TEST BANK for Medical-Surgical Nursing: Concepts
for Clinical Judgment and Collaborative Care
11th Edition by Donna D. Ignatavicius,
All chapters 1 - 74
,
,
,Chapter 01: Overview of Professional Nursing Concepts for Medical- ju ju ju ju ju ju ju ju
Surgical Nursing
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MULTIPLE CHOICE j u
1. A nurse wishes to provide client-ju ju ju ju ju
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 j u j u j u j u j u j u
b. Ensures that all the clients basic needs are met ju ju j u ju j u j u ju ju
c. Tells the client and family about all upcoming tests ju ju j u ju j u j u j u j u
d. Thoroughly orients the client and family to the room j u j u ju j u j u j u j u j u
CORRECT ANSWER: A ju j u
Competency in client- ju ju
focused care is demonstrated when the nurse focuses on communication, culture, respect compassion, client education,
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andempowerment. Byassessing the effect of the clients culture onhealthcare, this nurse is practicing client-
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focused care. Providing for basic needs does not demonstrate this competence. Simplytellingthe clienta bouta llupco
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mingtestsisnotproviding empowering education. Orienting the client and family to the room is an important safety me
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asure, but not directly related to demonstrating client-centered care.
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DIF: Understanding/Comprehension REF: 3 j u j u j u
KEY: Patient- ju
centered care| culture MSC: Integrated Process: Caring NOT: Client Nee ju ju ju ju ju ju ju ju ju
ds Category: Psychosocial Integrity
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2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76 mm Hg 30 min
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utes ago, and now is 88/50 mm Hg. What action by the nurse is best?
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a. Call the Rapid Response Team. j u ju j u ju
b. Document and continue to monitor. j u ju j u j u
c. Notify the primary care provider. j u ju j u ju
d. Repeat blood pressure measurement in 15 minutes. j u j u j u j u j u j u
CORRECT ANSWER: A ju j u
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer eith
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er respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse should call the RRT. Chan
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ges in blood pressure, mental status, heart rate, and pain are particularly significant.
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Documentation isvital,butthe nurse mustdo morethandocument. The primarycareprovider shouldbe notified, uj uj uj uj uj uj uj uj uj uj uj uj uj uj uj uj ju ju
but this is not the priority over calling the RRT. The clients blood pressure should be reassessed frequently, but the
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priority is getting the rapid care to the client. ju ju ju ju ju ju ju ju
DIF: Applying/Application REF: 3 j u j u j u
KEY: Rapid Response Team (RRT)| medical emergencies MSC: ju ju ju ju ju ju j u ju
Integrated Process: Communication and Documentation ju ju ju ju
,NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
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3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to help the cli
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ent promote his or her own safety?
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a. Encourage the client and family to be active partners. ju ju j u ju j u j u j u j u
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 ju j u
Each action could be important for the client or family to perform. However, encouraging the client to be active inhi
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sor her healthcareasa partner isthe most critical. The other a ctions areverylimited inscope and do not provide the broa
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d protection that being active and involved does.
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DIF: Understanding/Comprehension REF: 3 K
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EY: Patient safety
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,MSC: Integrated Process: Teaching/Learning
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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 inpatient medical-
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surgical unit. The preceptor advises the student that which is the priority when working as a professional nurse?
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a. Attending to holistic client needs j u j u j u j u
b. Ensuring client safety j u j u
c. Not making medication errors j u j u j u
d. Providing client-focused care j u j u
CORRECT ANSWER: B ju j u
All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up to 98,000 de
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aths result each year from errors in hospital care, according to the 2000 Institute of Medicine report. Many more clients h
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ave suffered injuries and less serious outcomes. Every nurse has the responsibility to guard the clients safety.
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DIF: Understanding/Comprehension REF: 2 K
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EY: Patient safety
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MSC: Integrated Process: Nursing Process: Intervention
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NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most i
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mportant thing the client can do to protect against errors? ju ju ju ju ju ju ju ju ju
a. Bring a list of all medications and what they are for.
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b. Keep the doctors phone number by the telephone.
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c. Make sure all providers wash hands before entering the room.
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d. Write down the name of each caregiver who comes in the room.
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CORRECT ANSWER: A ju j u
Medication errors are the most common type of health care mistake. The Joint Commissions Speak Up campaign en ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
courages clients to help ensure their safety. One recommendation is for clients to know all their medications and why the
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y take them. This will help prevent medication errors.
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DIF: Applying/Application REF: 4
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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
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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
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b. Gives the client accurate information when questioned ju j u j u j u j u j u
c. Keeps the promises made to the client and family ju ju j u ju ju j u ju j u
d. Treats the client fairly compared to other clients ju ju j u j u j u ju j u
CORRECT ANSWER: A ju j u
Autonomy is self- ju ju
,determination. The client should make decisions regarding care. When the nurse obtains a signature on the consent for
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m, assessing if the client still has questions is vital, because without full information the client cannot practice auton
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omy. Giving accurate information is practicing with veracity.
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Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.
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DIF: Applying/Application REF: 4
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KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
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NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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7. A student nurse asks the faculty to explain best practices when communicating with a person from the lesbian, gay
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, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the faculty is most accurate?
