FTT L FTT L FTTL L
T
F FTT L FTT L
Ignatavicius: Medical-Surgical Nursing,10th Edition
L
FTT L
FTT FTT L FTT L
MULTIPLE F T T L CHOICE
1. A new nurse is working with a preceptor on an inpatient medical-surgical unit.
F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TTL
The preceptor advises the student that which is the priority when working as a
F TT L F TT L L
T
F L
T
F F TT L L
FTT F TT L L
FTT L
T
F L
FTT FTT L F TT L L
T
F L
T
F
professional nurse?
F TT L F TT L
a. Attending to holistic client needs L
T
F L
FT FTL L
FTT
b. Ensuring client safety L
TT
F L
FTT
c. Not making medication errors L
TT
F L
T
F L
T
F
d. Providing client-focused care F T T L F T T L
ANS: B F T T L
All actions are appropriate for the professional nurse. However, ensuring client safety is the
L
T
F FTTL L
FTT F TT L L
FTT L
FTT FTT L L
T
F FTT L FTT L FTT L L
T
F FTT L
priority. Up to 98,000 deaths result each year from errors in hospital care, according to
F TT L F TT L F TT L L
FTT F TT L F TT L F TT L F TT L F TT L F TT L FTT L F TT L F TT L FTT L FTT L
the 2000 Institute of Medicine report. Many more clients have suffered injuries and less
F TT L F TT L L
FTT L
FTT L
T
F L
T
F FTTL L
T
F FTT L L
FTT L
FTT L
FTT F TT L FTT L
serious outcomes. Every nurse has the responsibility to guard the client’s safety.
L
FT F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
DIF: Understanding/Comprehension REF: 2 KEY: Patient safety F TT L T
FL
MSC: Integrated Process: Nursing Process: Intervention
F TT L F TT L F TT L F TT L F TT L F TT L
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
F T T L FTT L L
T
F FTT L FTT L L
T
F L
T
F L
T
F FTT L FTT L L
FTT
Control
F TT L
2. A nurse is orienting a new client and family to the inpatient unit. What information does the
L
FTT L
FTT FTT L L
T
F F TT L FTT L FTTL F TT L L
T
F FTT L L
T
F L
FTT FTT L FTT L L
FTT L
FTT
nurse provide to help the client promote his or her own safety?
F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
a. Encourage the client and family to be active partners. L
FTT L
FTT FTT L L
FTT L
T
F FTT L FTT L FTTL
b. Have the client monitor hand hygiene in caregivers. FTT L L
FTT F TT L FTT L FTTL L
T
F FTT L
c. Offer the family the opportunity to stay with the client. FTTL FTT L L
T
F L
FTT L
T
F F TT L L
FTT L
FTT FTT L
d. Tell the client to always wear his or her armband. FTT L FTT L FTT L L
T
F F TT L FTT L T
FL FTT L L
FTT
ANS: A F T T L
Each action could be important for the client or family to perform. However, encouraging
L
T
F FTT L FTT L FTT L FTT L FTT L FTTL FTT L FTT L L
T
F L
FTT FT L L
FTT
the client to be active in his or her health care as a partner is the most critical. The other
F TT L F TT L F TT L F TT L FTT L F TT L F TT L F TT L F TT L F TT L F TT L L
FTT FTT L F TT L F TT L L
FTT F TT L F TT L F TT L F TT L
actions are very limited in scope and do not provide the broad protection that being active
F TT L FTT L FTT L L
T
F FTT L FTT L FTT L FTT L FTT L F TT L L
TT
F FT L FTT L F TT L L
FTT L
T
F
and involved does.
F TT L F TT L F TT L
DIF: Understanding/Comprehension REF: 3 KEY: Patient safety F TT L T
FL
MSC: Integrated Process: Teaching/Learning
F TT L F T T L F TT L F TT L
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
F T T L FTT L L
T
F L
FTT L
T
F L
T
F L
T
F L
T
F L
F TT FTT L L
FTT
Control
F TT L
3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressure
FTT L FTT L L
FTT FTT L L
FTT F TT L FTT L FTT L T
FL L
FTT F TT L L
FTT FTT L L
FTT FTT L
was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse
F TT L T
FL FTT L FTT L FTT L FTT L L
T
F FTTL L
FTT FTTL T
F L F TT L FTT L F TT L FTT L F TT L FTT L F TT L
is best?
