10/31/23, 5:28 AM Test bank - medical surgical nursing 10th edition ignatavicius workman-bte …
about:blank 1/593
Medical Su rgical Nursing 10th Edition Ignatavicius Workman Test B ank 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 prec eptor advises the
new nurse that which is the when working as a professional nurse? priority a.Attending holistic client needsto
b.Ensuring client safety
c.Not making medic ation errors
d.Providing client-focused c are
ANS: B All actions are appropriate for the professional nurse. Howe ver, ensuring client safety is the priority. Health care errors have been widely reported for 25 years, many of which result in client injury, death, and increased health care costs. There are se veral national and international orga nizations that have either recommended or mandated safety initiatives. Every nurse has the responsibility to guard the client’s safet y. The othe r acti ons are important for quality nursing, but they are not as vital as providing safet y. Not making medication errors does provide safety, but is too narrow in scope to be 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 Control 2.A nurse is orienting a new client and fa mily to the medica l-surgical unit. What information
does the nurse provide to best help the client promote his or her own safety?
a.Encourage the clie nt and family be active partners.to
b.Have the client monitor hand hygiene caregiver s. in
c.Offer the fa mily the opportunity stay with the client. to
d.Tell the client alway s wear his or her armband. to
ANS: A Each action could be important for the c lient or famil y to perform. However, encouraging 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 ntrol Co
3.A nurse is caring for a postoperative clie nt on the surgical unit. The client’s 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.Call the Rapid Response Team.
b.Document and continue monitor.to
c.Notify the primary health care provider.
d.Repeat the blood pre ssure 15 minutes.in
Btestbanks.comharry 10/31/23, 5:28 AM Test bank - medical surgical nursing 10th edition ignatavicius workman-bte …
about:blank 2/593 ANS: A The purpose of the Rapid Response Team (RRT) is to intervene whe n clients are deteriorating before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse would call the RRT. Changes in blood pressure, mental status, heart rate, temperature, oxyge n saturation, and last 2 hours’ urine output are particularl y significant and are part of the Modified Early Warning Sy stem guide. Documentation is vital, but the nurse must do more than document. The primary health care provider would be notified, but this is not more important than calling the RRT. The client’s blood pressure would be reassessed fr equently, but the priority is getting the rapid care the client. to DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Rapid Response Team (RRT), Clinical judgment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse wishe s provide client-centered care all intera ctions. Which action to in by the nurse best demonstrates this concept? a. Assesses for c ultural influences affecting health care . b. Ensures that all the basic needs are met. client’s
c. Tells the client and fa mily about all upcoming tests. d. Thoroughly orie nts the client and family to the room. ANS: A Showing respect for the client and family’s preferences and needs is essential to ensure a holistic or “whole person” approach to care. By assessing the effect of the client’s culture on- health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client and family to the room is an important safety mea sure, but not directly related to demonstrating client-centered care. DIF: Understanding TOP: Integrated Process: Culture and Spirituality KEY: Client-centered care, Culture MSC: Client Needs Category: Psychosocial Integrity 5. A client is going to be admitted for a sche duled surgical procedure. Which action does the nurse explain is the important thing the c lient do to protect against errors? most can
a. Bring a list of all medica tions and what they a re for. b. Keep the phone number the telephone. provider’s by
c. Make sure that all providers wash hands before e ntering the room. d. Write down the name of each caregiver who comes the room. in
ANS: A Medication reconciliation is a formal process in which the client’s actual curre nt medications are compared to the prescribed medications at the time of admission, transfe r, or discharge. This National client Safety Goal is important to reduce medication err ors. The client would not have to be responsible for providers washing their hands, and even if the client does so, this is too narrow to be the most important action to prevent errors. Keeping the provider’s phone number nearby and documenting every one who enters the room also do not guarantee safety. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Client safety, Informatics MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control Btestbanks.comharry 10/31/23, 5:28 AM Test bank - medical surgical nursing 10th edition ignatavicius workman-bte …
about:blank 3/593 6. Which action by the nurse working with a client best demonstrates respect for autonom y? a. Asks the c lient has questions before signing a consent. if
b. Gives the client accurate information when questioned. c. Keeps the promises made the client and fa mily. to
d. Treats the client fairly c ompared other c lients. to
ANS: A Autonomy is self-determination. The client would make decisions regarding care . When the nurse obtains a signature on the consent form, assessing if the clie nt still has questions is vital, because without full information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity . Treating the client fairly is providing social justice. DIF: Applying TOP: Integrated Process: Caring KEY: Ethics, Autonomy MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse asks a more seasoned colleague to explain best practices when communicating with a person from the lesbian, gay , bisexual, transgender, and questioning/queer (LGBTQ) community. What answer by the faculty is accura te? most a. Avoid embarrassing the client by asking questions. b. Don’t make assumptions about his or her he alth needs. c. Most LGBTQ people do not want share infor mation. to
d. No differences exist communicating with this population. in
ANS: B Many members of the LGBTQ community ha ve faced discrimination from health care providers and may be reluctant to seek health care. The nurse would never make a ssumptions about the needs of members of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the clie nt with an y health care need is more likel y to answer honestly. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Health care disparities, LGBTQ MSC: Client Needs Category: Psychosocial Integrity 8. A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days ago and has pain that is unrelieve d by the prescribe d opioid pain medication. Which statement comprises the background portion of the SBAR format for communication? a. “I would like you order a diffe rent pain to medication.”
b. “This client has allerg ies morphine and to codeine.”
c. “Dr. doesn’t Smith like nonsteroidal anti-inflammatory meds.”
d. “This client had a va ginal h ysterectomy 2 days ago.”
