TEST BANK for Ignatavicius: Medical-
Surgical Nursing, 8th Edition / Updated
for 2024
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. Encourage the client and family to be active partners.
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, 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 Control
3. A nurse is caring for a postoperative client 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 to monitor.
c. Notify the primary health care provider.
, d. Repeat the blood pressure in 15 minutes.
Btestbanks.com
ANS: A
The purpose of the Rapid Response Team (RRT) is to
intervene when 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, oxygen saturation, and last 2 hours’ urine output
are particularly significant and are part of the
Modified Early Warning System 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 frequently, but the priority is getting the
rapid care to the client.
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 wishes to provide client-centered care in all
interactions. Which action by the nurse best
demonstrates this concept?
a. Assesses for cultural influences affecting health care.
b. Ensures that all the client’s basic needs are met.
c. Tells the client and family about all upcoming tests.
d. Thoroughly orients 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 clientfocused 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 measure, 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 scheduled surgical
procedure. Which action does the nurse explain is the most
important thing the client can do to protect against errors?
a. Bring a list of all medications and what they are for.
b. Keep the provider’s phone number by the telephone.
c. Make sure that all providers wash hands before entering the
room.
d. Write down the name of each caregiver who comes in the
room.
ANS: A
Medication reconciliation is a formal process in which the
client’s actual current medications are compared to the
prescribed medications at the time of admission, transfer, or
discharge. This National client Safety Goal is important to
reduce medication errors. 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 everyone 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.com
6. Which action by the nurse working with a client best
demonstrates respect for autonomy?
a. Asks if the client has questions before signing a consent.
b. Gives the client accurate information when questioned.
c. Keeps the promises made to the client and family.
d. Treats the client fairly compared to other clients.
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 client 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
Surgical Nursing, 8th Edition / Updated
for 2024
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. Encourage the client and family to be active partners.
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, 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 Control
3. A nurse is caring for a postoperative client 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 to monitor.
c. Notify the primary health care provider.
, d. Repeat the blood pressure in 15 minutes.
Btestbanks.com
ANS: A
The purpose of the Rapid Response Team (RRT) is to
intervene when 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, oxygen saturation, and last 2 hours’ urine output
are particularly significant and are part of the
Modified Early Warning System 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 frequently, but the priority is getting the
rapid care to the client.
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 wishes to provide client-centered care in all
interactions. Which action by the nurse best
demonstrates this concept?
a. Assesses for cultural influences affecting health care.
b. Ensures that all the client’s basic needs are met.
c. Tells the client and family about all upcoming tests.
d. Thoroughly orients 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 clientfocused 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 measure, 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 scheduled surgical
procedure. Which action does the nurse explain is the most
important thing the client can do to protect against errors?
a. Bring a list of all medications and what they are for.
b. Keep the provider’s phone number by the telephone.
c. Make sure that all providers wash hands before entering the
room.
d. Write down the name of each caregiver who comes in the
room.
ANS: A
Medication reconciliation is a formal process in which the
client’s actual current medications are compared to the
prescribed medications at the time of admission, transfer, or
discharge. This National client Safety Goal is important to
reduce medication errors. 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 everyone 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.com
6. Which action by the nurse working with a client best
demonstrates respect for autonomy?
a. Asks if the client has questions before signing a consent.
b. Gives the client accurate information when questioned.
c. Keeps the promises made to the client and family.
d. Treats the client fairly compared to other clients.
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 client 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
