Medical-Surgical Nursing:

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,Overview of Professional Nursing Concepts for Medical- @
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Surgical Nursing
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1. A nurse wishes to provide client-
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centered care in all interactions. Which action by the nurse best demonstrates this concept?
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a. Assesses for cultural influences affecting health care
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b. Ensures that all the clients basic needs are met
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c. Tells the client and family about all upcoming tests
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d. Thoroughly orients the client and family to the room
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ANS: A :@


Competency in client- :@ :@


focused care is demonstrated when the nurse focuses on communication, culture, respect
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ent ed ucation, and empowerment. By assessing the effect of the clients culture on health
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nurse is practici ng client-
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focused care. Providing for basic needs does not demonstrate this competence.
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Simply telling the client about all upcoming tests is not providing empowering education.
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@client and family to the room is an important safety measure, but not directly related to
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g client- centered care.
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DIF: Understanding/Comprehension REF: 3
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@KEY: Patient- :@


centered care| culture MSC: Integrated Process: Caring NOT: Client
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N eeds Category: Psychosocial Integrity
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2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 14
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2/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
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a. Call the Rapid Response Team.
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b. Document and continue to monitor. :@ :@ :@ :@


c. Notify the primary care provider.
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d. Repeat blood pressure measurement in 15 minutes.
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ANS: A :@


The purpose of the Rapid Response Team (RRT) is to intervene when clients are deterior
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ating before they suffer either respiratory or cardiac arrest. Since the client has manifested a significan
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t change, the nurse s hould call the RRT. Changes in blood pressure, mental status, heart rate, and p
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ain are particularly significant. Documentation is vital, but the nurse must do more than document. Th
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e primary care provider should be no tified, but this is not the priority over calling the RRT. The clie
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nts blood pressure should be reassessed freq uently, but the priority is getting the rapid care to the clie
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nt.

DIF: Applying/Application REF: 3
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KEY: Rapid Response Team (RRT)| medical emergencies
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MS C: Integrated Process: Communication and Documentatio
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n
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
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3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse prov
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ide to h elp the client promote his or her own safety?
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a. Encourage the client and family to be active partners.
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b. Have the client monitor hand hygiene in caregivers.
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c. Offer the family the opportunity to stay with the client.
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d. Tell the client to always wear his or her armband.
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ANS: A :@


Each action could be important for the client or family to perform. However, encouraging
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@the client to be active in his or her health care as a partner is the most critical. The other actions a
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re very limited in scope a nd do not provide the broad protection that being active and involved doe
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, s.

DIF: Understanding/Comprehension REF: 3 K
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EY: Patient safety
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