ANS: B Btestbanks.comharry 10/31/23, 5:28 AM Test bank - medical surgical nursing 10th edition ignatavicius workman-bte …
about:blank 4/593 SBAR is a recommended form of communication, and the acrony m stands for , Situation
Background Assessment Recommendation , , and . Appropriate background information includes allergies to medications the on-call health care provider might order. Situation describes what is happening right now that must be communicated; the c lient’s surgery 2 days ago would be considered background. would include an analysis Assessment of the client’s
problem; none of the options has assessment information. Asking for a different pain medication is a recommendation. is a statement of what is needed or what Recommendation outcome is desired. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Teamwork and collaboration, SBAR MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. A nurse working on a cardiac unit delegated taking vital sig ns to an experienced assistive personnel (AP). Four hours later, the nurse notes that the client’s blood pressure taken by the
AP was much higher than previous readings, and the client’s mental status has cha nged. What action by the nurse woul d likely have prevented this nega tive outcome? most a. Determining if to the AP knew how take blood pressure b. Double-checking the APby taking another blood pressure c. Providing more appropriate supervision of the AP
d. Taking the blood pressure instead of delegating the task ANS: C Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated tasks. The nurse would either have asked the AP about the vital signs or instructed the AP to report them right away. An experienced AP would know how to take vital signs and the nurse would not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a AP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the A P. DIF: Analyzing TOP: Integrated Process: Communication and Documentation KEY: Teamwork and collaboration, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. A newly graduated nurse in the hospital states that because of being so new, participation in quality improve ment (QI) projects not wise. Wh at response is by the precepting nurse is ? best
a. “All staff nurse s are required participate quality improve ment to in here.”
b. “Even being ne w, you c an implement activities designe d improve to care.”
c. “It’s easy to identify what indicators would be used to mea sure quality.”
d. “You should ask be as signed to the research and to quality committee.”
ANS: B The preceptor would try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. I dentif ying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nur se to start. Asking to be assigned to the QI c ommittee does not give the nurse information about how to implement QI in daily practice. DIF: Applying TOP: Integrated Process: Communication and Documentation Btestbanks.comharry
about:blank 1/593
Medical Su rgical Nursing 10th Edition Ignatavicius Workman Test B ank 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 prec eptor advises the
new nurse that which is the when working as a professional nurse? priority a.Attending holistic client needsto
b.Ensuring client safety
c.Not making medic ation errors
d.Providing client-focused c are
ANS: B All actions are appropriate for the professional nurse. Howe ver, ensuring client safety is the priority. Health care errors have been widely reported for 25 years, many of which result in client injury, death, and increased health care costs. There are se veral national and international orga nizations that have either recommended or mandated safety initiatives. Every nurse has the responsibility to guard the client’s safet y. The othe r acti ons are important for quality nursing, but they are not as vital as providing safet y. Not making medication errors does provide safety, but is too narrow in scope to be 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 Control 2.A nurse is orienting a new client and fa mily to the medica l-surgical unit. What information
does the nurse provide to best help the client promote his or her own safety?
a.Encourage the clie nt and family be active partners.to
b.Have the client monitor hand hygiene caregiver s. in
c.Offer the fa mily the opportunity stay with the client. to
d.Tell the client alway s wear his or her armband. to
ANS: A Each action could be important for the c lient or famil y to perform. However, encouraging 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 ntrol Co
3.A nurse is caring for a postoperative clie nt on the surgical unit. The client’s 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.Call the Rapid Response Team.
b.Document and continue monitor.to
c.Notify the primary health care provider.
