Test bank for Medical Surgical Nursing 7th Edition by Donna D.Ignatavicius and M.Linda Workman Complete Guide A+

Test bank for Medical
Surgical Nursing 7th Edition
by Donna D.Ignatavicius and
M.Linda Workman

,Test bank for Medical Surgical Nursing 7th editio
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nby Donna D.Ignatavicius and M.Linda Workman
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Chapter 1: Introduction to Medical-Surgical Nursing
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MULTIPLERCHOICE

1. WhichRactionRdemonstratesRthatRtheRnurseRunderstandsRtheRpurposeRofRtheRRapidRResponseRTeam?


a. MonitoringRtheRclientRforRchangesRinRpostoperativeRstatusRsuchRasRwoundR
infection


b. DocumentingRallRchangesRobservedRinRtheRclientRandRmaintainingRaR
postoperative flow sheet R R




c. NotifyingRtheRphysicianRofRtheRclient’sRchangeRinRbloodRpressureRfromR
140 to 88 mm Hg systolic
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d. NotifyingRtheRphysicianRofRtheRclient’sRincreaseRinRrestlessnessRafterR
medication change R




ANS:RC

The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to c
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lients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Tea
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m, which responds to client arrests, it intervenes rapidly for those who are beginning to declineclini
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cally. It would be appropriate for the RRT to intervene when the client has experienced a 52-
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Rpoint drop in blood pressure. Monitoring the client’s postoperative status, maintaining a postoperat
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ive flow sheet, and notifying the physician of a change in the client’s status after a medication chan
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ge would not be considered activities of the Rapid Response Team.
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DIF:RCognitiveRLevel:RComprehension/UnderstandingRREF:Rpp.R2-3

TOP:RClientRNeedsRCategory:RSafeRandREffectiveRCareREnvironmentR(ManagementRofRCare—
CollaborationRwithRInterdisciplinaryRTeam)

MSC:RIntegratedRProcess:RNursingRProcessR(Assessment)

,2. TheRJointRCommissionRfocusesRonRsafetyRinRhealthRcare.RWhichRactionRbyRtheRnurseRreflectsRTheR
Joint Commission’s main objective?
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a. PerformingRrange-of-motionRexercisesRonRtheRclientRthreeRtimesReachRday



b. EnsuringRthatRtheRclientRisReatingR100%RofRtheRmealsRservedRtoRhimRorR
her


c. AssessingRtheRclient’sRrespirationsRwhenRadministeringRopioids



d. DelegatingRtoRtheRnursingRassistantRtoRgiveRtheRclientRaRcompleteRbathR
daily


ANS:RC

It is important for the nurse to assess respirations of the client when administering opioids because
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of the possibility of respiratory depression. The other interventions may or may not be necessary in
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the care of the client and do not focus on safety.
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DIF:RCognitiveRLevel:RApplication/ApplyingRorRhigherRREF:RN/A

TOP:RClientRNeedsRCategory:RSafeRandREffectiveRCareREnvironmentR(SafetyRandRInfectionRControl)RM

SC:RIntegratedRProcess:RNursingRProcessR(Assessment)

3. WhichRactionRbyRtheRnurseRshowsRanRunderstandingRofRtheRprincipleRofRself-determination?


a. AllowingRaRpostoperativeRclientRtoRdecideRtoRtakeRmedicationRwithRfruitR
juice rather than water R R R




b. AllowingRaRteenagerRtoRdecideRnotRtoRgoRtoRaRclinicRwhenRthereRisR
evidence that she is having profuse vaginal bleeding
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c. AllowingRaRparentRtoRdecideRnotRtoRproceedRwithRaRlifesavingRoperationR
for a 12-year-old client
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, d. AllowingRanRolderRclientRwithRdementiaRtoRdecideRnotRtoRtakeRcardiacR
medication throughout the shift
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ANS:RA

Respect for people is one of three basic ethical principles that nurses and other health care professio
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nals should use as a basis for clinical decision making. Respect implies that clients are treated as aut
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onomous individuals capable of making informed decisions about their care. This client autonomy i
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s referred to as self-determination, or self-
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management, and is best illustrated byallowing a client to decide to take medication with fruit juice
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rather than water. The other answer choices would not illustrate self-
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determination appropriately and might possibly endanger the client’s life.
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DIF:RCognitiveRLevel:RApplication/ApplyingRorRhigherRREF:RN/A

TOP:RClientRNeedsRCategory:RSafeRandREffectiveRCareREnvironmentR(ManagementRofRCare—
EthicalRPractice)RMSC:RIntegratedRProcess:RNursingRProcessR(Assessment)

4. TheRnurseRisRinitiatingRaRseriesRofRteachingRsessionsRwithRanRolderRclient.RWhatRisRtheRnurse’sR
highest-priority, client-centered action before beginning the session?
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a. EnsureRthatRtheRclient’sRfamilyRisRpresentRandRwillRparticipate.



b. MakeRcertainRthatRtheRclientRisRwearingRhisRglasses.



c. HaveRprintedRhandoutsRreadyRtoRuseRduringRtheRsession.



d. ScheduleRtheRsessionRforRearlyReveningRafterRtheRclient’sRmeal.



ANS:RB

The most important client-
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centered action is to ensure that the client is wearing his or her glasses.The ability to see adequate
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ly will outweigh the need for family presence, use of printed handouts,and hunger (or lack thereo
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f).

DIF:RCognitiveRLevel:RApplication/ApplyingRorRhigherRREF:RN/A

TOP:RClientRNeedsRCategory:RHealthRPromotionRandRMaintenanceR(PrinciplesRofRTeaching/Learning)