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TEST BANK For Medical-Surgical Nursing 10th Edition Concepts for Interprofessional Collaborative Care, by Donna D. Ignatavicius, All chapters 1 – 69$18.49
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MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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2. A nurse is orienting a new client and family to the medical-
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surgical unit. What information does the nurse provide to best help the client promote h
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is or her own safety?
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a. Encourage the client and family to be active partners. tx tx tx tx tx tx tx tx
b. Have the client monitor hand hygiene in caregivers.
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c. Offer the family the opportunity to stay with the client.
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d. Tell the client to always wear his or her armband.
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CORRECT ANSWER: A
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, Each action could be important for the client or family to perform. However, encouraging th
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e client to be active in his or her health care as a safety partner is the most critical. The oth
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er actions are very limited in scope and do not provide the broad protection that being activ
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MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressur
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e was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the n
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urse take first?
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a. Call the Rapid Response Team.
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b. Document and continue to monitor. tx tx tx tx
c. Notify the primary health care provider.
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d. Repeat the blood pressure in 15 minutes.
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, CORRECT ANSWER: A tx tx
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deterioratin
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g before they suffer either respiratory or cardiac arrest. Since the client has manifested a sig
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nificant change, the nurse would call the RRT. Changes in blood pressure, mental status, he
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art rate, temperature, oxygen saturation, and last 2 hours’ urine output are particularly sign
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ificant and are part of the Modified Early Warning System guide. Documentation is vital, but
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the nurse must do more than document. The primary health care provider would be notifie
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d, but this is not more important than calling the RRT. The client’s blood pressure would be
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reassessed frequently, but the priority is getting the rapid care to the client.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation KEY: Rapid R
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esponse Team (RRT), Clinical judgment tx tx tx tx
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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4. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse
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best demonstrates this concept?
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a. Assesses for cultural influences affecting health care. tx tx tx tx tx tx
b. Ensures that all the client’s basic needs are met. tx tx tx tx tx tx tx tx
c. Tells the client and family about all upcoming tests.
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d. Thoroughly orients the client and family to the room. tx tx tx tx tx tx tx tx
CORRECT ANSWER: A tx tx
Showing respect for the client and family’s preferences and needs is essential to ensure a h
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olistic or “whole- tx tx
person” approach to care. By assessing the effect of the client’s culture on health care, this
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nurse is practicing client- tx tx tx
focused care. Providing for basic needs does not demonstrate this competence. Simply telli
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ng the client about all upcoming tests is not providing empowering education. Orienting the
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client and family to the room is an important safety measure, but not directly related to de
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monstrating client-centered care. tx tx
DIF: Understanding
TOP: Integrated Process: Culture and Spirituality KEY: Client-centered care, Culture
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MSC: Client Needs Category: Psychosocial Integrity
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5. A client is going to be admitted for a scheduled surgical procedure. Which action does t
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he nurse explain is the most important thing the client can do to protect against errors
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?
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