Chapter 1: Introduction to Medical-Surgical Nursing
Chapter 1: Introduction to Medical-Surgical Nursing
Test Bank
MULTIPLE CHOICE
1. 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
ANS: C
The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to
clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code
Team, which responds to client arrests, it intervenes rapidly for those who are beginning to decline
clinically. It would be appropriate for the RRT to intervene when the client has experienced a 52-
point drop in blood pressure. Monitoring the client’s postoperative status, maintaining a
postoperative flow sheet, and notifying the physician of a change in the client’s status after a
medication change would not be considered activities of the Rapid Response Team.
DIF: Cognitive Level: Comprehension/Understanding REF: pp. 2-3
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team)
MSC: Integrated Process: Nursing Process (Assessment)
2. 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
ANS: C
It is important for the nurse to assess respirations of the client when administering opioids because
of the possibility of respiratory depression. The other interventions may or may not be necessary in
the care of the client and do not focus on safety.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control)
MSC: Integrated Process: Nursing Process (Assessment)
3. 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
ANS: A
Respect for people is one of three basic ethical principles that nurses and other health care
professionals should use as a basis for clinical decision making. Respect implies that clients are
treated as autonomous individuals capable of making informed decisions about their care. This
client autonomy is referred to as self-determination, or self-management, and is best illustrated by
allowing a client to decide to take medication with fruit juice rather than water. The other answer
choices would not illustrate self-determination appropriately and might possibly endanger the
client’s life.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Nursing Process (Assessment)
4. 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.
ANS: B
The most important client-centered action is to ensure that the client is wearing his or her glasses.
The ability to see adequately will outweigh the need for family presence, use of printed handouts,
and hunger (or lack thereof).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
5. 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
ANS: D
Client-centered care is best illustrated by the nurse researching Vietnamese culture and native
cooking before discussing meal planning. This shows that the nurse is interested and is involved in
the client’s care. The nurse can then suggest foods from the standard diabetic menu to the client and
his or her family.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration)
MSC: Integrated Process: Teaching/Learning
6. 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 wline wto wgive wintravenous wfluid wto wa wdehydrated
client.
w
b. Use wsterile wtechnique wwhen wchanging wdressings won wa wnew
wsurgical wsite.
c. Intubate wa wclient wwhose woxygen wsaturation wis w92%.
d. Prescribe waspirin wfor wa wclient wwho wpresents wwith wan wacute
wmyocardial winfarction
ANS: wB
The wonly wintervention widentified wwithin wthe wscope wof wnursing wpractice wis wto wuse wsterile
wtechnique. wCentral wline winsertion, wintubation, wand wprescription ware wfunctions wof wthe
wphysician.
DIF: wCognitive wLevel: wApplication/Applying wor whigher wREF: wN/A
TOP: wClient wNeeds wCategory: wSafe wand wEffective wCare wEnvironment w(Management wof wCare—Legal
wRights wand wResponsibilities)
MSC: wIntegrated wProcess: wNursing wProcess w(Implementation)
7. Which waction wby wthe wnurse wdemonstrates wthe wbest wpractice wfor wnursing
wdocumentation won wa wcomputerized wrecord?
a. Deleting wall wdocumentation werrors won wthe wcomputerized wrecord
b. Using wred wfont wto wdenote wall wsignificant wevents wthat whave
woccurred
c. Waiting wuntil wthe wend wof wthe wshift wto wrecord wa wsummary wof
information
w
d. Documenting wassessment wdata wat wthe wpoint wof wcare
ANS: wD
The wbest wpractice wfor wnursing wdocumentation wis wto wdocument was wsoon was wthe wassessment wis
wcompleted. wThe wother wpractices wlisted ware wineffective wand ware wnot wrecommended.
DIF: wCognitive wLevel: wApplication/Applying wor whigher wREF: wN/A
TOP: wClient wNeeds wCategory: wSafe wand wEffective wCare wEnvironment w(Management wof wCare—Legal
wRights wand wResponsibilities)
MSC: wIntegrated wProcess: wCommunication wand wDocumentation
8. A wclient wis wscheduled wfor wa wmastectomy. wAs wshe wis wabout wto wreceive wthe wpreoperative
wmedication, wshe wtells wthe wnurse wthat wshe wdoes wnot wwant wto whave wher wbreast wremoved
wbut wwants wa wlumpectomy. wWhich wresponse windicates wthat wthe wnurse wis wacting was wa
Chapter 1: Introduction to Medical-Surgical Nursing
Test Bank
MULTIPLE CHOICE
1. 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
ANS: C
The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to
clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code
Team, which responds to client arrests, it intervenes rapidly for those who are beginning to decline
clinically. It would be appropriate for the RRT to intervene when the client has experienced a 52-
point drop in blood pressure. Monitoring the client’s postoperative status, maintaining a
postoperative flow sheet, and notifying the physician of a change in the client’s status after a
medication change would not be considered activities of the Rapid Response Team.
