Medical-Surgical Nursing:
Concepts for Clinical Judgment and Collaborative Care 11th
Edition by Ignatavicius
Chapters 1-69
,Concepts for Medical-Surgical NursingIgnatavicius: Medical-Surgical Nursing, 11th
Edition
MULTIPLE CHOICE
1. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor
advises thenew nurse that which is the priority when working as a professional nurse?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care
ACCURATE ANSWER: B
Rationale:All actions are appropriate for the professional nurse. However, ensuring
client safety is thepriority. Health care errors have been widely reported for 25 years,
many of which result inclient injury, death, and increased health care costs. There are
several national and international organizations that have either recommended or
mandated safety initiatives.
Every nurse has the responsibility to guard the client’s safety. The other actions are
importantfor quality nursing, but they are not as vital as providing safety. Not making
medication errorsdoes provide safety, but is too narrow in scope to be the best accurate
answerwer.
DIF: Understanding TOP: Integrated Process: Nursing Process:
InterventionKEY: Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. A nurse is orienting a new client and family to the medical-surgical unit. What
informationdoes the nurse provide to best 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.
ACCURATE ANSWER:
A
Rationale:Each action could be important for the client or family to perform. However,
encouraging theclient to be active in his or her health care as a safety partner is the most
critical. The other actions are very limited in scope and do not provide the broad
protection that being active andinvolved does.
DIF: Understanding TOP: Integrated Process:
Teaching/LearningKEY: Client safety
MSC: 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 client’s blood
pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action
would the nursetake first?
a. Call the Rapid Response Team.
, b. Document and continue to monitor.
c. Notify the primary health care provider.
d. Repeat the blood pressure in 15 minutes.
ACCURATE ANSWER: A
Rationale:The purpose of the Rapid Response Team (RRT) is to intervene when clients
are deterioratingbefore they suffer either respiratory or cardiac arrest. Since the client
has manifested a significant change, the nurse would call the RRT. Changes in blood
pressure, mental status, heart rate, temperature, oxygen saturation, and last 2 hours’
urine output are particularly significant and are part of the Modified Early Warning
System guide. Documentation is vital, but the nurse must do more than document. The
primary health care provider would be notified, but this is not more important than
calling the RRT. The client’s blood pressure would be reassessed frequently, but the
priority is getting the rapid care to the client.
DIF: Applying TOP: Integrated Process: Communication and
DocumentationKEY: Rapid Response Team (RRT), Clinical judgment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A nurse wishes to provide client-centered care 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 client’s basic needs are met.
c. Tells the client and family about all upcoming tests.
d. Thoroughly orients the client and family to the room.
ACCURATE ANSWER: A
Rationale:Showing respect for the client and family’s preferences and needs is essential
to ensure a holistic or “whole-person” approach to care. By assessing the effect of the
client’s culture onhealth 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 importantsafety measure, but not directly related to demonstrating
client-centered care.
DIF: Understanding TOP: Integrated Process: Culture and Spirituality
KEY: Client-centered care, Culture MSC: Client Needs Category: Psychosocial
Integrity
5. A client is going to be admitted for a scheduled surgical procedure. Which action
does thenurse explain is the most important thing the client can do to protect
against errors?
a. Bring a list of all medications and what they are for.
b. Keep the provider’s phone number by the telephone.
c. Make sure that all providers wash hands before entering the room.
d. Write down the name of each caregiver who comes in the room.
ACCURATE ANSWER: A
Rationale:Medication reconciliation is a formal process in which the client’s actual
current medicationsare compared to the prescribed medications at the time of
admission, traccurate answerfer, or discharge. This National client Safety Goal is
important to reduce medication errors. The client would not have to be responsible for
providers washing their hands, and even if the client does so, this is too narrow to be the
, most important action to prevent errors. Keeping the provider’s phone number nearby
and documenting everyone who enters the room also do not guarantee safety.
DIF: Applying TOP: Integrated Process:
Teaching/LearningKEY: Client safety, Informatics
MSC: 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.
ACCURATE ANSWER: A
Rationale:Autonomy is self-determination. The client would make decisions regarding
care. When the nurse obtains a signature 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 TOP: Integrated Process: Caring KEY: Ethics, Autonomy
MSC: Client Needs Category: Safe and Effective Care Environment: Management of
Care
7. A nurse asks a more seasoned colleague to explain best practices when communicating
with aperson from the lesbian, gay, bisexual, traccurate answergender, and
questioning/queer (LGBTQ) community. What accurate answerwer by the faculty is
most accurate?
a. Avoid embarrassing the client by asking questions.
b. Don’t make assumptions about his or her health needs.
c. Most LGBTQ people do not want to share information.
d. No differences exist in communicating with this population.
ACCURATE ANSWER: B
Rationale:Many members of the LGBTQ community have faced discrimination from
health care providers and may be reluctant to seek health care. The nurse would never
make assumptions about the needs of members of this population. Rather, respectful
questions are appropriate. Ifapproached with sensitivity, the client with any health care
need is more likely to accurate answerwer honestly.
DIF: Understanding TOP: Integrated Process: Teaching/Learning
KEY: Health care disparities, LGBTQ MSC: Client Needs Category: Psychosocial Integrity
8. A nurse is calling the on-call health care provider about a client who had a
hysterectomy 2days ago and has pain that is unrelieved by the prescribed opioid
pain medication. Which statement comprises the background portion of the SBAR
format for communication?
a. “I would like you to order a different pain medication.”
b. “This client has allergies to morphine and codeine.”
c. “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.”
d. “This client had a vaginal hysterectomy 2 days ago.”