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a. Avoid embarrassing the client by asking questions.
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b. Dont make assumptions about their health needs.
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c. Most LGBTQ people do not want to share information.
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,d. No differences exist in communicating with this population.
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CORRECT ANSWER: B ju j u
Many members of the LGBTQ community have faced discrimination from health care providers and may be reluctant to
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seekhealth care.The nurseshouldnever makea ssumptions about the needs of members of this population. Rather, res
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pectful questions are appropriate. If approached with sensitivity, the client with any health care need is more likely to
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answer honestly. ju
DIF: Understanding/Comprehension REF: 4 K ju ju ju ju
EY: LGBTQ| diversity ju ju
MSC: Integrated Process: Teaching/Learning j u j u j u
NOT: Client Needs Category: Psychosocial Integrity j u j u j u j u j u
8. A nurse is calling the on- ju ju ju ju ju
call physician about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed narc
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otic 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.
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b. B: This client has allergies to morphine and codeine.
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c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
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d. S: This client had a vaginal hysterectomy 2 days ago.
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CORRECT ANSWER: B ju j u
SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment,
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andRecommendation. Appropriate backgroundinformation includesa llergiesto medications the on-
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call physician might order. Situation describes what is happening right now that must be communicated; the clients surge
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ry 2 days ago would be considered background. Assessment would include an analysis of the clients problem; askin
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g for a different pain medication is a recommendation. Recommendation is a statement of what is needed or what outc
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ome is desired; this information about the surgeons preference might be better placed in background.
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DIF: Applying/Application REF: 5 KE ju ju ju ju
Y: SBAR| communication
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MSC: Integrated Process: Communication and Documentation j u j u j u j u j u
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 person
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nel (UAP). Four hours later, the nurse notes the clients blood pressure is much higher than previous readings, and th
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e clients mental status has changed. What action by the nurse would most likely have prevented this negative o
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utcome?
a. Determining if the UAP knew how to take blood pressure j u ju ju j u j u j u j u ju j u
b. Double-checking the UAP by taking another blood pressure j u j u j u j u j u j u j u
c. Providing more appropriate supervision of the UAP j u j u j u j u j u j u
d. Taking the blood pressure instead of delegating the task j u j u j u j u j u j u j u j u
,CORRECT ANSWER: C ju j u
Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated
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tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP to report them right aw
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ay. An experienced UAP should know how to take vital signs and the nurse should not have to assess this at this point.
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Double-
checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a UAP and are perm
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issible 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
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KEY: Supervision| delegation| unlicensed assistive personnel MS
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C: 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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10. Anurseistalkingwitha client whois movingtoa newstatea ndneedstofinda new doctor andhospital there. Wha
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t advice by the nurse is best?
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, a. Ask the hospitals there about standard nurse-client ratios. j u j u j u j u j u j u j u
b. Choose the hospital that has the newest technology. ju ju ju j u ju j u ju
c. Find a hospital that is accredited by The Joint Commission. ju ju ju ju ju j u ju ju ju
d. Use a facility affiliated with a medical or nursing school. ju ju ju ju j u ju j u j u j u
CORRECT ANSWER: C ju j u
Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance that the facility has a focus on s ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
afety. Nurse- ju
client ratios differ by unit type and change over time. New technology doesnt necessarily meanthe hospitalissafe.A
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ffiliation witha health professions school hasseveraladvantages, but safety is most important. uj ju uj ju uj uj uj uj uj ju ju ju ju
DIF: Understanding/Comprehension REF: 2 KEY:
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The Joint Commission (TJC)| accreditation
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MSC: Integrated Process: Communication and Documentation j u j u j u j u j u
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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11. A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improve
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ment (QI) projects. What response by the precepting nurse is best?
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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. j u ju j u ju j u j u j u j u j u j u
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. ju ju ju ju ju ju ju ju j u ju ju
CORRECT ANSWER: B ju j u
The preceptor should try to reassure the nurse that implementing QI measures is not out of line for a newly licensed n
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urse. Simply stating that all nurses are required to participate does not help the nurse understand how thatispossible andi
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sdismissive. Identifying indicators of qualityisnot aneasy, quick process a ndwouldnot be the best place to suggest a n
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ew nurse to start. Asking to be assigned to the QI committee does not give the nurse information about how to implem
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ent QI in daily practice.
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DIF: Applying/Application REF: 6 KE ju ju ju ju
Y: Quality improvement
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MSC: Integrated Process: Communication and Documentation j u j u j u j u j u
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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MULTIPLE RESPONSE j u
1. A nurse is interested in making interdisciplinary work a high priority. Which actions by the nurse best demonst
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rate this skill? (Select all that apply.)
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a. Consults with other disciplines on client care ju j u j u j u j u j u
b. Coordinates discharge planning for home safety j u j u j u j u j u
c. Participates in comprehensive client rounding j u j u j u j u
d. Routinely asks other disciplines about client progress j u j u j u j u j u j u
e. Shows the nursing care plans to other disciplines ju j u j u ju j u ju j u