FTT L F TT L
a. Call the Rapid Response Team. T
F L FTT L L
T
F L
T
F
b. Document and continue to monitor. FTT L FTT L T
F L L
FTT
c. Notify the primary care provider. L
T
F FTT L L
FTT L
T
F
d. Repeat blood pressure measurement in 15 minutes. TT
F L L
T
F L
FTT L
FTT L
T
F L
FTT
, ANS: A F T T L
The purpose of the Rapid Response Team (RRT) is to intervene when clients are
F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
deteriorating before they suffer either respiratory or cardiac arrest. Since the client has
F TT L F TT L FTT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
manifested a significant change, the nurse should call the RRT. Changes in blood
F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L FTT L F TT L F TT L F TT L
pressure, mental status, heart rate, and pain are particularly significant. Documentation is
F TT L F TT L FTTL L
FTT FTT L L
T
F L
FTT L
T
F FTT L L
FTT FTT L L
T
F
vital, but the nurse must do more than document. The primary care provider should be
L
T
F FTT L FTT L F TT L FTT L F TT L FTTL T
F L L
FTT FTT L F TT L L
FTT L
FTT F TT L FTT L
notified, but this is not the priority over calling the RRT. The client’s blood pressure
FTT L FTT L L
FTT L
FTT F TT L F TT L F TT L F TT L F TT L F TT L FTT L F TT L F TT L F TT L F TT L
should be reassessed frequently, but the priority is getting the rapid care to the client.
F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
DIF: Applying/Application REF: 3
KEY: Rapid Response Team (RRT)| medical emergencies
FT L F T T L L
T
F FTT L L
T
F L
T
F L
FTT
MSC: Integrated Process: Communication and Documentation
F T T L F T T L F T T L F T T L F T T L
NOT: Client Needs Category: Physiological Integrity: Physiological
F T T L F T T L F T T L F T T L F T T L F T T L F T T L Adaptation
4. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse
L
FTT FTT L L
T
F FTT L FTT L L
FTT FTT L FTT L F TT L FTT L FTT L L
FTT FTT L FTT L
best demonstrates this concept?
F TT L F TT L F TT L F TT L
a. Assesses for cultural influences affecting health care F T T L F T T L F T T L F T T L F T T L F T T L
b. Ensures that all the clients’ basic needs are met L
T
F FTT L L
FTT FTT L F TT L T
F L FTT L FTT L
c. Tells the client and family about all upcoming tests L
T
F L
TT
F L
FTT L
FTT L
T
F F TT L FTL F TT L
d. Thoroughly orients the client and family to the room L
FTT L
T
F FTT L FTL F TT L L
FT FTT L FTTL
ANS: A F T T L
Competency in client-focused care is demonstrated when the nurse focuses on F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
communication, culture, respect, compassion, client education, and empowerment. By
F TT L T
F L L
T
F L
T
F L
T
F L
T
F T
FL L
T
F T
FL
assessing the effect of the client’s culture on health care, this nurse is practicing
F TT L F TT L F TT L F TT L FTT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
client-focused care. Providing for basic needs does not demonstrate this competence. F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
Simply telling the client about all upcoming tests is not providing empowering
F TT L F TT L FTT L F TT L F TT L F TT L F TT L FTT L F TT L F TT L F TT L F TT L
education. Orienting the client and family to the room is an important safety measure, but
F TT L F TT L L
T
F FTT L T
F L FTT L L
FTT FTT L L
FTT FTT L L
FTT L
FTT FTT L FTT L FTT L
not directly related to demonstrating client-centered care.
F TT L L
FTT F TT L F TT L F TT L F TT L F TT L
DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated Process: Caring
F T T L F TT L F TT L FTT L L
T
F L
T
F
NOT: Client Needs Category: Psychosocial Integrity
F TT L F T T L F TT L F TT L F TT L F TT L
5. A client is going to be admitted for a scheduled surgical procedure. Which action does the
L
FTT F TT L L
T
F T
FL FTT L T
F L FTT L FTT L F TT L F TT L FTT L F TT L FTT L TT
F L L
T
F
nurse explain is the most important thing the client can do to protect against errors?
F TT L F TT L F TT L FTT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
a. Bring a list of all medications and what they are for. L
TT
F FTTL FTT L FTTL FTT L L
FTT FTT L L
FTT T
FL L
FTT
b. Keep the doctor’s phone number by the telephone. FTT L FTT L L
T
F L
FTT FTT L L
FT FTT L
c. Make sure all providers wash hands before entering the room. FTT L FTT L FTT L L
F TT L
FTT T
FL FTT L L
T
F FTT L
d. Write down the name of each caregiver who comes in the room. FTT L FT L FTT L FTT L FTT L F TT L F TT L FTT L L
T
F FTTL L
T
F
ANS: A F T T L
Medication errors are the most common type of health care mistake. The Joint F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
Commission’s Speak Up campaign encourages clients to help ensure their safety. One
F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
recommendation is for clients to know all their medications and why they take them. This
F TT L FTT L FTT L F TT L FTTL FTT L L
T
F L
FTT F TT L L
T
F FTT L FTT L FTT L L
T
F L
T
F
will help prevent medication errors.
