Interprofessional Collaborative Care 10th
Edition by Donna D. Ignatavicius Chapter 1-69
|Complete Guide A+
,Chapter 01: Overview of Professional Nursing Concepts for Medical-
Surgical Nursing Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A new nurse is working with a preceptor on a medical-
surgical unit. The preceptor advises the new nurse that which is the priority wh
en working as a professional nurse?
a. Attending to holistic client needs
b. Ensuring80client80safety
c. Not making medication errors
d. Providing client-focused care
ANS: B
All actions are appropriate for the professional nurse. However, ensuring client safe
ty is the priority. Health care errors have been widely reported for 25 years, man
y of which result in client injury, death, and increased health care costs. There a
re several national and international organizations that have either recommended or
mandated safety initiatives.
Every nurse has the responsibility to guard the client9s safety. The other actions
are important for quality nursing, but they are not as vital as providing safety. N
ot making medication errors does provide safety, but is too narrow in scope to b
e the best answer.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Intervention KEY: Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Co
ntrol
2. A nurse is orienting a new client and family to the medical-
surgical unit. What information does the nurse provide to best help the client
promote his or her own safety?
a. Encourage80the80client80and80family80to80be80active80partners.
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.
ANS: A
Each action could be important for the client or family to perform. However, enc
ouraging the client 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 and involved does.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning KEY: Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Co
ntrol
3. A nurse is caring for a postoperative client on the surgical unit. The client9s
blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg.
What action would the nurse take first?
a. Call80the80Rapid80Response80Team.
b. Document and continue to monitor.
,c. Notify the primary health care provider.
d. Repeat the blood pressure in 15 minutes.
s , s ,
, ANS: s , s , A
The purpose of the Rapid Response Team (RRT) is to intervene when clients
s , s , s , s , s , s , s , s , s , s , s , s ,
are deteriorating before they suffer either respiratory or cardiac arrest. Since
s , s, s , s , s , s , s , s , s , s , s , s
,the client has manifested a significant change, the nurse would call the RRT
s , s, s , s , s , s , s , s , s , s , s , s ,
. Changes in blood pressure, mental status, heart rate, temperature, oxygen sa
s , s , s , s , s , s , s , s , s , s , s ,
turation, and last 2 s , s , s ,
hours9 urine output are particularly significant and are part of the Modifie
s , s , s , s , s , s , s , s , s , s , s ,
d Earl y Warning System guide. Documentation is vital, but the nurse must
s , s, s , s , s , s , s , s , s , s , s , s , s
,do more tha n document. The primary health care provider would be notifie
s , s , s, s , s , s , s , s , s , s , s , s ,
d, but this is not more important than calling the RRT. The client9s blood
s , s , s , s , s , s , s , s , s , s , s , s , s , s
,pressure would be reass essed frequently, but the priority is getting the ras , s , s , s , s , s , s , s , s , s , s , s ,
pid care to the client. s , s , s , s ,
DIF: Applying
TOP: Integrated Process: Communication and Documentation K s , s , s , s , s , s ,
EY: Rapid Response Team (RRT), Clinical judgment
s, s , s , s , s , s ,
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
s, s, s , s , s , s , s , s ,
4. A nurse wishes to
s , provide client- s , s , s , s ,
centered care in all interactions. Which action by the nu s , s , s , s , s , s , s , s , s ,
rse best demonstrates this concept?
s, s , s , s ,
a. Assesses80for80cultural80influences80affecting80health80care.
b. Ensures that all the client9s basic needs are met. s , s , s , s , s , s , s , s ,
c. Tells the client and family about all upcoming tests. s , s , s , s , s , s , s , s ,
d. Thoroughly orients the client and family to the room. s , s , s , s , s , s , s , s ,
ANS: s , s , A
Showing respect for the client and family9s preferences and needs is essent
s , s , s , s , s , s , s , s , s , s , s ,
ial to ensure a holistic or <whole-
s , s , s , s , s , s ,
person= approach to care. By assessing the effect of the client9s culture on
s , s , s , s , s , s , s , s , s , s , s , s ,
s health care, this nurse is practicing client-
, s, s , s , s , s , s ,
focused care. Providing for basic needs does not demonstrate this competenc
s , s , s , s , s , s , s , s , s , s ,
e. Si mply telling the client about all upcoming tests is not providing emp
s , s, s , s , s , s , s , s , s , s , s , s , s ,
owering educ ation. Orienting the client and family to the room is an imp
s , s, s , s , s , s , s , s , s , s , s , s , s ,
ortant safety measure, but not directly related to demonstrating client-
s , s , s, s , s , s , s , s , s ,
centered care. s ,
DIF: Understanding
TOP: Integrated Process: Culture and Spirituality KEY: s , s , s , s , s , s ,
Client-
centered care, Culture s , s ,
MSC: Client Needs Category: Psychosocial Integrity s,s, s , s , s , s ,
5. A client is going to be admitted for a scheduled surgical procedure. W
s , s , s , s , s , s , s , s , s , s , s , s ,
hich ac tion does the nurse explain is the most important thing the client
s , s, s , s , s , s , s , s , s , s , s , s , s ,
s can do to protect against errors?
, s , s , s, s , s ,
a. Bring80a80list80of80all80medications80and80what80they80are80for.
b. Keep the provider9s phone number by the telephone. s , s , s , s , s , s , s ,
c. Make sure that all providers wash hands before entering the room. s , s , s , s , s , s , s , s , s , s ,
d. Write down the name of each caregiver who comes in the room. s , s , s , s , s , s , s , s,s, s , s , s ,
ANS: s , s , A
Medication reconciliation is a formal process in which the client9s actual cur s , s , s , s , s , s , s , s , s , s , s ,
rent m edications are compared to the prescribed medications at the time of
s , s, s , s , s , s , s , s , s , s , s , s ,
s admission, t ransfer, or discharge. This National client Safety Goal is imp
, s , s , s , s , s , s , s , s , s , s , s ,
ortant to reduce me dication errors. The client would not have to be respo
s , s , s , s , s , s , s , s , s , s , s , s , s ,
nsible for providers washin g their hands, and even if the client does so,
s , s , s , s, s , s , s , s , s , s , s , s , s , s
,this is too narrow to be the mo st important action to prevent errors. K
s , s , s , s , s , s , s , s, s , s , s , s , s , s ,
eeping the provider9s phone number nearb y and documenting everyone who
s , s , s , s , s , s, s , s , s , s , s
,enters the room also do not guarantee safety. s , s , s , s , s , s , s ,