Ignatavicius: Medical-Surgical Nursing, 7th Edition
Chapter 1: Introduction to Medical-Surgical Nursing
Test Bank
MULTIPLE CHOICE
1. Which action demonstrates that the nurse understands the purpose of the Rapid
Response Team?
a. Monitoring the client for changes in postoperative status such as wound infection
b. Documenting all changes observed in the client and maintaining a postoperative flow
sheet
c. Notifying the physician of the client’s change in blood pressure from 140 to 88 mm
Hg systolic
d. Notifying the physician of the client’s increase in restlessness after medication
change
ANS: C
The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing
care to clients before a respiratory or cardiac arrest occurs. Although the RRT does not
replace the Code Team, which responds to client arrests, it intervenes rapidly for those who
are beginning to decline clinically. It would be appropriate for the RRT to intervene when
the client has experienced a 52-point drop in blood pressure. Monitoring the client’s
postoperative status, maintaining a postoperative flow sheet, and notifying the physician of
a change in the client’s status after a medication change would not be considered activities
of the Rapid Response Team.
DIF: Cognitive Level: Comprehension/Understanding REF: pp. 2-3
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—
Collaboration with Interdisciplinary Team)
,MSC: Integrated Process: Nursing Process (Assessment)
2. The Joint Commission focuses on safety in health care. Which action by the nurse
reflects The Joint Commission’s main objective?
a. Performing range-of-motion exercises on the client three times each day
b. Ensuring that the client is eating 100% of the meals served to him or her
c. Assessing the client’s respirations when administering opioids
d. Delegating to the nursing assistant to give the client a complete bath daily
ANS: C
It is important for the nurse to assess respirations of the client when administering opioids
because of the possibility of respiratory depression. The other interventions may or may
not be necessary in the care of the client and do not focus on safety.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
Control)
MSC: Integrated Process: Nursing Process (Assessment)
3. Which action by the nurse shows an understanding of the principle of self-
determination?
a. Allowing a postoperative client to decide to take medication with fruit juice rather
than water
b. Allowing a teenager to decide not to go to a clinic when there is evidence that she is
having profuse vaginal bleeding
c. Allowing a parent to decide not to proceed with a lifesaving operation for a 12-year-
old client
d. Allowing an older client with dementia to decide not to take cardiac medication
throughout the shift
,ANS: A
Respect for people is one of three basic ethical principles that nurses and other health care
professionals should use as a basis for clinical decision making. Respect implies that clients
are treated as autonomous individuals capable of making informed decisions about their
care. This client autonomy is referred to as self-determination, or self-management, and is
best illustrated by allowing a client to decide to take medication with fruit juice rather than
water. The other answer choices would not illustrate self-determination appropriately and
might possibly endanger the client’s life.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—
Ethical Practice) MSC: Integrated Process: Nursing Process (Assessment)
4. The nurse is initiating a series of teaching sessions with an older client. What is the
nurse’s highest-priority, client-centered action before beginning the session?
a. Ensure that the client’s family is present and will participate.
b. Make certain that the client is wearing his glasses.
c. Have printed handouts ready to use during the session.
d. Schedule the session for early evening after the client’s meal.
ANS: B
The most important client-centered action is to ensure that the client is wearing his or her
glasses. The ability to see adequately will outweigh the need for family presence, use of
printed handouts, and hunger (or lack thereof).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of
Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
, 5. Which action best demonstrates the nurse using client-centered care when planning a
menu for a Vietnamese client who is newly diagnosed with diabetes?
a. Asking the client what food he or she would eat on a standard diabetic menu
b. Asking family members to make selections for the client from a diabetic menu
c. Ordering a typical diabetic meal for the client and planning diet teaching
d. Researching the Vietnamese culture before discussing diabetic meal planning
ANS: D
Client-centered care is best illustrated by the nurse researching Vietnamese culture and
native cooking before discussing meal planning. This shows that the nurse is interested and
is involved in the client’s care. The nurse can then suggest foods from the standard diabetic
menu to the client and his or her family.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition
and Oral Hydration) MSC: Integrated Process: Teaching/Learning
6. The Institute for Healthcare Improvement (IHI) identified interventions to save client
lives. Which actions are within the scope of nursing practice to improve quality of care?
a. Insert a central line to give intravenous fluid to a dehydrated client.
b. Use sterile technique when changing dressings on a new surgical site.
c. Intubate a client whose oxygen saturation is 92%.
