TEST BANK FOR
MEDICAL SURGICAL :CONCEPTS
FOR INTERPROFFESSIONAL
COLLABORATIVE CARE 9TH
EDITION IGNATAVICIUS
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1
Chapter 01: Overview of Professional Nursing Concepts for Medical-
Surgical Nursing
MULTIPLE CHOICE
1. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse
best demonstrates this concept?
a. Assesses for cultural influences affecting health care
b. Ensures that all the clients basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room
ANS: A
Competency in client-focused care is demonstrated when the nursefocuses on communication, culture,
respect compassion, client education, and empowerment. By assessing the effect of the clients culture on
health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this
competence. Simply telling the client about all upcoming tests is not providing empowering education.
Orienting the client andfamily to theroom is animportantsafetymeasure,
butnotdirectlyrelatedtodemonstratingclient-centered care.
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76
mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse isbest?
a. Call the Rapid Response Team.
b. Document and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes.
ANS: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they
suffereitherrespiratoryorcardiacarrest. Sincetheclienthasmanifestedasignificantchange, thenurseshould
call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significant.
Documentation is vital, but the nursemust do more than document. The primary care provider
should be notified, but this is not the priority over calling the RRT. The clients blood pressure should
be reassessed frequently, but the priority is getting the rapid care to theclient.
DIF: Applying/Application REF: 3
KEY: Rapid Response Team (RRT)| medical emergencies
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse
provide to help the client promote his or her own safety?
a. Encourage the client and family to be active partners.
b. Have the client monitor hand hygiene in caregivers.
c. Offer the family the opportunity to stay with the client.
d. Tell the client to always wear his or her armband.
ANS: A
Each action could be important for the client or family to perform. However, encouraging the client to be
active in his or her health care as a partner is the most critical. The other actions are very limited in
scope and do not provide the broad protection that being active and involveddoes.
,MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
4. A new nurse is working with a preceptor on an inpatientmedical-surgical unit. The preceptor advises
the student that which is the priority when working as a professionalnurse?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care
ANS: B
All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up to
98,000 deaths result each year from errors in hospital care, according to the 2000 Institute of Medicine
report. Many more clients have suffered injuries and less serious outcomes. Every nurse has the
responsibility to guard the clients safety.
DIF: Understanding/Comprehension REF: 2
KEY: Patient safety
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse
explain is the most important thing the client can do to protect againsterrors?
a. Bring a list of all medications and what they are for.
b. Keep the doctors phone number by the telephone.
c. Make sure all providers wash hands before entering the room.
d. Write down the name of each caregiver who comes in the room.
ANS: A
Medication errors are the most common type of health care mistake. The Joint Commissions Speak Up
campaign encourages clients to help ensure their safety. One recommendation is for clients to know all their
medications and why they take them. This will help prevent medication errors.
DIF: Applying/Application REF: 4
KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
a. Asks if the client has questions before signing a consent
b. Gives the client accurate information when questioned
c. Keeps the promises made to the client and family
d. Treats the client fairly compared to other clients
ANS: A
Autonomy is self-determination. The client should make decisions regarding care. When the nurseobtainsa
signature on the consent form, assessing if the client still has questions is vital, because without full
information the client cannot practice autonomy. Giving accurate information is practicing with veracity.
Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.
DIF: Applying/Application REF: 4
KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A student nurse asks the faculty to explain best practices when communicating with a person from the
lesbian, gay, bisexual, transgender, andqueer/questioning (LGBTQ) community. Whatanswerbythe faculty
is most accurate?
a. Avoid embarrassing the client by asking questions.
b. Dont make assumptions about their health needs.
c. Most LGBTQ people do not want to share information.
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ANS: B
Manymembersofthe LGBTQcommunity have faceddiscrimination from health care providersandmaybe
reluctant to seek health care. The nurse should never make assumptions about the needs of members of this
population. Rather, respectful questionsareappropriate. If approached with sensitivity, the clientwith any
health care need is more likely to answer honestly.
8. A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain
that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR
format for communication?
a. A: I would like you to order a different pain medication.
b. B: This client has allergies to morphine and codeine.
c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
d. S: This client had a vaginal hysterectomy 2 days ago.
ANS: B
SBAR is a recommended form of communication, and the acronym stands for Situation, Background,
Assessment, and Recommendation. Appropriatebackgroundinformationincludesallergies to medicationsthe
on-callphysicianmightorder. Situationdescribeswhat is happening rightnow thatmustbecommunicated; the
clients surgery 2 days ago would be considered background. Assessment would include an analysis of the
clients problem; asking for a different pain medication is a recommendation. Recommendation is a
statement of what is needed or what outcome is desired; this information about the surgeons preference
might be better placed in background.
DIF: Applying/ApplicationREF: 5
KEY: SBAR| communication
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive
personnel (UAP). Four hours later, the nurse notes the clients blood pressure is much higherthan
previous readings, and the clients mental status has changed. What action by the nurse would most
likely have prevented this negative outcome?
a. Determining if the UAP knew how to take blood pressure
b. Double-checking the UAP by taking another blood pressure
c. Providing more appropriate supervision of the UAP
d. Taking the blood pressure instead of delegating the task
ANS: C
Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on
delegated tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP to
report them right away. An experienced UAP should know how to take vital signs and the nurse should not
have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are
within the scope of practice for a UAP and are permissible to delegate. The only appropriate answer is that
the nurse did not provide adequate instruction to the UAP.
DIF: Applying/Application REF: 6
KEY: Supervision| delegation| unlicensed assistive personnel
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
10. A nurse is talking with a client who is moving to a new state and needs to find a new doctor and
hospital there. What advice by the nurse is best?
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