TEST BANK FOR Medical-Surgical Nursing: Concepts for Clinical
Judgment and Collaborative Care (Evolve) 11th Edition by
Donna D. Ignatavicius
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Complete Test Bank with Questions and Answers
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Chapter 01: Overview of Professional Nursing Concepts for Medical- Surgical Nursing
MULTIPLE CHOICE
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1. A nurse wishes to provide client-centered care in all interactions. Which action by the
nurse best demonstrates this concept?
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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
ANS: A
Competency in client-focused care is demonstrated when the nurse focuses on communication,
culture, respect compassion, client education, and empowerment. By 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 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.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated Process: Caring NOT: 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.
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c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes.
ANS: A
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The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating
before they suffer either respiratory or cardiac arrest.
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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. Documentation is
vital, but the nurse must do more than document. The primary care provider should be notified,
but thisis not the priority over calling the RRT. The clients blood pressure should
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be reassessed frequently, but the priority is getting the rapid care to the client.
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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?
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.
,ANS: A
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 protection that being active and involved does.
DIF: Understanding/Comprehension REF: 3 KEY: Patient safety
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
Control
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4. A new nurse is working with a preceptor on an in-patient 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
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b. Ensuring client safety
c. Not making medication errors
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d. Providing client-focused care
ANS: B
All actions are appropriate for the professional nurse. However, ensuring client safety is the
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priority. Up to 98,000 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.
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Every nurse has the responsibility to guard the clients safety.
DIF: Understanding/Comprehension REF: 2 KEY: Patient safety
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
Control
5. 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.
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. This will help prevent medication
errors.
DIF: Applying/Application REF: 4
KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/Learning
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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?
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a. Asks if the client has questions before signing a consent
b. Gives the client accurate information when questioned
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c. Keeps the promises made to the client and family
d. Treats the client fairly compared to other clients
ANS: A
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Autonomy is self-determination. The client should make decisions regarding care. When the
nurse obtains a signature on the consent form, assessing if the client still has questions is vital,
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because without full information the client cannot practice autonomy. Giving accurate
information is practicing with veracity. Keeping promises is upholding fidelity. Treating the
client fairly is providing social justice.
DIF: Applying/Application REF: 4
KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
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 maybe reluctant to seek health care. The nurse should never make assumptions about the
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needs of members of this population. Rather, respectful questions are appropriate. Ifapproached
with sensitivity, the client with any health care need is more likely to answer honestly.
DIF: Understanding/Comprehension REF: 4 KEY: LGBTQ| diversity
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MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
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8. A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago
and has pain that is unrelieved by the prescribed narcotic pain medication. Which statement is
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part of the SBAR format for communication?
a. A: I would like you to order a different pain medication.
b. B: This client has allergies to morphine and codeine.
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c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
d. S: This client had a vaginal hysterectomy 2 days ago.
ANS: B
SBAR is a recommended form of communication, and the acronym stands for Situation,
Background, Assessment, and Recommendation.
Appropriate back ground information includes allergies to medications the
on-call physician might order. Situation describes what is happening right
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,thatmustbecommunicated; 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 statement of what is needed or what
outcome is desired; this information about the surgeons preference might be better placed in
background.
DIF: Applying/ApplicationREF: 5 KEY: SBAR| communication
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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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 higherthan previous readings, and the clients mental status has changed. What action by
the nurse would most likely have prevented this negative outcome?
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a. Determining if the UAP knew how to take blood pressure
b. Double-checking the UAP by taking another blood pressure
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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 about the vital
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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 are within 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.
DIF: Applying/Application REF: 6
KEY: Supervision| delegation| unlicensed 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.
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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.
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ANS: C
Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance that the
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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.
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DIF: Understanding/Comprehension REF: 2 KEY: The Joint Commission (TJC)| accreditation
MSC: Integrated Process: Communication and Documentation
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NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
Control
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 isbest?
a. All staff nurses are required to participate in quality improvementhere.
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.
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 licensednurse. Simply statingthatallnursesarerequired to participatedoesnothelpthe
nurseunderstand 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/ApplicationREF: 6 KEY: Quality improvement
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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 interdisciplinarywork ahigh priority. Which actions by
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the nursebest demonstrate this skill? (Select all that apply.)
a. Consults with other disciplines on client care
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b. Coordinates discharge planning for home safety
c. Participates in comprehensive client rounding
d. Routinely asks other disciplines about client progress
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e. Shows the nursing care plans to other disciplines
ANS: A, B, C, D
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Collaboratingwith theinterdisciplinary team involvesplanning, implementing,
andevaluatingclient care asa team with all other disciplines included. Simply showing other
caregivers the nursing care plan is not actively involving them or collaborating with them.
DIF: Applying/Application REF: 4
KEY: Collaboration| interdisciplinary team
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
,2. A nurse manager wishes to ensure that the nurses on the unit are practicing at their
highest levels of competency. Whichareasshould themanager assess to determine if thenursing
staffdemonstratecompetency according to the Institute of Medicine (IOM) report Health
Professions Education: A Bridge to Quality? (Select all that apply.)
a. Collaborating with an interdisciplinary team
b. Implementing evidence-based care
c. Providing family-focused care
d. Routinely using informatics in practice
e. Using quality improvement in client care
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ANS: A, B, D, E
The IOM reportlists five broad core competencies thatall health care providers should practice.
Theseinclude collaboratingwiththeinterdisciplinaryteam, implementingevidence-
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basedpractice, providingclient-focused care, using informatics in client care, and using quality
improvement in client care.
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DIF: Remembering/Knowledge REF: 3
KEY: Competencies| Institute of Medicine (IOM) MSC: Integrated Process: Nursing Process:
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Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
Control
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3. The nurse utilizing evidence-based practice (EBP) considers which factors when planning
care? (Select all that apply.)
a. Cost-saving measures
b. Nurses expertise
c. Client preferences
d. Research findings
e. Values of the client
, ANS: B, C, D, E
EBP consists of utilizing current evidence, the clients values and preferences, and the nurses
expertise when planning care. It does not include cost-saving measures.
DIF: Remembering/Knowledge REF: 6 KEY: Evidence-based practice (EBP)
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A nursemanagerwants to improve hand-off communication among the staff. What actions
by themanager would best help achieve this goal? (Select all that apply.)
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a. Attendhand-offrounds to coachandmentor.
b. Conduct audits of staff using a new template.
c. Create a template of topics to include in report.
d. Encourage staff to ask questions during hand-off.
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e. Give raises based on compliance with reporting.
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ANS: A, B, C, D
A good tool for standardizing hand-off reports and other critical communication is the SHARE
model. SHARE standsforstandardizecriticalinformation, hardwirewithin your system, allow
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opportunities to askquestions, reinforce quality and measurement, and educate and coach.
Attending hand-off report gives the manager opportunities to educate and coach. Conducting
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audits is part of reinforcing quality. Creating a template is hardwiring within the system.
Encouraging staff to ask questions and think critically about the information is allowing
opportunities to ask questions. The manager may need to tie raises into compliance if the staff is
resistive and other measures have failed, but this is not part of the SHARE model.
DIF: Applying/Application REF: 5 KEY: SHARE| hand-off communication
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Car
