Ignatavicius: Medical-Surgical Nursing, 7th Edition
Chapter 1: Introduction to Medical-Surgical Nursing
Test Bank
MULTIPLE CHOICE
1. Which action
... [Show More] demonstrates that the nurse understands the purpose of the Rapid
Response Team?
a. Monitoring the client for changes in postoperative status such as wound infection
b. Documenting all changes observed in the client and maintaining a postoperative
flow sheet
c. Notifying the physician of the client’s change in blood pressure from 140 to 88
mm Hg systolic
d. Notifying the physician of the client’s increase in restlessness after medication
change
ANS: C
The Rapid Response Team (RRT) saves lives and decreases the risk for harm by
providing care to clients before a respiratory or cardiac arrest occurs. Although the RRT
does not replace the Code Team, which responds to client arrests, it intervenes rapidly for
those who are beginning to decline clinically. It would be appropriate for the RRT to
intervene when the client has experienced a 52-point drop in blood pressure. Monitoring
the client’s postoperative status, maintaining a postoperative flow sheet, and notifying the
physician of a change in the client’s status after a medication change would not be
considered activities of the Rapid Response Team.
DIF: Cognitive Level: Comprehension/Understanding REF: pp. 2-3
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
Care—Collaboration with Interdisciplinary Team)
MSC: Integrated Process: Nursing Process (Assessment)
2. The Joint Commission focuses on safety in health care. Which action by the nurse
reflects The Joint Commission’s main objective?
a. Performing range-of-motion exercises on the client three times each day
b. Ensuring that the client is eating 100% of the meals served to him or her
c. Assessing the client’s respirations when administering opioids
d. Delegating to the nursing assistant to give the client a complete bath daily
ANS: C
It is important for the nurse to assess respirations of the client when administering opioids
because of the possibility of respiratory depression. The other interventions may or may
not be necessary in the care of the client and do not focus on safety.
DIF: Cognitive Level: Application/Applying or higher REF: N/A [Show Less]