Medical-Surgical Nursing: n7
Concepts for Clinical Judgment and Collaborative Care 11th
n7 n7 n7 n7 n7 n7 n7
Edition by Ignatavicius
n7 n7 n7
Chapters 1-69 n7
, Concepts for Medical-Surgical NursingIgnatavicius: Medical-Surgical Nursing, 11th
n7 n7 n7 7
n n7 n7 n7
Edition
n7
MULTIPLE CHOICE n7
1. A new nurse is working with a preceptor on a medical-surgical unit. The
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
preceptor advises thenew nurse that which is the priority when working as a
n7 n7 n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
professional nurse?
n7 n7
a. Attending to holistic client needs n7 n7 n7 n7
b. Ensuring client safety n7 n7
c. Not making medication errors
n7 n7 n7
d. Providing client-focused care n7 n7
ACCURATE ANSWER: n7
B
n7
Rationale:All actions are appropriate for the professional nurse. However,
n7 n7 n7 n7 n7 n7 n7 n7
ensuring client safety is thepriority. Health care errors have been widely
n7 n7 n7 n7 n7 7
n n7 n7 n7 n7 n7 n7
reported for 25 years, many of which result inclient injury, death, and
n7 n7 n7 n7 n7 n7 n7 n7 n7 7
n n7 n7 n7
increased health care costs. There are several national and international
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
organizations that have either recommended or mandated safety initiatives.
n7 n7 n7 n7 n7 n7 n7 n7 n7
Every nurse has the responsibility to guard the client’s safety. The other actions
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
are importantfor quality nursing, but they are not as vital as providing safety.
n7 n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Not making medication errorsdoes provide safety, but is too narrow in scope to
n7 n7 n7 n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7
be the best accurate answerwer.
n7 n7 n7 n7 n7
DIF: Understanding TOP: Integrated Process: Nursing Process: n 7 n7 n7 n7
InterventionKEY: Client safety
n7 7
n n7 n7
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
n 7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Control
n7
2. A nurse is orienting a new client and family to the medical-surgical unit. What
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
informationdoes the nurse provide to best help the client promote his or her
n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
own safety?
n7 n7
a. Encourage the client and family to be active partners. n7 n7 n7 n7 n7 n7 n7 n7
b. Have the client monitor hand hygiene in caregivers.
n7 n7 n7 n7 n7 n7 n7
c. Offer the family the opportunity to stay with the client.
n7 n7 n7 n7 n7 n7 n7 n7 n7
d. Tell the client to always wear his or her armband.
n7 n7 n7 n7 n7 n7 n7 n7 n7
ACCURATE ANSWER: n7
A
n7
Rationale:Each action could be important for the client or family to perform.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
n7 However, encouraging theclient to be active in his or her health care as a safety
n7 n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
n7 partner is the most critical. The other actions are very limited in scope and do
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
n7 not provide the broad protection that being active andinvolved does.
n7 n7 n7 n7 n7 n7 n7 n7 7
n n7
DIF: Understanding TOP: Integrated Process: n 7 n7
Teaching/LearningKEY: Client safety
n7 7
n n7 n7
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
n 7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Control
n7
,3. A nurse is caring for a postoperative client on the surgical unit. The client’s
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
What action would the nursetake first?
n7 n7 n7 n7 n7 7
n n7
a. Call the Rapid Response Team.
n7 n7 n7 n7
b. Document and continue to monitor. n7 n7 n7 n7
c. Notify the primary health care provider.
n7 n7 n7 n7 n7
d. Repeat the blood pressure in 15 minutes.n7 n7 n7 n7 n7 n7
ACCURATE ANSWER: A n7 n7
Rationale:The purpose of the Rapid Response Team (RRT) is to intervene when
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
clients are deterioratingbefore they suffer either respiratory or cardiac arrest.
