MEDICAL-SURGICAL NURSING:
a a
CONCEPTS FOR CLINICAL JUDGMENT AND
a a a a
COLLABORATIVE CARE 11TH EDITION BY
a a a a a
IGNATAVICIUS
a
CHAPTERS 1-69
a
,Concepts for Medical-Surgical NursingIgnatavicius: Medical-Surgical Nursing,
a a a a a a
11th Edition
a a
MULTIPLE aCHOICE
, 1. A anew anurse ais aworking awith aa apreceptor aon aa amedical-surgical aunit. aThe
apreceptor aadvises atheanew anurse athat awhich ais athe apriority awhen aworking aas aa
aprofessional anurse?
a. Attending ato aholistic aclient aneeds
b. Ensuring aclient asafety
c. Not amaking amedication aerrors
d. Providing aclient-focused acare
ACCURATE
aANSWER: a B
Rationale:All aactions aare aappropriate afor athe aprofessional anurse. aHowever,
aensuring aclient asafety ais atheapriority. aHealth acare aerrors ahave abeen awidely
areported afor a25 ayears, amany aof awhich aresult ainaclient ainjury, adeath, aand
aincreased ahealth acare acosts. aThere aare aseveral anational aand ainternational
aorganizations athat ahave aeither arecommended aor amandated asafety ainitiatives.
Every anurse ahas athe aresponsibility ato aguard athe aclient’s asafety. aThe aother aactions
aare aimportanta for aquality anursing, abut athey aare anot aas avital aas aproviding asafety.
aNot amaking amedication aerrorsadoes aprovide asafety, abut ais atoo anarrow ain ascope ato
abe athe abest aaccurate aanswerwer.
DIF: Understanding TOP: a Integrated aProcess: aNursing aProcess:
aInterventiona
KEY: a Client asafety
MSC: a Client aNeeds aCategory: aSafe aand aEffective aCare aEnvironment: aSafety aand aInfection
aControl
2. A anurse ais aorienting aa anew aclient aand afamily ato athe amedical-surgical aunit.
aWhat ainformationadoes athe anurse aprovide ato abest ahelp athe aclient apromote ahis
aor aher aown asafety?
a. