1. A new nurse is working with a preceptor on an inpatient medical-surgical unit. The
preceptor advises the student that which is the priority when
... [Show More] working as a professional
nurse?
◦ Attending to holistic client needs
◦ Ensuring client safety
◦ Not making medication errors
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
2. 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 most critical. The other actions are
◦
◦ very limited in scope and do not provide the broad protection that
being active and involved does.
◦ DIF: Understanding/Comprehension REF: 3
KEY: Patient safety MSC: Integrated Process: Teaching/
Learning
◦ NOT: Client Needs Category: Safe and Effective Care
Environment: Safety and Infection Control
3. 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?
4. Call the Rapid Response Team.
5. Document and continue to monitor.
6. Notify the primary care provider.
7. Repeat blood pressure measurement
in 15 minutes. ANS: A
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 theclient has manifested 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.
b. DIF: Applying/Application REF: 3
c. KEY: Rapid
Response Team (RRT)|medical
emergencies MSC: Integrated
Process:
Communication and Documentation
d. NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
◦
8. A nurse wishes to provide client-centered care in all interactions. Which
action by the nurse best demonstrates this concept?
9. Assesses for cultural influences affecting health care
10. Ensures that all the clients basic needs are met
11. Tells the client and family about all upcoming tests
12. Thoroughly orients the client and
family to the room ANS: A
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
◦
b. 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 not directly
related to demonstrating client-centered care.
c. DIF: Understanding/Comprehension REF: 3
d. KEY: Patient-centered
care| culture MSC:Integrated Process:
Caring NOT: Client Needs Category:
Psychosocial Integrity [Show Less]