TEST BANK
Test Bank for Medical Surgical Nursing Concepts for Clinical Judgement &
Collaborative Care
11th Edition
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,Donna D. Ignatavicius: Medical-Surgical Nursing: Concepts for Clinical Judgment
and Collaborative Care, 11th Edition
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical
Nursing MULTIPLE CHOICE
1. A nurse wishes to provide client-centered care in all interactions. Which
action by the nurse best demonstrates this concept?
a. Assesses for cultural influences affecting health care
b. Ensures that all the clients basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room
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ANS: A
Competency in client-focused care is demonstrated when the nurse focuses on
communication, culture, respect compassion, client education, and empowerment. By
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assessing the effect of the clients culture on health care, this nurse is practicing client-
focused care. Providing for basic needs does not demonstrate this competence. Simply
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telling the client about all upcoming tests is not providing empowering education.
Orienting the client and family to the room is an important safety measure, but not
directly related to demonstrating client-centered care.
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DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated
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Process: CaringNOT: Client Needs Category:
Psychosocial Integrity
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood
pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action
by the nurse is best?
a. Call the Rapid Response Team.
b. Document and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes.
ANS: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are
,deteriorating before they suffer either respiratory or cardiac arrest. Since the client has
manifested a significant change, the nurse should call the RRT. Changes in blood
pressure, mental status, heart rate, and pain are particularly significant.
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,Documentation is vital, but the nurse must do more than document. The primary
care provider should be notified, but this is not the priority over calling the RRT. The
clients blood pressure should be reassessed frequently, but the priority is getting
the rapid care to the client.
DIF: Applying/Application REF: 3
KEY: Rapid Response Team (RRT)| medical
emergencies MSC: Integrated Process:
Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is orienting a new client and family to the inpatient unit. What information
does the nurse provide to help the client promote his or her own safety?
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a. Encourage the client and family to be active partners.
b. Have the client monitor hand hygiene in caregivers.
c. Offer the family the opportunity to stay with the client.
d. Tell the client to always wear his or her armband.
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ANS: A
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Each action could be important for the client or family to perform. However,
encouraging the client to be active in his or her health care as a partner is the most
critical. The other actions are very limited in scope and do not provide the broad
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protection that being active and involved does.
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DIF:
Understanding/Comprehension
REF: 3KEY: Patient safety
,MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
Control
4. A client is going to be admitted for a scheduled surgical procedure. Which action
does the nurse explain is the most important thing the client can do to protect against
errors?
a. Bring a list of all medications and what they are for.
b. Keep the doctors phone number by the telephone.
c. Make sure all providers wash hands before entering the room.
d. Write down the name of each caregiver who comes in the room.
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ANS: A
Medication errors are the most common type of health care mistake. The Joint
Commissions Speak Up campaign encourages clients to help ensure their safety. One
recommendation is for clients to know all their medications and why they take them.
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This will help prevent medication errors.
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DIF: Applying/Application REF: 4
KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
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Control
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5. A new nurse is working with a preceptor on an inpatient medical-surgical unit. The
preceptor advises the student that which is the priority when working as a
professional nurse?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care
ANS: B
All actions are appropriate for the professional nurse. However, ensuring client safety is
the priority. Up to98,000 deaths result each year from errors in hospital care, according
to the 2000 Institute of Medicine report. Many more clients have suffered injuries and
less serious outcomes. Every nurse has the responsibility to guard the clients safety.
,DIF:
Understanding/Comprehension
REF: 2KEY: Patient safety
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
Control
6. Which action by the nurse working with a client best demonstrates respect for
autonomy?
a. Asks if the client has questions before signing a consent
b. Gives the client accurate information when questioned
c. Keeps the promises made to the client and family
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d. Treats the client fairly compared to other clients
ANS: A
Autonomy is self-determination. The client should make decisions regarding care. When
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the nurse obtains a signature on the consent form, assessing if the client still has
questions is vital, because without full information the client cannot practice autonomy.
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Giving accurate information is practicing with veracity.
Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.
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DIF: Applying/Application REF: 4
KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
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NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A student nurse asks the faculty to explain best practices when communicating with
a person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ)
community. What answer by the faculty is most accurate?
a. Avoid embarrassing the client by asking questions.
b. Dont make assumptions about their health needs.
c. Most LGBTQ people do not want to share information.
,d. No differences exist in communicating with this population.
ANS: B
Many members of the LGBTQ community have faced discrimination from health care
providers and may bereluctant to seek health care. The nurse should never make
assumptions about the needs of members of this population. Rather, respectful questions
are appropriate. If approached with sensitivity, the client with any health care need is
more likely to answer honestly.
