Medical-Surgical Nursing:
Concepts for Clinical Judgment and Collaborative Care 11th
Edition by Ignatavicius
Chapters 1-69
,Concepts for Medical-Surgical NursingIgnatavicius: Medical-
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Surgical Nursing, 11th Editionfg fg fg
MULTIPLE CHOICE fg
1. A new nurse is working with a preceptor on a medical-
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surgical unit. The preceptor advises thenew nurse that which is the priority when working
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as a professional nurse?
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a. Attending to holistic client needs fg fg fg fg
b. Ensuring client safety fg fg
c. Not making medication errors fg fg fg
d. Providing client-focused care fg fg
ACCURATE ANSWER: B fg f g
Rationale:All actions are appropriate for the professional nurse. However, ensuring clien fg fg fg fg fg fg fg fg fg fg
t safety is thepriority. Health care errors have been widely reported for 25 years, many of
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which result inclient injury, death, and increased health care costs. There are several nat
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ional and international organizations that have either recommended or mandated safety
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initiatives.
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Every nurse has the responsibility to guard the client’s safety. The other actions are import
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antfor quality nursing, but they are not as vital as providing safety. Not making medication
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errorsdoes provide safety, but is too narrow in scope to be the best accurate answerwer.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: InterventionKEY: Client safety f g fg fg fg fg gf fg fg
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 informationdoes the nurse provide to best help the client promote hi
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s or her own safety?
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a. Encourage the client and family to be active partners. fg fg fg fg fg fg fg fg
b. Have the client monitor hand hygiene in caregivers. fg fg fg fg fg fg fg
c. Offer the family the opportunity to stay with the client. fg fg fg fg fg fg fg fg fg
d. Tell the client to always wear his or her armband. fg fg fg fg fg fg fg fg fg
ACCURATE ANSWER: A fg f g
Rationale:Each action could be important for the client or family to perform. However, enc fg fg fg fg fg fg fg fg fg fg fg fg fg
ouraging theclient to be active in his or her health care as a safety partner is the most critica
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l. The other actions are very limited in scope and do not provide the broad protection that b
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eing active andinvolved does. fg fg gf fg
DIF: Understanding
TOP: Integrated Process: Teaching/LearningKEY: Client safety f g fg fg gf fg fg
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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ursetake first? gf fg
a. Call the Rapid Response Team. fg fg fg fg
b. Document and continue to monitor. fg fg fg fg
, c. Notify the primary health care provider. fg fg fg fg fg
d. Repeat the blood pressure in 15 minutes. fg fg fg fg fg fg
ACCURATE ANSWER: A fg f g
Rationale:The purpose of the Rapid Response Team (RRT) is to intervene when clients are fg fg fg fg fg fg fg fg fg fg fg fg fg fg
deterioratingbefore they suffer either respiratory or cardiac arrest. Since the client has ma gf fg fg fg fg fg fg fg fg fg fg fg fg
nifested a significant change, the nurse would call the RRT. Changes in blood pressure, men
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tal status, heart rate, temperature, oxygen saturation, and last 2 hours’ urine output are par
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ticularly significant and are part of the Modified Early Warning System guide. Documentati
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on is vital, but the nurse must do more than document. The primary health care provider w
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ould be notified, but this is not more important than calling the RRT. The client’s blood pres
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sure would be reassessed frequently, but the priority is getting the rapid care to the client.
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DIF: Applying
TOP: Integrated Process: Communication and DocumentationKEY: Rapid f g fg fg fg fg gf fg fg
Response Team (RRT), Clinical judgment fg fg fg fg
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? fg fg fg
a. Assesses for cultural influences affecting health care. fg fg fg fg fg fg
b. Ensures that all the client’s basic needs are met. fg fg fg fg fg fg fg fg
c. Tells the client and family about all upcoming tests. fg fg fg fg fg fg fg fg
d. Thoroughly orients the client and family to the room. fg fg fg fg fg fg fg fg
ACCURATE ANSWER: A fg f g
Rationale:Showing respect for the client and family’s preferences and needs is essential to fg fg fg fg fg fg fg fg fg fg fg fg f
ensure a holistic or “whole-
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person” approach to care. By assessing the effect of the client’s culture onhealth care, this
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nurse is practicing client- fg fg fg
focused care. Providing for basic needs does not demonstrate this competence. Simply tell
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ing the client about all upcoming tests is not providing empowering education. Orienting t
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he client and family to the room is an importantsafety measure, but not directly related to
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demonstrating client-centered care. fg fg
DIF: Understanding
TOP: Integrated Process: Culture and Spirituality KEY: Client-centered care, Culture
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MSC: Client Needs Category: Psychosocial Integrity f g fg fg fg fg
5. A client is going to be admitted for a scheduled surgical procedure. Which action does t
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henurse explain is the most important thing the client can do to protect against errors?