n7 n7 n7 7
n n7 n7 n7 n7 n7 n7 n7
Since the client has manifested a significant change, the nurse would call the
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
RRT. Changes in blood pressure, mental status, heart rate, temperature, oxygen
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
saturation, and last 2 hours’ urine output are particularly significant and are part
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
of the Modified Early Warning System guide. Documentation is vital, but the
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
nurse must do more than document. The primary health care provider would be
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
notified, but this is not more important than calling the RRT. The client’s blood
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
pressure would be reassessed frequently, but the priority is getting the rapid care
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
to the client.
n7 n7 n7
DIF: Applying TOP: Integrated Process: Communication and n 7 n7 n7 n7
DocumentationKEY: Rapid Response Team (RRT), Clinical judgment
n7 7
n n7 n7 n7 n7 n7 n7
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
n 7 n7 n7 n7 n7 n7 n7
4. A nurse wishes to provide client-centered care in all interactions. Which action by
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
the nurse
n7 n7
best demonstrates this concept?
n7 n7 n7
a. Assesses for cultural influences affecting health care.
n7 n7 n7 n7 n7 n7
b. Ensures that all the client’s basic needs are met.
n7 n7 n7 n7 n7 n7 n7 n7
c. Tells the client and family about all upcoming tests.
n7 n7 n7 n7 n7 n7 n7 n7
d. Thoroughly orients the client and family to the room. n7 n7 n7 n7 n7 n7 n7 n7
ACCURATE ANSWER: A n7 n7
Rationale:Showing respect for the client and family’s preferences and needs is n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
essential to ensure a holistic or “whole-person” approach to care. By assessing
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
the effect of the client’s culture onhealth care, this nurse is practicing client-
n7 n7 n7 n7 n7 n7 n7 7
n n7 n7 n7 n7 n7 n7
focused care. Providing for basic needs does not demonstrate this competence.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Simply telling the client about all upcoming tests is not providing empowering
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
education. Orienting the client and family to the room is an importantsafety
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 7
n
measure, but not directly related to demonstrating client-centered care.
n7 n7 n7 n7 n7 n7 n7 n7 n7
DIF: Understanding TOP: Integrated Process: Culture and n7 n7 n7 n7
Spirituality KEY: Client-centered care, Culture MSC: Client Needs Category:
n7 n7 n 7 n7 n7 n 7 n7 n7
Psychosocial Integrity
n7 n7
5. A client is going to be admitted for a scheduled surgical procedure. Which
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
action does thenurse explain is the most important thing the client can do to
n7 n7 n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
protect against errors?
n7 n7 n7
a. Bring a list of all medications and what they are for.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
b. Keep the provider’s phone number by the telephone.
n7 n7 n7 n7 n7 n7 n7
c. Make sure that all providers wash hands before entering the room.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
d. Write down the name of each caregiver who comes in the room.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
ACCURATE ANSWER: A n7 n7
, Rationale:Medication reconciliation is a formal process in which the client’s actual n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
current medicationsare compared to the prescribed medications at the time of
n7 n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7
admission, traccurate answerfer, or discharge. This National client Safety Goal is
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
important to reduce medication errors. The client would not have to be
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
responsible for providers washing their hands, and even if the client does so,
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
this is too narrow to be the most important action to prevent errors. Keeping
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
the provider’s phone number nearby and documenting everyone who enters the
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
room also do not guarantee safety.
n7 n7 n7 n7 n7 n7
DIF: Applying TOP: Integrated Process: n 7 n7
Teaching/LearningKEY: Client safety, Informatics
n7 7
n n7 n7 n7
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
n 7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Control
n7
6. Which action by the nurse working with a client best demonstrates respect for
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
autonomy?
n7
a. Asks if the client has questions before signing a consent.
n7 n7 n7 n7 n7 n7 n7 n7 n7
b. Gives the client accurate information when questioned.
n7 n7 n7 n7 n7 n7
c. Keeps the promises made to the client and family.
n7 n7 n7 n7 n7 n7 n7 n7
d. Treats the client fairly compared to other clients.
