,
,
, Overview ofProfessional NursingConceptsfor Medical- $# $# $# $# $# $#
Surgical Nursing
$# $#
MULTIPLE CHOICE $#
1. A nurse wishes to provide client-
$# $# $# $# $#
centered care in all interactions. Which action by the nurse best demonstrates this concept?
$# $# $# $# $# $# $# $# $# $# za $# $#
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 nurse focuses on communication, culture, respect compassion, clien
$# $# $# $# $# $# $# $# $# $# $# $ # $#
t ed ucation, and empowerment. By assessing the effect of the clients culture on health care,
$# $# $# $# this nurse $# $# $# $# $# $# $# $# $# $# $# $ # $ # $ # $
#is practici ng 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 cl
$# $# $# $# $# $# $# $# $# $# $# $# $# $# $#
ient and family to the room is an important safety measure, but not directly related to demonstrating clie
$# $# $# $# $# $# $# z$ # $# $# $# $# za $# $# $# $#
nt- centered care.
$# $#
DIF: Understanding/Comprehension REF: 3
$ # $ # $ # $#
KEY: Patient- $#
centered care| culture MSC: Integrated Process: Caring NOT: Client N
$# $# $# $# $# $# $# $# $# $#
eeds Category: Psychosocial Integrity
$# $# $#
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/7
$# $# $# $# $# $# $# $# $# $# $# $# $# $# $# $# $#
6 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
za $# $# $# za $# $# $# $# $# $# $# za $# $# $# $# $#
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 deteriorati
$ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ #
ng before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant cha
$ # $# $# $# $# $# $# $# $# $# $# $# $# $# $# $#
nge, the nurse s hould 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 no tified, but this is not the priority over calling the RRT. The clients blood pres
$# $# $# $# $# $# za $# $# $# $# $# $# $# $# $# $# $# $#
sure should be reassessed freq uently, but the priority is getting the rapid care to the client.
$# $# $# $# $# $# za $# $# $# $# $# $# $# $# $#
DIF: Applying/Application REF: 3
$# $# $#
KEY: Rapid Response Team (RRT)| medical emergencies M
$# $# $# $# $# $# $ #
S C: Integrated Process: Communication and Documentation
$# $# $# $# $# za
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 nurse provide
$# $# $# za $# $# $# $# $# $# $# $# $# $# $# $# $# $# $
to h elp the client promote his or her own safety?
# $ # $# $# $# $# $# $# $# $# z$ #
a. Encourage the client and family to be active partners.
$# $# $# $# $# $# $# $#
b. Have the client monitor hand hygiene in caregivers.
$# $# za$# $# $# $# $#
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 th
$ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ #
e client to be active in his or her health care as a partner is the most critical. The other actions are ver
$ # $ # $# $# $# $# $# $# $# $# $# $# $# $# $# $# za $# $# $# $# $#
y limited in scope a nd do not provide the broad protection that being active and involved does.
$# $# $# $# $# $ # $# za $# $# $# $# $# $# $# $# $#
DIF: Understanding/Comprehension REF: 3 KE
$# $# $# $#
,
, Overview ofProfessional NursingConceptsfor Medical- $# $# $# $# $# $#
Surgical Nursing
$# $#
MULTIPLE CHOICE $#
1. A nurse wishes to provide client-
$# $# $# $# $#
centered care in all interactions. Which action by the nurse best demonstrates this concept?
$# $# $# $# $# $# $# $# $# $# za $# $#
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 nurse focuses on communication, culture, respect compassion, clien
$# $# $# $# $# $# $# $# $# $# $# $ # $#
t ed ucation, and empowerment. By assessing the effect of the clients culture on health care,
$# $# $# $# this nurse $# $# $# $# $# $# $# $# $# $# $# $ # $ # $ # $
#is practici ng 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 cl
$# $# $# $# $# $# $# $# $# $# $# $# $# $# $#
ient and family to the room is an important safety measure, but not directly related to demonstrating clie
$# $# $# $# $# $# $# z$ # $# $# $# $# za $# $# $# $#
nt- centered care.
$# $#
DIF: Understanding/Comprehension REF: 3
$ # $ # $ # $#
KEY: Patient- $#
centered care| culture MSC: Integrated Process: Caring NOT: Client N
$# $# $# $# $# $# $# $# $# $#
eeds Category: Psychosocial Integrity
$# $# $#
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/7
$# $# $# $# $# $# $# $# $# $# $# $# $# $# $# $# $#
6 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
za $# $# $# za $# $# $# $# $# $# $# za $# $# $# $# $#
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 deteriorati
$ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ #
ng before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant cha
$ # $# $# $# $# $# $# $# $# $# $# $# $# $# $# $#
nge, the nurse s hould 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 no tified, but this is not the priority over calling the RRT. The clients blood pres
$# $# $# $# $# $# za $# $# $# $# $# $# $# $# $# $# $# $#
sure should be reassessed freq uently, but the priority is getting the rapid care to the client.
$# $# $# $# $# $# za $# $# $# $# $# $# $# $# $#
DIF: Applying/Application REF: 3
$# $# $#
KEY: Rapid Response Team (RRT)| medical emergencies M
$# $# $# $# $# $# $ #
S C: Integrated Process: Communication and Documentation
$# $# $# $# $# za
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 nurse provide
$# $# $# za $# $# $# $# $# $# $# $# $# $# $# $# $# $# $
to h elp the client promote his or her own safety?
# $ # $# $# $# $# $# $# $# $# z$ #
a. Encourage the client and family to be active partners.
$# $# $# $# $# $# $# $#
b. Have the client monitor hand hygiene in caregivers.
$# $# za$# $# $# $# $#
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 th
$ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ # $ #
e client to be active in his or her health care as a partner is the most critical. The other actions are ver
$ # $ # $# $# $# $# $# $# $# $# $# $# $# $# $# $# za $# $# $# $# $#
y limited in scope a nd do not provide the broad protection that being active and involved does.
$# $# $# $# $# $ # $# za $# $# $# $# $# $# $# $# $#
DIF: Understanding/Comprehension REF: 3 KE
$# $# $# $#