DIF:
Understanding/Comprehension
REF: 4KEY: LGBTQ| diversity
MSC: Integrated Process: Teaching/Learning
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NOT: Client Needs Category: Psychosocial Integrity
8. A nurse is calling the on-call physician about a client who had a hysterectomy 2 days
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ago and has pain that is unrelieved by the prescribed narcotic pain medication.
Which statement is part of the SBAR format for communication?
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a. A: I would like you to order a different pain medication.
b. B: This client has allergies to morphine and codeine.
c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
d. S: This client had a vaginal hysterectomy 2 days ago.
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ANS: B
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SBAR is a recommended form of communication, and the acronym stands for
Situation, Background, Assessment, and Recommendation. Appropriate background
information includes allergies to medications theon-call physician might order.
Situation describes what is happening right now that must be communicated; the clients
surgery 2 days ago would be considered background. Assessment would include an
analysis of the clients problem; asking for a different pain medication is a
recommendation. Recommendation is a statementof what is needed or what outcome
is desired; this information about the surgeons preference might be betterplaced in
background.
DIF: Applying/Application
REF: 5KEY: SBAR|
communication
,MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced
unlicensed assistive personnel (UAP). Four hours later, the nurse notes the clients
blood pressure is much higher than previous readings, and the clients mental status
has changed. What action by the nurse would most likely have prevented this
negative outcome?
a. Determining if the UAP knew how to take blood pressure
b. Double-checking the UAP by taking another blood pressure
c. Providing more appropriate supervision of the UAP
d. Taking the blood pressure instead of delegating the task
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ANS: C
Supervision is one of the five rights of delegation and includes directing, evaluating,
and following up on delegated tasks. The nurse should either have asked the UAP
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about the vital signs or instructed the UAP to report them right away. An experienced
UAP should know how to take vital signs and the nurse should not have to assess this
at this point. Double-checking the work defeats the purpose of delegation. Vital signs
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arewithin the scope of practice for a UAP and are permissible to delegate. The only
appropriate answer is that the nurse did not provide adequate instruction to the UAP.
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DIF: Applying/Application REF: 6
KEY: Supervision| delegation| unlicensed
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assistive personnel MSC: Integrated Process:
Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
10. A nurse is talking with a client who is moving to a new state and needs to find a new
doctor and hospital there. What advice by the nurse is best?
,a. Ask the hospitals there about standard nurse-client ratios.
b. Choose the hospital that has the newest technology.
c. Find a hospital that is accredited by The Joint Commission.
d. Use a facility affiliated with a medical or nursing school.
ANS: C
Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance
that the facility has a focus on safety. Nurse-client ratios differ by unit type and change
over time. New technology doesnt necessarily mean the hospital is safe. Affiliation with a
health professions school has several advantages, but safety is most important.
DIF: Understanding/Comprehension
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REF: 2 KEY: The Joint Commission
(TJC)| accreditation
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
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11. A newly graduated nurse in the hospital states that, since she is so new, she cannot
participate in quality improvement (QI) projects. What response by the precepting
nurse is best?
a. All staff nurses are required to participate in quality improvement here.
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b. Even being new, you can implement activities designed to improve care.
c. Its easy to identify what indicators should be used to measure quality.
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d. You should ask to be assigned to the research and quality committee.
ANS: B
The preceptor should try to reassure the nurse that implementing QI measures is not
out of line for a newly licensed nurse. Simply stating that all nurses are required to
participate does not help the nurse understand how that is possible and is dismissive.
Identifying indicators of quality is not an easy, quick process and would not be the best
place to suggest a new nurse to start. Asking to be assigned to the QI committee does
not give the nurse information about how to implement QI in daily practice.
DIF: Applying/Application
REF: 6KEY: Quality
improvement
, MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. A nurse is interested in making interdisciplinary work a high priority. Which
actions by the nurse best demonstrate this skill? (Select all that apply.)
a. Consults with other disciplines on client care
b. Coordinates discharge planning for home safety
c. Participates in comprehensive client rounding
d. Routinely asks other disciplines about client progress
e. Shows the nursing care plans to other disciplines
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ANS: A, B, C, D
Collaborating with the interdisciplinary team involves planning, implementing, and
evaluating client care as a team with all other disciplines included. Simply showing other
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caregivers the nursing care plan is not actively involving them or collaborating with
them.
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DIF: Applying/Application REF: 4
KEY: Collaboration| interdisciplinary team
MSC: Integrated Process: Communication and Documentation
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NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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2. A nurse manager wishes to ensure that the nurses on the unit are practicing at their
highest levels of competency. Which areas should the manager assess to determine if
the nursing staff demonstrate competency according to the Institute of Medicine
(IOM) report Health Professions Education: A Bridge to Quality? (Select all that
apply.)