DIF: Cognitive Level: Comprehension/Understanding REF: pp. 2-3
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team)
MSC: Integrated Process: Nursing Process (Assessment)
2. 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
ANS: C
It is important for the nurse to assess respirations of the client when administering opioids because
of the possibility of respiratory depression. The other interventions may or may not be necessary in
the care of the client and do not focus on safety.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control)
MSC: Integrated Process: Nursing Process (Assessment)
3. 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
ANS: A
Respect for people is one of three basic ethical principles that nurses and other health care
professionals should use as a basis for clinical decision making. Respect implies that clients are
treated as autonomous individuals capable of making informed decisions about their care. This
client autonomy is referred to as self-determination, or self-management, and is best illustrated by
allowing a client to decide to take medication with fruit juice rather than water. The other answer
choices would not illustrate self-determination appropriately and might possibly endanger the
client’s life.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Nursing Process (Assessment)
4. 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.
ANS: B
The most important client-centered action is to ensure that the client is wearing his or her glasses.
The ability to see adequately will outweigh the need for family presence, use of printed handouts,
and hunger (or lack thereof).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
5. 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
ANS: D
Client-centered care is best illustrated by the nurse researching Vietnamese culture and native
cooking before discussing meal planning. This shows that the nurse is interested and is involved in
the client’s care. The nurse can then suggest foods from the standard diabetic menu to the client and
his or her family.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration)
MSC: Integrated Process: Teaching/Learning
6. 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 wline wto wgive wintravenous wfluid wto wa wdehydrated
client.
w
b. Use wsterile wtechnique wwhen wchanging wdressings won wa wnew
wsurgical wsite.
c. Intubate wa wclient wwhose woxygen wsaturation wis w92%.
d. Prescribe waspirin wfor wa wclient wwho wpresents wwith wan wacute
wmyocardial winfarction
ANS: wB
The wonly wintervention widentified wwithin wthe wscope wof wnursing wpractice wis wto wuse wsterile
wtechnique. wCentral wline winsertion, wintubation, wand wprescription ware wfunctions wof wthe
wphysician.
DIF: wCognitive wLevel: wApplication/Applying wor whigher wREF: wN/A
TOP: wClient wNeeds wCategory: wSafe wand wEffective wCare wEnvironment w(Management wof wCare—Legal
wRights wand wResponsibilities)
MSC: wIntegrated wProcess: wNursing wProcess w(Implementation)
7. Which waction wby wthe wnurse wdemonstrates wthe wbest wpractice wfor wnursing
wdocumentation won wa wcomputerized wrecord?
a. Deleting wall wdocumentation werrors won wthe wcomputerized wrecord
b. Using wred wfont wto wdenote wall wsignificant wevents wthat whave
woccurred
c. Waiting wuntil wthe wend wof wthe wshift wto wrecord wa wsummary wof
information
w
d. Documenting wassessment wdata wat wthe wpoint wof wcare
ANS: wD
The wbest wpractice wfor wnursing wdocumentation wis wto wdocument was wsoon was wthe wassessment wis
wcompleted. wThe wother wpractices wlisted ware wineffective wand ware wnot wrecommended.
DIF: wCognitive wLevel: wApplication/Applying wor whigher wREF: wN/A
TOP: wClient wNeeds wCategory: wSafe wand wEffective wCare wEnvironment w(Management wof wCare—Legal
wRights wand wResponsibilities)
MSC: wIntegrated wProcess: wCommunication wand wDocumentation
8. A wclient wis wscheduled wfor wa wmastectomy. wAs wshe wis wabout wto wreceive wthe wpreoperative
wmedication, wshe wtells wthe wnurse wthat wshe wdoes wnot wwant wto whave wher wbreast wremoved
wbut wwants wa wlumpectomy. wWhich wresponse windicates wthat wthe wnurse wis wacting was wa
