Test Bank For Medical-Surgical Nursing: Concepts For Clinical Judgment And Collaborative Care 11TH Edition By Donna D. Ignatavicius Isbn: Complete Guide With Rationales

Medical-Surgical Nursing: n1




Concepts for Clinical Judgment and Collaborative Care 11th
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Edition by Ignatavicius
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Chapters 1-69 n1

, Concepts for Medical-Surgical NursingIgnatavicius: Medical-Surgical Nursing, 11th
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Edition
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MULTIPLE CHOICE n1




1. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor
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advises thenew nurse that which is the priority when working as a professional
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nurse?
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a. Attending to holistic client needs n1 n1 n1 n1



b. Ensuring client safety n1 n1



c. Not making medication errors
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d. Providing client-focused care n1 n1




ACCURATE ANSWER: n1



B
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Rationale:All actions are appropriate for the professional nurse. However, ensuring
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client safety is thepriority. Health care errors have been widely reported for 25
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years, many of which result inclient injury, death, and increased health care costs.
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There are several national and international organizations that have either
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recommended or mandated safety initiatives.
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Every nurse has the responsibility to guard the client’s safety. The other actions are
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importantfor quality nursing, but they are not as vital as providing safety. Not
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making medication errorsdoes provide safety, but is too narrow in scope to be the
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best accurate answerwer.
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DIF: Understanding TOP: Integrated Process: Nursing Process: n 1 n1 n1 n1



InterventionKEY: Client safety
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MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
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Control
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2. A nurse is orienting a new client and family to the medical-surgical unit. What
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informationdoes the nurse provide to best help the client promote his or her own
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safety?
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a. Encourage the client and family to be active partners. n1 n1 n1 n1 n1 n1 n1 n1



b. Have the client monitor hand hygiene in caregivers.
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c. Offer the family the opportunity to stay with the client.
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d. Tell the client to always wear his or her armband.
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ACCURATE ANSWER: n1



A
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Rationale:Each action could be important for the client or family to perform.
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n1 However, encouraging theclient to be active in his or her health care as a safety
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n1 partner is the most critical. The other actions are very limited in scope and do not
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n1 provide the broad protection that being active andinvolved does.
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DIF: Understanding TOP: Integrated Process: n 1 n1



Teaching/LearningKEY: Client safety
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MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
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Control
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,3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood
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pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What
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action would the nursetake first?
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a. Call the Rapid Response Team.n1 n1 n1 n1



b. Document and continue to monitor. n1 n1 n1 n1



c. Notify the primary health care provider. n1 n1 n1 n1 n1



d. Repeat the blood pressure in 15 minutes. n1 n1 n1 n1 n1 n1




ACCURATE ANSWER: A n1 n1



Rationale:The purpose of the Rapid Response Team (RRT) is to intervene when n1 n1 n1 n1 n1 n1 n1 n1 n1 n1 n1



clients are deterioratingbefore they suffer either respiratory or cardiac arrest. Since
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the client has manifested a significant change, the nurse would call the RRT. Changes
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in blood pressure, mental status, heart rate, temperature, oxygen saturation, and last
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2 hours’ urine output are particularly significant and are part of the Modified Early
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Warning System guide. Documentation is vital, but the nurse must do more than
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document. The primary health care provider would be notified, but this is not more
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important than calling the RRT. The client’s blood pressure would be reassessed
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frequently, but the priority is getting the rapid care to the client.
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DIF: Applying TOP: Integrated Process: Communication and n 1 n1 n1 n1



DocumentationKEY: Rapid Response Team (RRT), Clinical judgment
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MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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4. A nurse wishes to provide client-centered care in all interactions. Which action by the
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nurse
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best demonstrates this concept?
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a. Assesses for cultural influences affecting health care. n1 n1 n1 n1 n1 n1



b. Ensures that all the client’s basic needs are met. n1 n1 n1 n1 n1 n1 n1 n1



c. Tells the client and family about all upcoming tests.
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d. Thoroughly orients the client and family to the room. n1 n1 n1 n1 n1 n1 n1 n1




