with the client. Reassuring the client of survival
is not honest, especially given that the survival rate for heart failure clients is not good.
LO: 9

Inc.

(Osborn) Chapter 42: Learning Outcomes (Number and Title)

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[Osborn] chapter 42

Learning Outcomes [Number and Title]

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Correct Answer: 30% to 50%

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Teach clients about modifiable risk factors.

Correct Answer: Teach clients about modifiable risk factors.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

4. The nurse is performing an admission assessment on a client who presents to the

Osborn, et al., Test Item File for Medical-Surgical Nursing:

LVEF is within normal limits.

Correct Answer: LVEF is within normal limits.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Consumes 5% of meals and complains of nausea.

Correct Answer: Consumes 5% of meals and complains of nausea.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Respiration of 36 per minute

Correct Answer: Respirations of 36 per minute

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Airway and oxygenation status

Correct Answer: Airway and oxygenation status

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Correct Answer: BNP

Osborn, et al., Test Item File for Medical-Surgical Nursing:

PCWP 612 mmHg

Correct Answer: PCWP 612 mmHg

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Avoid large crowds.

Correct Answer: Avoid large crowds.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

I will have my spouse pick up my new medications in a few days.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

I will keep my hemoglobin A1C less than 6.4.

Correct Answer: I will keep my hemoglobin A1C less than 6.4.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Correct Answer: ACE inhibitors

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Provide comfort and reduce any distressing respiratory symptoms.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Other serious comorbidities

Correct Answer: 1Other serious comorbidities

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

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