d.Repeat the blood pre ssure 15 minutes.in
Btestbanks.comharry 10/31/23, 5:28 AM Test bank - medical surgical nursing 10th edition ignatavicius workman-bte …
about:blank 2/593 ANS: A The purpose of the Rapid Response Team (RRT) is to intervene whe n clients are deteriorating before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse would call the RRT. Changes in blood pressure, mental status, heart rate, temperature, oxyge n saturation, and last 2 hours’ urine output are particularl y significant and are part of the Modified Early Warning Sy stem guide. Documentation is vital, but the nurse must do more than document. The primary health care provider would be notified, but this is not more important than calling the RRT. The client’s blood pressure would be reassessed fr equently, but the priority is getting the rapid care the client. to DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Rapid Response Team (RRT), Clinical judgment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse wishe s provide client-centered care all intera ctions. Which action to in by the nurse best demonstrates this concept? a. Assesses for c ultural influences affecting health care . b. Ensures that all the basic needs are met. client’s
c. Tells the client and fa mily about all upcoming tests. d. Thoroughly orie nts the client and family to the room. ANS: A Showing respect for the client and family’s preferences and needs is essential to ensure a holistic or “whole person” approach to care. By assessing the effect of the client’s culture on- health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client and family to the room is an important safety mea sure, but not directly related to demonstrating client-centered care. DIF: Understanding TOP: Integrated Process: Culture and Spirituality KEY: Client-centered care, Culture MSC: Client Needs Category: Psychosocial Integrity 5. A client is going to be admitted for a sche duled surgical procedure. Which action does the nurse explain is the important thing the c lient do to protect against errors? most can
a. Bring a list of all medica tions and what they a re for. b. Keep the phone number the telephone. provider’s by
c. Make sure that all providers wash hands before e ntering the room. d. Write down the name of each caregiver who comes the room. in
ANS: A Medication reconciliation is a formal process in which the client’s actual curre nt medications are compared to the prescribed medications at the time of admission, transfe r, or discharge. This National client Safety Goal is important to reduce medication err ors. The client would not have to be responsible for providers washing their hands, and even if the client does so, this is too narrow to be the most important action to prevent errors. Keeping the provider’s phone number nearby and documenting every one who enters the room also do not guarantee safety. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Client safety, Informatics MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control Btestbanks.comharry 10/31/23, 5:28 AM Test bank - medical surgical nursing 10th edition ignatavicius workman-bte …
about:blank 3/593 6. Which action by the nurse working with a client best demonstrates respect for autonom y? a. Asks the c lient has questions before signing a consent. if
b. Gives the client accurate information when questioned. c. Keeps the promises made the client and fa mily. to
d. Treats the client fairly c ompared other c lients. to
ANS: A Autonomy is self-determination. The client would make decisions regarding care . When the nurse obtains a signature on the consent form, assessing if the clie nt still has questions is vital, because without full information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity . Treating the client fairly is providing social justice. DIF: Applying TOP: Integrated Process: Caring KEY: Ethics, Autonomy MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse asks a more seasoned colleague to explain best practices when communicating with a person from the lesbian, gay , bisexual, transgender, and questioning/queer (LGBTQ) community. What answer by the faculty is accura te? most a. Avoid embarrassing the client by asking questions. b. Don’t make assumptions about his or her he alth needs. c. Most LGBTQ people do not want share infor mation. to
d. No differences exist communicating with this population. in
ANS: B Many members of the LGBTQ community ha ve faced discrimination from health care providers and may be reluctant to seek health care. The nurse would never make a ssumptions about the needs of members of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the clie nt with an y health care need is more likel y to answer honestly. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Health care disparities, LGBTQ MSC: Client Needs Category: Psychosocial Integrity 8. A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days ago and has pain that is unrelieve d by the prescribe d opioid pain medication. Which statement comprises the background portion of the SBAR format for communication? a. “I would like you order a diffe rent pain to medication.”
b. “This client has allerg ies morphine and to codeine.”
c. “Dr. doesn’t Smith like nonsteroidal anti-inflammatory meds.”
d. “This client had a va ginal h ysterectomy 2 days ago.”
ANS: B Btestbanks.comharry 10/31/23, 5:28 AM Test bank - medical surgical nursing 10th edition ignatavicius workman-bte …
about:blank 4/593 SBAR is a recommended form of communication, and the acrony m stands for , Situation
Background Assessment Recommendation , , and . Appropriate background information includes allergies to medications the on-call health care provider might order. Situation describes what is happening right now that must be communicated; the c lient’s surgery 2 days ago would be considered background. would include an analysis Assessment of the client’s
problem; none of the options has assessment information. Asking for a different pain medication is a recommendation. is a statement of what is needed or what Recommendation outcome is desired. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Teamwork and collaboration, SBAR MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. A nurse working on a cardiac unit delegated taking vital sig ns to an experienced assistive personnel (AP). Four hours later, the nurse notes that the client’s blood pressure taken by the
AP was much higher than previous readings, and the client’s mental status has cha nged. What action by the nurse woul d likely have prevented this nega tive outcome? most a. Determining if to the AP knew how take blood pressure b. Double-checking the APby taking another blood pressure c. Providing more appropriate supervision of the AP
d. Taking the blood pressure instead of delegating the task ANS: C Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated tasks. The nurse would either have asked the AP about the vital signs or instructed the AP to report them right away. An experienced AP would know how to take vital signs and the nurse would not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a AP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the A P. DIF: Analyzing TOP: Integrated Process: Communication and Documentation KEY: Teamwork and collaboration, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. A newly graduated nurse in the hospital states that because of being so new, participation in quality improve ment (QI) projects not wise. Wh at response is by the precepting nurse is ? best
a. “All staff nurse s are required participate quality improve ment to in here.”
b. “Even being ne w, you c an implement activities designe d improve to care.”
c. “It’s easy to identify what indicators would be used to mea sure quality.”
d. “You should ask be as signed to the research and to quality committee.”
ANS: B The preceptor would try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. I dentif ying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nur se to start. Asking to be assigned to the QI c ommittee does not give the nurse information about how to implement QI in daily practice. DIF: Applying TOP: Integrated Process: Communication and Documentation Btestbanks.comharry
