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 Edition
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MULTIPLE CHOICE gy
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 gy gy gy gy
b. Ensuring client safety gy gy
c. Not making medication errors gy gy gy
d. Providing client-focused care gy gy
ACCURATE ANSWER: B gy g y
Rationale:All actions are appropriate for the professional nurse. However, ensuring clie gy gy gy gy gy gy gy gy gy gy
nt safety is thepriority. Health care errors have been widely reported for 25 years, many
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of which result inclient injury, death, and increased health care costs. There are several
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national and international organizations that have either recommended or mandated sa
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fety initiatives. gy
Every nurse has the responsibility to guard the client’s safety. The other actions are impor
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tantfor quality nursing, but they are not as vital as providing safety. Not making medicatio
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n 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 g y gy gy gy gy gy gy gy
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
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his or her own safety?
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a. Encourage the client and family to be active partners. gy gy gy gy gy gy gy gy
b. Have the client monitor hand hygiene in caregivers. gy gy gy gy gy gy gy
c. Offer the family the opportunity to stay with the client. gy gy gy gy gy gy gy gy gy
d. Tell the client to always wear his or her armband. gy gy gy gy gy gy gy gy gy
ACCURATE ANSWER: gy g y
A
Rationale:Each action could be important for the client or family to perform. However, enc gy gy gy gy gy gy gy gy gy gy gy gy gy
ouraging theclient to be active in his or her health care as a safety partner is the most critic
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al. The other actions are very limited in scope and do not provide the broad protection tha
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t being active andinvolved does.
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DIF: Understanding
TOP: Integrated Process: Teaching/LearningKEY: Client safety g y gy gy gy gy gy
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 pressu
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re was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the
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nursetake first?
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a. Call the Rapid Response Team. gy gy gy gy
, b. Document and continue to monitor. gy gy gy gy
c. Notify the primary health care provider. gy gy gy gy gy
d. Repeat the blood pressure in 15 minutes. gy gy gy gy gy gy
ACCURATE ANSWER: A gy g y
Rationale:The purpose of the Rapid Response Team (RRT) is to intervene when clients are gy gy gy gy gy gy gy gy gy gy gy gy gy
deterioratingbefore they suffer either respiratory or cardiac arrest. Since the client has m
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anifested a significant change, the nurse would call the RRT. Changes in blood pressure, m
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ental status, heart rate, temperature, oxygen saturation, and last 2 hours’ urine output are
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particularly significant and are part of the Modified Early Warning System guide. Docume gy gy gy gy gy gy gy gy gy gy gy gy
ntation is vital, but the nurse must do more than document. The primary health care provi
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der would be notified, but this is not more important than calling the RRT. The client’s blo
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od pressure would be reassessed frequently, but the priority is getting the rapid care to th
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e client. gy
DIF: Applying
TOP: Integrated Process: Communication and DocumentationKEY: Rapid g y gy gy gy gy gy gy gy
Response Team (RRT), Clinical judgment gy gy gy gy
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? gy gy gy
a. Assesses for cultural influences affecting health care. gy gy gy gy gy gy
b. Ensures that all the client’s basic needs are met. gy gy gy gy gy gy gy gy
c. Tells the client and family about all upcoming tests. gy gy gy gy gy gy gy gy
d. Thoroughly orients the client and family to the room. gy gy gy gy gy gy gy gy
ACCURATE ANSWER: A gy g y
Rationale:Showing respect for the client and family’s preferences and needs is essential t gy gy gy gy gy gy gy gy gy gy gy gy
o 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-
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focused care. Providing for basic needs does not demonstrate this competence. Simply te
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lling the client about all upcoming tests is not providing empowering education. Orientin
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g the client and family to the room is an importantsafety measure, but not directly related
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to demonstrating client-centered care.
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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
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thenurse 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. gy gy gy gy gy gy gy gy gy gy
b. Keep the provider’s phone number by the telephone. gy gy gy gy gy gy gy
c. Make sure that all providers wash hands before entering the room.gy gy gy gy gy gy gy gy gy gy
d. Write down the name of each caregiver who comes in the room. gy gy gy gy gy gy gy gy gy gy gy
ACCURATE ANSWER: A gy g y
Rationale:Medication reconciliation is a formal process in which the client’s actual current gy gy gy gy gy gy gy gy gy gy gy gy
medicationsare compared to the prescribed medications at the time of admission, traccur gy gy gy gy gy gy gy gy gy gy gy gy
ate answerfer, or discharge. This National client Safety Goal is important to reduce medica
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tion errors. The client would not have to be responsible for providers washing their hands
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, and even if the client does so, this is too narrow to be the most important action to preven
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, t errors. Keeping the provider’s phone number nearby and documenting everyone who en
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ters the room also do not guarantee safety.
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DIF: Applying
TOP: Integrated Process: Teaching/LearningKEY: Client g y gy gy gy gy gy
safety, Informatics gy
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. gy gy gy gy gy gy gy gy gy
b. Gives the client accurate information when questioned. gy gy gy gy gy gy
c. Keeps the promises made to the client and family. gy gy gy gy gy gy gy gy
d. Treats the client fairly compared to other clients. gy gy gy gy gy gy gy
ACCURATE ANSWER: A gy g y
Rationale:Autonomy is self- gy gy
determination. The client would make decisions regarding care. When the nurse obtains a gy gy gy gy gy gy gy gy gy gy gy gy gy
signature on the consent form, assessing if the client still has questions is vital,because wit
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hout full information the client cannot practice autonomy. Giving accurate information is
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practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly i
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s providing social justice.
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DIF: Applying TOP: Integrated Process: Caring g y gy gy
KEY: Ethics, AutonomyMSC: Client Needs Category: Safe and Effective Care Envi gy gy gy g y gy gy gy gy gy gy gy
ronment: Management of Care gy gy gy
7. A nurse asks a more seasoned colleague to explain best practices when communicating wi
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th aperson from the lesbian, gay, bisexual, traccurate answergender, and questioning/qu
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eer (LGBTQ) community. What accurate answerwer by the faculty is most accurate?
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a. Avoid embarrassing the client by asking questions. gy gy gy gy gy gy
b. Don’t make assumptions about his or her health needs. gy gy gy gy gy gy gy gy
c. Most LGBTQ people do not want to share information. gy gy gy gy gy gy gy gy
d. No differences exist in communicating with this population.
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ACCURATE ANSWER: B gy g y
Rationale:Many members of the LGBTQ community have faced discrimination from healt gy gy gy gy gy gy gy gy gy gy
h care providers and may be reluctant to seek health care. The nurse would never make as
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sumptions about the needs of members of this population. Rather, respectful questions ar gy gy gy gy gy gy gy gy gy gy gy gy
e appropriate. Ifapproached with sensitivity, the client with any health care need is more l
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ikely to accurate answerwer honestly.
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DIF: Understanding TOP: Integrated Process: Teaching/Learning g y gy gy
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 pai
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n that is unrelieved by the prescribed opioid pain medication. Which statement compr
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ises 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.” gy gy gy gy gy gy gy
c. “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.”
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d. “This client had a vaginal hysterectomy 2 days ago.” gy gy gy gy gy gy gy gy
ACCURATE ANSWER: B gy g y
