Test Bank for Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9th edition by Donna D. Ignatavicius ISBN: 9780323444194, Chapter 1 - 74 Complete Guide.

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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e
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1




Chapter 01: Overview of Professional Nursing Concepts for Medical-
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Surgical Nursing
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MULTIPLE CHOICE v




1. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse
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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 v v v v v v v v


c. Tells the client and family about all upcoming tests
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d. Thoroughly orients the client and family to the room v v v v v v v v




ANS: A v


Competency in client-focused care is demonstrated when the nursefocuses on communication, culture,
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respect compassion, client education, and empowerment. By assessing the effect of the clients culture on
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health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this
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competence. Simply telling the client about all upcoming tests is not providing empowering education.
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Orienting the client andfamily to theroom is animportantsafetymeasure,
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butnotdirectlyrelatedtodemonstratingclient-centered care.
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DIF: Understanding/Comprehension REF: 3
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KEY: Patient-centered care| culture MSC: Integrated Process: Caring
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NOT: Client Needs 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
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142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse isbest?
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a. Call the Rapid Response Team.
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b. Document and continue to monitor. v v v v


c. Notify the primary care provider. v v v v


d. Repeat blood pressure measurement in 15 minutes.
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ANS: A v


The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they
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suffereitherrespiratoryorcardiacarrest. Sincetheclienthasmanifestedasignificantchange, thenurseshould
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call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly
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significant. Documentation is vital, but the nursemust do more than document. The primary
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vcare provider should be notified, but this is not the priority over calling the RRT. The clients blood
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pressure should
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be reassessed frequently, but the priority is getting the rapid care to theclient.
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DIF: Applying/Application REF: 3
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KEY: Rapid Response Team (RRT)| medical emergencies
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MSC: Integrated Process: Communication and Documentation
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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
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nurse provide to help the client promote his or her own safety?
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a. Encourage the client and family to be active partners. v v v v v v v v


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 v


Each action could be important for the client or family to perform. However, encouraging the client to
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be active in his or her health care as a partner is the most critical. The other actions are very limited
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vin scope and do not provide the broad protection that being active and involveddoes.
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DIF: Understanding/Comprehension REF: 3
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KEY: Patient safety
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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e
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MSC: Integrated Process: Teaching/Learning
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NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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4. A new nurse is working with a preceptor on an inpatientmedical-surgical unit. The preceptor
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advises the student that which is the priority when working as a professionalnurse?
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a. Attending to holistic client needs v v v v


b. Ensuring client safety v v


c. Not making medication errors
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d. Providing client-focused care v v




ANS: B v


All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up to
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98,000 deaths result each year from errors in hospital care, according to the 2000 Institute of Medicine
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report. Many more clients have suffered injuries and less serious outcomes. Every nurse has the
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responsibility to guard the clients safety.
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DIF: Understanding/Comprehension REF: 2
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KEY: Patient safety
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MSC: Integrated Process: Nursing Process: Intervention
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NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse
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explain is the most important thing the client can do to protect againsterrors?
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a. Bring a list of all medications and what they are for.
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b. Keep the doctors phone number by the telephone.
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c. Make sure all providers wash hands before entering the room.
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d. Write down the name of each caregiver who comes in the room.
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ANS: A v


Medication errors are the most common type of health care mistake. The Joint Commissions Speak Up
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campaign encourages clients to help ensure their safety. One recommendation is for clients to know all
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their medications and why they take them. This will help prevent medication errors.
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DIF: Applying/Application REF: 4
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KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/Learning
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NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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6. Which action by the nurse working with a client best demonstrates respect for autonomy?
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a. Asks if the client has questions before signing a consent
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b. Gives the client accurate information when questioned
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c. Keeps the promises made to the client and family
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d. Treats the client fairly compared to other clients
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ANS: A v


Autonomy is self-determination. The client should make decisions regarding care. When the nurseobtainsa
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signature on the consent form, assessing if the client still has questions is vital, because without full
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information the client cannot practice autonomy. Giving accurate information is practicing with veracity.
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Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.
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DIF: Applying/Application REF: 4
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KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
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NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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7. A student nurse asks the faculty to explain best practices when communicating with a person from the
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lesbian, gay, bisexual, transgender, andqueer/questioning (LGBTQ) community. Whatanswerbythe faculty
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is most accurate?
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a. Avoid embarrassing the client by asking questions.
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b. Dont make assumptions about their health needs.
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c. Most LGBTQ people do not want to share information.
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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e
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d. No differences exist in communicating with this population.
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ANS: B v


Manymembersofthe LGBTQcommunity have faceddiscrimination from health care providersandmaybe v v v v v v v


reluctant to seek health care. The nurse should never make assumptions about the needs of members of
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this population. Rather, respectful questionsareappropriate. If approached with sensitivity, the clientwith
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any health care need is more likely to answer honestly.
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DIF: Understanding/Comprehension REF: 4
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KEY: LGBTQ| diversity
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MSC: Integrated Process: Teaching/Learning
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NOT: Client Needs Category: Psychosocial Integrity
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8. A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has
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pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the
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SBAR format for communication?
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a. A: I would like you to order a different pain medication.
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b. B: This client has allergies to morphine and codeine.
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c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
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d. S: This client had a vaginal hysterectomy 2 days ago.
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ANS: B v


SBAR is a recommended form of communication, and the acronym stands for Situation, Background,
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Assessment, and Recommendation. Appropriatebackgroundinformationincludesallergies to medicationsthe
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on-callphysicianmightorder. Situationdescribeswhat is happening rightnow thatmustbecommunicated;
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the clients surgery 2 days ago would be considered background. Assessment would include an analysis of
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the clients problem; asking for a different pain medication is a recommendation. Recommendation is a
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statement of what is needed or what outcome is desired; this information about the surgeons preference
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might be better placed in background.
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DIF: Applying/ApplicationREF: 5
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KEY: SBAR| communication
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MSC: Integrated Process: Communication and Documentation
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NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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9. A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive
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personnel (UAP). Four hours later, the nurse notes the clients blood pressure is much higherthan
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previous readings, and the clients mental status has changed. What action by the nurse would most
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likely have prevented this negative outcome?
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a. Determining if the UAP knew how to take blood pressure v v v v v v v v v


b. Double-checking the UAP by taking another blood pressure v v v v v v v


c. Providing more appropriate supervision of the UAP v v v v v v


d. Taking the blood pressure instead of delegating the task
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ANS: C v


Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on
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delegated tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP
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to report them right away. An experienced UAP should know how to take vital signs and the nurse should
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not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital
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signs are within the scope of practice for a UAP and are permissible to delegate. The only appropriate
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answer is that the nurse did not provide adequate instruction to the UAP.
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DIF: Applying/Application REF: 6
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KEY: Supervision| delegation| unlicensed assistive personnel
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MSC: Integrated Process: Communication and Documentation
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NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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10. A nurse is talking with a client who is moving to a new state and needs to find a new doctor
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and hospital there. What advice by the nurse is best?
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