F TT L F TT L F TT L F TT L F TT L
DIF: Applying/Application REF: 4
KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/Learning
F T T L F TT L FTTL L
T
F FTT L F TT L FTT L L
T
F
, NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
F T T L FTT L L
T
F FTT L L
T
F L
T
F L
T
F L
T
F F TT L FTT L FTTL
Control
F TT L
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
L
T
F FTT L L
T
F L
FTT L
FTT FTT L L
T
F F TT L FTT L L
FTT L
T
F F TT L FTL
a. Asks if the client has questions before signing a consent L
T
F L
FTT L
FTT L
FTT L
FTT FTT L FTTL L
FT FTTL
b. Gives the client accurate information when questioned F T T L F T T L F T T L F T T L F T T L F T T L
c. Keeps the promises made to the client and family FTTL FTTL FTT L FTT L FTT L L
FTT FTT L FTT L
d. Treats the client fairly compared to other clients FTTL FTTL FTT L L
T
F L
T
F L
T
F FTT L
ANS: A F T T L
Autonomy is self-determination. The client should make decisions regarding care. When the T
FL L
T
F FTT L FTT L L
FTT FTT L L
T
F L
T
F L
FTT L
TT
F L
FTT
nurse obtains a signature on the consent form, assessing if the client still has questions is
F TT L F TT L L
FTT F TT L F TT L F TT L F TT L F TT L F TT L F TT L L
FTT F TT L F TT L F TT L F TT L F TT L
vital, because without full information the client cannot practice autonomy. Giving accurate
F TT L FTT L F TT L F TT L F TT L T
FL L
FTT L
FTT FTT L FTT L FTT L T
F L
information is practicing with veracity. Keeping promises is upholding fidelity. Treating the
F TT L FTT L FTTL F TT L FTT L FTT L FTT L FTT L T
FL FTT L T
F L L
T
F
client fairly is providing social justice.
F TT L F TT L F TT L F TT L F TT L F TT L
DIF: Applying/Application REF: 4
KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
F T T L T
F L FTT L F TT L L
FTT L
T
F
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
F T T L L
FT L
T
F FTT L L
T
F L
T
F FTT L L
T
F L
FTT FTT L T
F L
7. A student nurse asks the faculty to explain best practices when communicating with a
L
TT
F FTT L L
FTT T
FL FTT L FTT L L
FTT FTT L FTT L L
FTT L
FTT F TT L L
FTT
person from the lesbian, gay, bisexual, transgender, and queer/questioning
F TT L F TT L FTT L FTT L F TT L F TT L FTT L FTT L F TT L
(LGBTQ) community. What answer by the faculty is most accurate?
FT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
a. Avoid embarrassing the client by asking questions. FTTL L
T
F FTT L FTT L L
T
F L
T
F
b. Don’t make assumptions about their health needs. L
FTT L
T
F L
T
F FTT L L
FTT L
FTT
c. Most LGBTQ people do not want to share information. T
F L FTT L L
FTT FTTL F TT L FTTL FTT L L
T
F
d. No differences exist in communicating with this population.
L
T
F FTT L F TT L FTTL L
TT
F L
T
F L
FTT
ANS: B F T T L
Many members of the LGBTQ community have faced discrimination from health care
F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
providers and may be reluctant to seek health care. The nurse should never make
F TT L FTT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
assumptions about the needs of members of this population. Rather, respectful questions are
F TT L T
FL L
FTT L
FTT FTT L FTT L FTTL L
T
F FTT L F TT L L
FTT FTT L L
T
F
appropriate. If approached with sensitivity, the client with any health care need is more
F TT L F TT L FTTL F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
likely to answer honestly.
F TT L F TT L F TT L F TT L
DIF: Understanding/Comprehension REF: 4 KEY: LGBTQ| F TT L
diversity MSC: Integrated Process: Teaching/Learning
L
T
F F TT L F T T L F TT L F TT L
NOT: Client Needs Category: Psychosocial Integrity
F T T L L
T
F T
FL FTTL L
T
F
8. A nurse is calling the on-call physician about a client who had a hysterectomy 2 days
F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
ago and has pain that is unrelieved by the prescribed narcotic pain medication. Which
FTT L F TT L FTT L L
FTT L
T
F L
T
F FT L FTT L FTT L FTT L L
FTT L
FTT FTTL F TT L
statement is part of the SBAR format for communication?
FTT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L F TT L
a. A: “I would like you to order a different pain medication.”
FTT L FT L FTT L L
FTT F TT L L
FTT L
FTT FTT L F TT L L
FTT
b. B: “This client has allergies to morphine and codeine.”
FTT L L
FTT FTT L L
FTT T
FL FTTL L
T
F FTT L
c. R: “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.”
L
T
F FTT L TT
F L L
T
F T
F L L
T
F T
FL
d. S: “This client had a vaginal hysterectomy 2 days ago.”
L
T
F L
FTT L
FTT L
FTT FTTL L
TT
F L
T
F FTT L L
T
F
F TT L ANS: F T T L B