d. Prescribe aspirin for a client who presents with an acute myocardial infarction
ANS: B
The only intervention identified within the scope of nursing practice is to use sterile
technique. Central line insertion, intubation, and prescription are functions of the physician.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
Chapter 1: Introduction to Medical-Surgical Nursing
Test Bank
MULTIPLE CHOICE
1. Which action demonstrates that the nurse understands the purpose of the Rapid
Response Team?
a. Monitoring the client for changes in postoperative status such as wound infection
b. Documenting all changes observed in the client and maintaining a postoperative flow
sheet
c. Notifying the physician of the client’s change in blood pressure from 140 to 88 mm
Hg systolic
d. Notifying the physician of the client’s increase in restlessness after medication
change
ANS: C
The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing
care to clients before a respiratory or cardiac arrest occurs. Although the RRT does not
replace the Code Team, which responds to client arrests, it intervenes rapidly for those who
are beginning to decline clinically. It would be appropriate for the RRT to intervene when
the client has experienced a 52-point drop in blood pressure. Monitoring the client’s
postoperative status, maintaining a postoperative flow sheet, and notifying the physician of
a change in the client’s status after a medication change would not be considered activities
of the Rapid Response Team.
DIF: Cognitive Level: Comprehension/Understanding REF: pp. 2-3
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—
Collaboration with Interdisciplinary Team)
,MSC: Integrated Process: Nursing Process (Assessment)
2. The Joint Commission focuses on safety in health care. Which action by the nurse
reflects The Joint Commission’s main objective?
a. Performing range-of-motion exercises on the client three times each day
b. Ensuring that the client is eating 100% of the meals served to him or her
c. Assessing the client’s respirations when administering opioids
d. Delegating to the nursing assistant to give the client a complete bath daily
ANS: C
It is important for the nurse to assess respirations of the client when administering opioids
because of the possibility of respiratory depression. The other interventions may or may
not be necessary in the care of the client and do not focus on safety.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
Control)
MSC: Integrated Process: Nursing Process (Assessment)
3. Which action by the nurse shows an understanding of the principle of self-
determination?
a. Allowing a postoperative client to decide to take medication with fruit juice rather
than water
b. Allowing a teenager to decide not to go to a clinic when there is evidence that she is
having profuse vaginal bleeding
c. Allowing a parent to decide not to proceed with a lifesaving operation for a 12-year-
old client
d. Allowing an older client with dementia to decide not to take cardiac medication
throughout the shift
,ANS: A
Respect for people is one of three basic ethical principles that nurses and other health care
professionals should use as a basis for clinical decision making. Respect implies that clients
are treated as autonomous individuals capable of making informed decisions about their
care. This client autonomy is referred to as self-determination, or self-management, and is
best illustrated by allowing a client to decide to take medication with fruit juice rather than
water. The other answer choices would not illustrate self-determination appropriately and
might possibly endanger the client’s life.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—
Ethical Practice) MSC: Integrated Process: Nursing Process (Assessment)
4. The nurse is initiating a series of teaching sessions with an older client. What is the
nurse’s highest-priority, client-centered action before beginning the session?
a. Ensure that the client’s family is present and will participate.
b. Make certain that the client is wearing his glasses.
c. Have printed handouts ready to use during the session.
d. Schedule the session for early evening after the client’s meal.
ANS: B
The most important client-centered action is to ensure that the client is wearing his or her
glasses. The ability to see adequately will outweigh the need for family presence, use of
printed handouts, and hunger (or lack thereof).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of
Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
, 5. Which action best demonstrates the nurse using client-centered care when planning a
menu for a Vietnamese client who is newly diagnosed with diabetes?
a. Asking the client what food he or she would eat on a standard diabetic menu
b. Asking family members to make selections for the client from a diabetic menu
c. Ordering a typical diabetic meal for the client and planning diet teaching
d. Researching the Vietnamese culture before discussing diabetic meal planning
ANS: D
Client-centered care is best illustrated by the nurse researching Vietnamese culture and
native cooking before discussing meal planning. This shows that the nurse is interested and
is involved in the client’s care. The nurse can then suggest foods from the standard diabetic
menu to the client and his or her family.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition
and Oral Hydration) MSC: Integrated Process: Teaching/Learning
6. The Institute for Healthcare Improvement (IHI) identified interventions to save client
lives. Which actions are within the scope of nursing practice to improve quality of care?
a. Insert a central line to give intravenous fluid to a dehydrated client.
b. Use sterile technique when changing dressings on a new surgical site.
c. Intubate a client whose oxygen saturation is 92%.
d. Prescribe aspirin for a client who presents with an acute myocardial infarction
ANS: B
The only intervention identified within the scope of nursing practice is to use sterile
technique. Central line insertion, intubation, and prescription are functions of the physician.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