n7 n7 n7 n7 n7 n7 n7
ACCURATE ANSWER: A n7 n7
Rationale:Autonomy is self-determination. The client would make decisions n7 n7 n7 n7 n7 n7 n7
regarding care. When the nurse obtains a signature on the consent form,
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
assessing if the client still has questions is vital,because without full information
n7 n7 n7 n7 n7 n7 n7 n7 n7 7
n n7 n7 n7
the client cannot practice autonomy. Giving accurate information is practicing
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
with veracity. Keeping promises is upholding fidelity. Treating the client fairly is
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
providing social justice.
n7 n7 n7
DIF: Applying TOP: Integrated Process: Caring KEY: Ethics, n 7 n7 n7 n7
AutonomyMSC: Client Needs Category: Safe and Effective Care Environment:
n7 7
n n 7 n7 n7 n7 n7 n7 n7 n7
Management of Care
n7 n7 n7
7. A nurse asks a more seasoned colleague to explain best practices when
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
communicating with aperson from the lesbian, gay, bisexual, traccurate
n7 n7 n7 7
n n7 n7 n7 n7 n7 n7
answergender, and questioning/queer (LGBTQ) community. What accurate
n7 n7 n7 n7 n7 n7 n7
answerwer by the faculty is most accurate?
n7 n7 n7 n7 n7 n7 n7
a. Avoid embarrassing the client by asking questions.
n7 n7 n7 n7 n7 n7
b. Don’t make assumptions about his or her health needs.
n7 n7 n7 n7 n7 n7 n7 n7
c. Most LGBTQ people do not want to share information.
n7 n7 n7 n7 n7 n7 n7 n7
d. No differences exist in communicating with this population.
n7 n7 n7 n7 n7 n7 n7
ACCURATE ANSWER: B n7 n7
Rationale:Many members of the LGBTQ community have faced discrimination from
n7 n7 n7 n7 n7 n7 n7 n7 n7
n7 health care providers and may be reluctant to seek health care. The nurse would
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
n7 never make assumptions about the needs of members of this population. Rather,
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
n7 respectful questions are appropriate. Ifapproached with sensitivity, the client with
n7 n7 n7 n7 7
n n7 n7 n7 n7 n7
n7 any health care need is more likely to accurate answerwer honestly.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
DIF: Understanding TOP: Integrated Process: Teaching/Learning n 7 n7 n7
KEY: Health care disparities, LGBTQ MSC: Client Needs Category: Psychosocial Integrity
n 7 n7 n7 n7 n 7 n7 n7 n7 n7
8. A nurse is calling the on-call health care provider about a client who had a
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
hysterectomy 2days ago and has pain that is unrelieved by the prescribed
n7 n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
opioid pain medication. Which statement comprises the background portion of
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Concepts for Clinical Judgment and Collaborative Care 11th
n7 n7 n7 n7 n7 n7 n7
Edition by Ignatavicius
n7 n7 n7
Chapters 1-69 n7
, Concepts for Medical-Surgical NursingIgnatavicius: Medical-Surgical Nursing, 11th
n7 n7 n7 7
n n7 n7 n7
Edition
n7
MULTIPLE CHOICE n7
1. A new nurse is working with a preceptor on a medical-surgical unit. The
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
preceptor advises thenew nurse that which is the priority when working as a
n7 n7 n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
professional nurse?
n7 n7
a. Attending to holistic client needs n7 n7 n7 n7
b. Ensuring client safety n7 n7
c. Not making medication errors
n7 n7 n7
d. Providing client-focused care n7 n7
ACCURATE ANSWER: n7
B
n7
Rationale:All actions are appropriate for the professional nurse. However,
n7 n7 n7 n7 n7 n7 n7 n7
ensuring client safety is thepriority. Health care errors have been widely
n7 n7 n7 n7 n7 7
n n7 n7 n7 n7 n7 n7
reported for 25 years, many of which result inclient injury, death, and
n7 n7 n7 n7 n7 n7 n7 n7 n7 7
n n7 n7 n7
increased health care costs. There are several national and international
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
organizations that have either recommended or mandated safety initiatives.