ACCURATE ANSWER: B
Concepts for Clinical Judgment and Collaborative Care 11th
Edition by Ignatavicius
Chapters 1-69
,Concepts for Medical-Surgical NursingIgnatavicius: Medical-Surgical Nursing, 11th
Edition
MULTIPLE CHOICE
1. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor
advises thenew nurse that which is the priority when working as a professional nurse?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care
ACCURATE ANSWER: B
Rationale:All actions are appropriate for the professional nurse. However, ensuring
client safety is thepriority. Health care errors have been widely reported for 25 years,
many of which result inclient injury, death, and increased health care costs. There are
several national and international organizations that have either recommended or
mandated safety initiatives.
Every nurse has the responsibility to guard the client’s safety. The other actions are
importantfor quality nursing, but they are not as vital as providing safety. Not making
medication errorsdoes provide safety, but is too narrow in scope to be the best accurate
answerwer.
DIF: Understanding TOP: Integrated Process: Nursing Process:
InterventionKEY: Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. A nurse is orienting a new client and family to the medical-surgical unit. What
informationdoes the nurse provide to best 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.
ACCURATE ANSWER:
A
Rationale:Each action could be important for the client or family to perform. However,
encouraging theclient to be active in his or her health care as a safety partner is the most
critical. The other actions are very limited in scope and do not provide the broad
protection that being active andinvolved does.
DIF: Understanding TOP: Integrated Process:
Teaching/LearningKEY: Client safety
MSC: 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 client’s blood
pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action
would the nursetake first?
a. Call the Rapid Response Team.
, b. Document and continue to monitor.
c. Notify the primary health care provider.
d. Repeat the blood pressure in 15 minutes.
ACCURATE ANSWER: A
Rationale:The purpose of the Rapid Response Team (RRT) is to intervene when clients
are deterioratingbefore they suffer either respiratory or cardiac arrest. Since the client
has manifested a significant change, the nurse would call the RRT. Changes in blood
pressure, mental status, heart rate, temperature, oxygen saturation, and last 2 hours’
urine output are particularly significant and are part of the Modified Early Warning
System guide. Documentation is vital, but the nurse must do more than document. The
primary health care provider would be notified, but this is not more important than
calling the RRT. The client’s blood pressure would be reassessed frequently, but the
priority is getting the rapid care to the client.
DIF: Applying TOP: Integrated Process: Communication and
DocumentationKEY: Rapid Response Team (RRT), Clinical judgment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A nurse wishes to provide client-centered care 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 client’s basic needs are met.
c. Tells the client and family about all upcoming tests.
d. Thoroughly orients the client and family to the room.
ACCURATE ANSWER: A
Rationale:Showing respect for the client and family’s preferences and needs is essential
to ensure a holistic or “whole-person” approach to care. By assessing the effect of the
client’s culture onhealth 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 importantsafety measure, but not directly related to demonstrating
client-centered care.
DIF: Understanding TOP: Integrated Process: Culture and Spirituality
KEY: Client-centered care, Culture MSC: Client Needs Category: Psychosocial
Integrity
5. A client is going to be admitted for a scheduled surgical procedure. Which action
does thenurse explain is the most important thing the client can do to protect
against errors?
a. Bring a list of all medications and what they are for.
b. Keep the provider’s phone number by the telephone.
c. Make sure that all providers wash hands before entering the room.
d. Write down the name of each caregiver who comes in the room.
ACCURATE ANSWER: A
Rationale:Medication reconciliation is a formal process in which the client’s actual
current medicationsare compared to the prescribed medications at the time of
admission, traccurate answerfer, or discharge. This National client Safety Goal is
important to reduce medication errors. The client would not have to be responsible for
providers washing their hands, and even if the client does so, this is too narrow to be the
, most important action to prevent errors. Keeping the provider’s phone number nearby
and documenting everyone who enters the room also do not guarantee safety.
DIF: Applying TOP: Integrated Process:
Teaching/LearningKEY: Client safety, Informatics
MSC: 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.
ACCURATE ANSWER: A
Rationale:Autonomy is self-determination. The client would make decisions regarding
care. When the nurse obtains a signature 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 TOP: Integrated Process: Caring KEY: Ethics, Autonomy
MSC: Client Needs Category: Safe and Effective Care Environment: Management of
Care
7. A nurse asks a more seasoned colleague to explain best practices when communicating
with aperson from the lesbian, gay, bisexual, traccurate answergender, and
questioning/queer (LGBTQ) community. What accurate answerwer by the faculty is
most accurate?
a. Avoid embarrassing the client by asking questions.
b. Don’t make assumptions about his or her health needs.
c. Most LGBTQ people do not want to share information.
d. No differences exist in communicating with this population.
ACCURATE ANSWER: B
Rationale:Many members of the LGBTQ community have faced discrimination from
health care providers and may be reluctant to seek health care. The nurse would never
make assumptions about the needs of members of this population. Rather, respectful
questions are appropriate. Ifapproached with sensitivity, the client with any health care
need is more likely to accurate answerwer honestly.
DIF: Understanding TOP: Integrated Process: Teaching/Learning
KEY: Health care disparities, LGBTQ MSC: Client Needs Category: Psychosocial Integrity
8. A nurse is calling the on-call health care provider about a client who had a
hysterectomy 2days ago and has pain that is unrelieved by the prescribed opioid
pain medication. Which statement comprises the background portion of the SBAR
format for communication?
a. “I would like you to order a different pain medication.”
b. “This client has allergies to morphine and codeine.”
c. “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.”
d. “This client had a vaginal hysterectomy 2 days ago.”
ACCURATE ANSWER: B
