Test Bank Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 11th edition
1. A nurse wishes to provide client-centered care
... [Show More] 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.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity
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 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 [Show Less]