TEST BANK OF MEDICAL SURGICAL NURSING IGNATAVICIUS 7TH EDITION

Which action demonstrates that the nurse understands the purpose of the Rapid Response Team? a. Monitoring the client for changes in postoperative status such as wound infection b. Documenting all changes observed in the client and maintaining a postoperative flow sheet c. Notifying the physician of the client’s change in blood pressure from 140 to 88 mm Hg systolic d. Notifying the physician of the client’s increase in restlessness after medication change The Joint Commission focuses on safety in health care. Which action by the nurse reflects The Joint Commission’s main objective? a. Performing range-of-motion exercises on the client three times each day b. Ensuring that the client is eating 100% of the meals served to him or her c. Assessing the client’s respirations when administering opioids d. Delegating to the nursing assistant to give the client a complete bath daily Which action by the nurse shows an understanding of the principle of self-determination? a. Allowing a postoperative client to decide to take medication with fruit juice rather than water b. Allowing a teenager to decide not to go to a clinic when there is evidence that she is having profuse vaginal bleeding c. Allowing a parent to decide not to proceed with a lifesaving operation for a 12-year-old client d. Allowing an older client with dementia to decide not to take cardiac medication throughout the shift The nurse is initiating a series of teaching sessions with an older client. What is the nurse’s highest-priority, client-centered action before beginning the session? a. Ensure that the client’s family is present and will participate. b. Make certain that the client is wearing his glasses. c. Have printed handouts ready to use during the session. d. Schedule the session for early evening after the client’s meal. Which action best demonstrates the nurse using client-centered care when planning a menu for a Vietnamese client who is newly diagnosed with diabetes? a. Asking the client what food he or she would eat on a standard diabetic menu b. Asking family members to make selections for the client from a diabetic menu c. Ordering a typical diabetic meal for the client and planning diet teaching d. Researching the Vietnamese culture before discussing diabetic meal planning The Institute for Healthcare Improvement (IHI) identified interventions to save client lives. Which actions are within the scope of nursing practice to improve quality of care? a. Insert a central line to give intravenous fluid to a dehydrated client. b. Use sterile technique when changing dressings on a new surgical site. c. Intubate a client whose oxygen saturation is 92%. d. Prescribe aspirin for a client who presents with an acute myocardial infarction Which action by the nurse demonstrates the best practice for nursing documentation on a computerized record? a. Deleting all documentation errors on the computerized record b. Using red font to denote all significant events that have occurred c. Waiting until the end of the shift to record a summary of information d. Documenting assessment data at the point of care A client is scheduled for a mastectomy. As she is about to receive the preoperative medication, she tells the nurse that she does not want to have her breast removed but wants a lumpectomy. Which response indicates that the nurse is acting as a client advocate? a. Telling the client her surgeon is excellent and knows what is best for her condition b. Calling the surgeon to come and explain all treatment options to the client c. Holding the client’s hand and offering to pray with her for a good outcome d. Arranging for a postoperative visit from a cancer survivor What priority assessment data should be shared with the interdisciplinary team from a client admitted to the emergency department with a lacerated artery? a. Information regarding next of kin to notify in case the client dies b. History about what medications the client is currently taking c. Measurement of blood pressure and pulse d. Assessment of rate and depth of respirations Which intervention can the client expect to receive from a medical- surgical nurse in an ambulatory care setting? a. Drawing blood for routine or preoperative testing b. Teaching the client how to change a dressing on an incision c. Obtaining the client’s signature on a surgical consent form d. Performing a comprehensive physical examination An emergency department (ED) nurse gives report on a client who is being transferred to the medical-surgical floor. Because of an identified risk for suicide, the ED nurse suggests that the floor nurse contact a sitter and behavioral health. This statement represents which part of the SBAR hand-off? a. Situation b. Background c. Assessment d. Recommendation The nurse is present when the physician discusses the potential effects of a chemotherapy regimen for a client with cancer. Weighing the benefits of the chemotherapy against possible side effects is an example of which ethical principle? a. Paternalism b. Beneficence c. Justice d. Autonomy The physician prescribes warfarin (Coumadin) 15 mg daily. The nurse notes that this is three times the normal dose for this client based on the client’s medication profile and laboratory work. What does the nurse do first? a. Give the dose and document the concern. b. Call the pharmacy for a consultation. c. Call the physician to question the order. d. Hold the medication for that day. Which statement best describes the process of nursing case management? a. The coordination of care services to at-risk populations b. A collaborative process to promote quality and cost-effective care c. The implementation of care to acutely ill, underserved populations d. A cost-effective care delivery model meeting the needs of specially defined groups Which client is best served by a case manager? a. An older woman with chronic cystitis b. A middle-aged man with moderate hypertension c. An older woman with chronic heart failure and diabetes mellitus d. A young adult with a fractured ankle from a sports injury The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse delegate to the unlicensed assistive personnel? a. Complete the nursing care plan. b. Assist the client with meals. c. Evaluate the pulse oximetry reading. d. Assess level of consciousness. MULTIPLE RESPONSE The nurse on a medical-surgical unit notices that there has been an increase in the number of client falls. Which methods would be effective in promoting quality improvement on this issue? (Select all that apply.) a. Identify causes of falls on the unit by looking at specific client cases. b. Look at the research and the literature on prevention of falls. c. Complain to the manager that team members are neglecting the clients. d. Use sit and stand alarms because they seem to be working on other units. e. Try more frequent rounding on clients as suggested by co-workers. Which settings would require maximum implementation of the nurse supervisor role? (Select all that apply.) a. Acute care setting b. Home care setting c. Skilled nursing facility d. Assisted-living facility e. Rehabilitation facility Which activities are within the role of the case manager? (Select all that apply.) a. Gathering and organizing data about a client from client records and interviews b. Planning care for a client with emphasis on client satisfaction c. Coordinating care among a variety of health care professionals and settings d. Promoting the client’s interests while negotiating necessary health care e. Advocating for the client and the family throughout the continuum of care f. Using resources for appropriate client health care services A client has metastatic lung cancer and is hospitalized for chemotherapy. Which intervention does the nurse delegate to the unlicensed assistive personnel? (Select all that apply.) a. Assist the client with repositioning. b. Teach the client to use the incentive spirometer. c. Take vital signs every 4 hours. d. Record intake and output measurements. e. Promote the expression of grief and loss. Chapter 2: Introduction to Complementary and Alternative Therapies Test Bank MULTIPLE CHOICE The nurse wishes to learn more about the client’s use of natural products and their effectiveness. The nurse consults the National Center for Complementary and Alternative Medicine because it is known that this center serves which function? a. Educates health professionals about complementary therapies b. Educates new mothers on the benefits of massage c. Engages in fundraising to offset client expenses with medical care d. Provides a scholarship for a student to study naturopathy A client is anxious about having a dressing change. Which statement indicates that the nurse is promoting appropriate complementary therapy? a. “I’ll call the doctor and ask for a larger dose of pain medication before the dressing change.” b. “As we begin the next dressing change, I want you to think of a beautiful, calm place where you feel happy and peaceful.” c. “I’ll get another nurse to stay in the room with us during the dressing change so that you have a hand to hold during the procedure.” d. “Are you familiar with acupuncture? It’s a very effective technique.” The nurse has designed a treatment plan that includes the use of massage. Which intervention will the nurse implement first? a. Assess the client to determine the most effective type of massage technique to use. b. Inspect the skin over the tissue to be massaged to ensure that it is not infected or bruised. c. Determine whether a licensed therapist will be needed to carry out the massage technique d. Obtain permission from the client to implement this type of technique