n7 n7 n7 n7 n7 n7 n7 n7 n7
Every nurse has the responsibility to guard the client’s safety. The other actions
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
are importantfor quality nursing, but they are not as vital as providing safety.
n7 n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Not making medication errorsdoes provide safety, but is too narrow in scope to
n7 n7 n7 n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7
be the best accurate answerwer.
n7 n7 n7 n7 n7
DIF: Understanding TOP: Integrated Process: Nursing Process: n 7 n7 n7 n7
InterventionKEY: Client safety
n7 7
n n7 n7
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
n 7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Control
n7
2. A nurse is orienting a new client and family to the medical-surgical unit. What
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
informationdoes the nurse provide to best help the client promote his or her
n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
own safety?
n7 n7
a. Encourage the client and family to be active partners. n7 n7 n7 n7 n7 n7 n7 n7
b. Have the client monitor hand hygiene in caregivers.
n7 n7 n7 n7 n7 n7 n7
c. Offer the family the opportunity to stay with the client.
n7 n7 n7 n7 n7 n7 n7 n7 n7
d. Tell the client to always wear his or her armband.
n7 n7 n7 n7 n7 n7 n7 n7 n7
ACCURATE ANSWER: n7
A
n7
Rationale:Each action could be important for the client or family to perform.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
n7 However, encouraging theclient to be active in his or her health care as a safety
n7 n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
n7 partner is the most critical. The other actions are very limited in scope and do
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
n7 not provide the broad protection that being active andinvolved does.
n7 n7 n7 n7 n7 n7 n7 n7 7
n n7
DIF: Understanding TOP: Integrated Process: n 7 n7
Teaching/LearningKEY: Client safety
n7 7
n n7 n7
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
n 7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Control
n7
,3. A nurse is caring for a postoperative client on the surgical unit. The client’s
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
What action would the nursetake first?
n7 n7 n7 n7 n7 7
n n7
a. Call the Rapid Response Team.
n7 n7 n7 n7
b. Document and continue to monitor. n7 n7 n7 n7
c. Notify the primary health care provider.
n7 n7 n7 n7 n7
d. Repeat the blood pressure in 15 minutes.n7 n7 n7 n7 n7 n7
ACCURATE ANSWER: A n7 n7
Rationale:The purpose of the Rapid Response Team (RRT) is to intervene when
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
clients are deterioratingbefore they suffer either respiratory or cardiac arrest.
n7 n7 n7 7
n n7 n7 n7 n7 n7 n7 n7
Since the client has manifested a significant change, the nurse would call the
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
RRT. Changes in blood pressure, mental status, heart rate, temperature, oxygen
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
saturation, and last 2 hours’ urine output are particularly significant and are part
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
of the Modified Early Warning System guide. Documentation is vital, but the
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
nurse must do more than document. The primary health care provider would be
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
notified, but this is not more important than calling the RRT. The client’s blood
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
pressure would be reassessed frequently, but the priority is getting the rapid care
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
to the client.
n7 n7 n7
DIF: Applying TOP: Integrated Process: Communication and n 7 n7 n7 n7
DocumentationKEY: Rapid Response Team (RRT), Clinical judgment
n7 7
n n7 n7 n7 n7 n7 n7
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
n 7 n7 n7 n7 n7 n7 n7
4. A nurse wishes to provide client-centered care in all interactions. Which action by
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
the nurse
n7 n7
best demonstrates this concept?
n7 n7 n7
a. Assesses for cultural influences affecting health care.
n7 n7 n7 n7 n7 n7
b. Ensures that all the client’s basic needs are met.
n7 n7 n7 n7 n7 n7 n7 n7
c. Tells the client and family about all upcoming tests.