ACCURATE ANSWER: A n1 n1



Rationale:Showing respect for the client and family’s preferences and needs is n1 n1 n1 n1 n1 n1 n1 n1 n1 n1



n1 essential to ensure a holistic or “whole-person” approach to care. By assessing the
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n1 effect of the client’s culture onhealth care, this nurse is practicing client-focused
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n1 care. Providing for basic needs does not demonstrate this competence. Simply
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n1 telling the client about all upcoming tests is not providing empowering education.
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n1 Orienting the client and family to the room is an importantsafety measure, but not
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n1 directly related to demonstrating client-centered care.
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DIF: Understanding TOP: Integrated Process: Culture and n1 n1 n1 n1



Spirituality KEY: Client-centered care, Culture MSC: Client Needs Category:
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Psychosocial Integrity
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5. A client is going to be admitted for a scheduled surgical procedure. Which action
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does thenurse explain is the most important thing the client can do to protect
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against errors?
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a. Bring a list of all medications and what they are for.
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b. Keep the provider’s phone number by the telephone.
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c. Make sure that all providers wash hands before entering the room.
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d. Write down the name of each caregiver who comes in the room.
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ACCURATE ANSWER: A n1 n1



Rationale:Medication reconciliation is a formal process in which the client’s actual n1 n1 n1 n1 n1 n1 n1 n1 n1 n1

, n1 current medicationsare compared to the prescribed medications at the time of
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n1 admission, traccurate answerfer, or discharge. This National client Safety Goal is
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n1 important to reduce medication errors. The client would not have to be responsible
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n1 for providers washing their hands, and even if the client does so, this is too narrow
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n1 to be the most important action to prevent errors. Keeping the provider’s phone
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n1 number nearby and documenting everyone who enters the room also do not
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n1 guarantee safety. n1




DIF: Applying TOP: Integrated Process: n 1 n1



Teaching/LearningKEY: Client safety, Informatics
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MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
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Control
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6. Which action by the nurse working with a client best demonstrates respect for
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n1 autonomy?
a. Asks if the client has questions before signing a consent.
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b. Gives the client accurate information when questioned.
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c. Keeps the promises made to the client and family.
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d. Treats the client fairly compared to other clients. n1 n1 n1 n1 n1 n1 n1




ACCURATE ANSWER: A n1 n1



Rationale:Autonomy is self-determination. The client would make decisions regarding n1 n1 n1 n1 n1 n1 n1 n1



n1 care. When the nurse obtains a signature on the consent form, assessing if the client
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n1 still has questions is vital,because without full information the client cannot practice
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n1 autonomy. Giving accurate information is practicing with veracity. Keeping promises
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n1 is upholding fidelity. Treating the client fairly is providing social justice.
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DIF: Applying TOP: Integrated Process: Caring KEY: Ethics, n 1 n1 n1 n1



AutonomyMSC: Client Needs Category: Safe and Effective Care Environment:
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Management of Care
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7. A nurse asks a more seasoned colleague to explain best practices when
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communicating with aperson from the lesbian, gay, bisexual, traccurate
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answergender, and questioning/queer (LGBTQ) community. What accurate
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answerwer by the faculty is most accurate?
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a. Avoid embarrassing the client by asking questions. n1 n1 n1 n1 n1 n1



b. Don’t make assumptions about his or her health needs.
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c. Most LGBTQ people do not want to share information.
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d. No differences exist in communicating with this population.
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ACCURATE ANSWER: B n1 n1



Rationale:Many members of the LGBTQ community have faced discrimination from n1 n1 n1 n1 n1 n1 n1 n1 n1



n1 health care providers and may be reluctant to seek health care. The nurse would
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n1 never make assumptions about the needs of members of this population. Rather,
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n1 respectful questions are appropriate. Ifapproached with sensitivity, the client with
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n1 any health care need is more likely to accurate answerwer honestly.
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DIF: Understanding TOP: Integrated Process: Teaching/Learning
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KEY: Health care disparities, LGBTQ
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8. A nurse is calling the on-call health care provider about a client who had a
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hysterectomy 2days ago and has pain that is unrelieved by the prescribed opioid
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pain medication. Which statement comprises the background portion of the SBAR
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format for communication?
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a. “I would like you to order a different pain medication.”
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