TEST BANK FOR MEDICAL
SURGICAL
NURSING:CONCEPTS FOR
CLINICAL JUDGEMENT AND
COLLABORATIVE CARE 9TH
EDITION IGNATAVICIUS
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical
NursingMULTIPLE CHOICE
• A nurse wishes to provide client-centered care in all
interactions. Which action by the nurse bestdemonstrates this
concept?
,• Assesses for cultural influences affecting health care
• Ensures that all the clients basic needs are met
• Tells the client and family about all upcoming tests
• Thoroughly orients the client and family to the room
ANS: A
Competency in client-focused care is demonstrated when the nurse focuses 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 and family to the room is an important safety measure,
but notdirectly related to demonstrating client-centered care.
• 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 is best?
• Call the Rapid Response Team.
• Document and continue to monitor.
• Notify the primary care provider.
• 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 suffer either respiratory or cardiac arrest. Since the
client hasmanifested a significant change, the nurse should call the RRT.
Changes in blood pressure, mental status, heart rate, and pain are particularly
significant.
Documentation is vital, but the nurse must 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 the client.
DIF: Applying/Application REF: 3
KEY: Rapid Response Team (RRT)|
medicalemergencies MSC:
Integrated Process:
Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
• 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?
• Encourage the client and family to be active partners.
• Have the client monitor hand hygiene in caregivers.
• Offer the family the opportunity to stay with the client.
• 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 mostcritical. The other actions are very limited in scope and do not
provide the broad protection that being active and involved does.
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and
Infection Control
• 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?
• Bring a list of all medications and what they are for.
• Keep the doctors phone number by the telephone.
• Make sure all providers wash hands before entering the room.
• 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
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