Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e
1
Chapter 01: Overview of Professional Nursing Concepts for
... [Show More] MedicalSurgical Nursing
MULTIPLE CHOICE
1. A nurse wishes to provide client-centered care in all interactions. Which action by the
nursebest 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
thiscompetence. Simply telling the client about all upcoming tests is not providing empowering education.
Orienting the client andfamily to theroom is
animportantsafetymeasure,butnotdirectlyrelatedtodemonstratingclientcentered 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
142/76mm 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
theysuffereitherrespiratoryorcardiacarrest. 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
nurseprovide 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.
DIF: Understanding/Comprehension REF:
3KEY: Patient safety
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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 2
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
advisesthe 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:
2KEY: 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
nurseexplain 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
theirmedications 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
nurseobtainsasignature 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
facultyis 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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