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a. Bring a list of all medications and what they are for. fg fg fg fg fg fg fg fg fg fg
b. Keep the provider’s phone number by the telephone. fg fg fg fg fg fg fg
c. Make sure that all providers wash hands before entering the room. fg fg fg fg fg fg fg fg fg fg
d. Write down the name of each caregiver who comes in the room. fg fg fg fg fg fg fg fg fg fg fg
ACCURATE ANSWER: A fg f g
Rationale:Medication reconciliation is a formal process in which the client’s actual current fg fg fg fg fg fg fg fg fg fg fg fg
medicationsare compared to the prescribed medications at the time of admission, traccura gf fg fg fg fg fg fg fg fg fg fg fg
te answerfer, or discharge. This National client Safety Goal is important to reduce medicati
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on errors. The client would not have to be responsible for providers washing their hands, a
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nd even if the client does so, this is too narrow to be the most important action to prevent er
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rors. Keeping the provider’s phone number nearby and documenting everyone who enters
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the room also do not guarantee safety.
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, DIF: Applying
TOP: Integrated Process: Teaching/LearningKEY: Client f g fg fg gf fg fg
safety, Informatics fg
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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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. fg fg fg fg fg fg fg fg fg
b. Gives the client accurate information when questioned. fg fg fg fg fg fg
c. Keeps the promises made to the client and family. fg fg fg fg fg fg fg fg
d. Treats the client fairly compared to other clients. fg fg fg fg fg fg fg
ACCURATE ANSWER: A fg f g
Rationale:Autonomy is self- fg fg
determination. The client would make decisions regarding care. When the nurse obtains a s fg fg fg fg fg fg fg fg fg fg fg fg fg
ignature on the consent form, assessing if the client still has questions is vital,because with
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out full information the client cannot practice autonomy. Giving accurate information is pr
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acticing with veracity. Keeping promises is upholding fidelity. Treating the client fairly is pr
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oviding social justice. fg fg
DIF: Applying TOP: Integrated Process: Caring f g fg fg
KEY: Ethics, AutonomyMSC: Client Needs Category: Safe and Effective Care Envir fg fg gf f g fg fg fg fg fg fg fg
onment: Management of Care fg fg fg
7. A nurse asks a more seasoned colleague to explain best practices when communicating wit
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h aperson from the lesbian, gay, bisexual, traccurate answergender, and questioning/quee
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r (LGBTQ) community. What accurate answerwer by the faculty is most accurate?
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a. Avoid embarrassing the client by asking questions. fg fg fg fg fg fg
b. Don’t make assumptions about his or her health needs. fg fg fg fg fg fg fg fg
c. Most LGBTQ people do not want to share information. fg fg fg fg fg fg fg fg
d. No differences exist in communicating with this population.
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ACCURATE ANSWER: B fg f g
Rationale:Many members of the LGBTQ community have faced discrimination from health fg fg fg fg fg fg fg fg fg fg fg
care providers and may be reluctant to seek health care. The nurse would never make assu
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mptions about the needs of members of this population. Rather, respectful questions are ap
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propriate. Ifapproached with sensitivity, the client with any health care need is more likely fg gf fg fg fg fg fg fg fg fg fg fg fg fg fg
to accurate answerwer honestly.
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DIF: Understanding TOP: Integrated Process: Teaching/Learning f g fg fg
KEY: Health care disparities, LGBTQ
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8. A nurse is calling the on-
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call health care provider about a client who had a hysterectomy 2days ago and has pain
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that is unrelieved by the prescribed opioid pain medication. Which statement comprise
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s the background portion of the SBAR format for communication?
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a. “I would like you to order a different pain medication.”
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b. “This client has allergies to morphine and codeine.” fg fg fg fg fg fg fg
c. “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.”
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d. “This client had a vaginal hysterectomy 2 days ago.” fg fg fg fg fg fg fg fg
ACCURATE ANSWER: B fg f g