n7 n7 n7 n7 n7 n7 n7 n7
d. Thoroughly orients the client and family to the room. n7 n7 n7 n7 n7 n7 n7 n7
ACCURATE ANSWER: A n7 n7
Rationale:Showing respect for the client and family’s preferences and needs is n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
essential to ensure a holistic or “whole-person” approach to care. By assessing
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
the effect of the client’s culture onhealth care, this nurse is practicing client-
n7 n7 n7 n7 n7 n7 n7 7
n n7 n7 n7 n7 n7 n7
focused care. Providing for basic needs does not demonstrate this competence.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Simply telling the client about all upcoming tests is not providing empowering
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
education. Orienting the client and family to the room is an importantsafety
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 7
n
measure, but not directly related to demonstrating client-centered care.
n7 n7 n7 n7 n7 n7 n7 n7 n7
DIF: Understanding TOP: Integrated Process: Culture and n7 n7 n7 n7
Spirituality KEY: Client-centered care, Culture MSC: Client Needs Category:
n7 n7 n 7 n7 n7 n 7 n7 n7
Psychosocial Integrity
n7 n7
5. A client is going to be admitted for a scheduled surgical procedure. Which
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
action does thenurse explain is the most important thing the client can do to
n7 n7 n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
protect against errors?
n7 n7 n7
a. Bring a list of all medications and what they are for.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
b. Keep the provider’s phone number by the telephone.
n7 n7 n7 n7 n7 n7 n7
c. Make sure that all providers wash hands before entering the room.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
d. Write down the name of each caregiver who comes in the room.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
ACCURATE ANSWER: A n7 n7
, Rationale:Medication reconciliation is a formal process in which the client’s actual n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
current medicationsare compared to the prescribed medications at the time of
n7 n7 7
n n7 n7 n7 n7 n7 n7 n7 n7 n7
admission, traccurate answerfer, or discharge. This National client Safety Goal is
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
important to reduce medication errors. The client would not have to be
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
responsible for providers washing their hands, and even if the client does so,
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
this is too narrow to be the most important action to prevent errors. Keeping
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
the provider’s phone number nearby and documenting everyone who enters the
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
room also do not guarantee safety.
n7 n7 n7 n7 n7 n7
DIF: Applying TOP: Integrated Process: n 7 n7
Teaching/LearningKEY: Client safety, Informatics
n7 7
n n7 n7 n7
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
n 7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Control
n7
6. Which action by the nurse working with a client best demonstrates respect for
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
autonomy?
n7
a. Asks if the client has questions before signing a consent.
n7 n7 n7 n7 n7 n7 n7 n7 n7
b. Gives the client accurate information when questioned.
n7 n7 n7 n7 n7 n7
c. Keeps the promises made to the client and family.
n7 n7 n7 n7 n7 n7 n7 n7
d. Treats the client fairly compared to other clients.
n7 n7 n7 n7 n7 n7 n7
ACCURATE ANSWER: A n7 n7
Rationale:Autonomy is self-determination. The client would make decisions n7 n7 n7 n7 n7 n7 n7
regarding care. When the nurse obtains a signature on the consent form,
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
assessing if the client still has questions is vital,because without full information
n7 n7 n7 n7 n7 n7 n7 n7 n7 7
n n7 n7 n7
the client cannot practice autonomy. Giving accurate information is practicing
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
with veracity. Keeping promises is upholding fidelity. Treating the client fairly is
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
providing social justice.
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DIF: Applying TOP: Integrated Process: Caring KEY: Ethics, n 7 n7 n7 n7
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.
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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 n7 n7
Rationale:Many members of the LGBTQ community have faced discrimination from
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n7 health care providers and may be reluctant to seek health care. The nurse would
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n7 never make assumptions about the needs of members of this population. Rather,
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n7 respectful questions are appropriate. Ifapproached with sensitivity, the client with
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n7 any health care need is more likely to accurate answerwer honestly.
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DIF: Understanding TOP: Integrated Process: Teaching/Learning n 7 n7 n7
KEY: Health care disparities, LGBTQ MSC: Client Needs Category: Psychosocial Integrity
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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
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opioid pain medication. Which statement comprises the background portion of
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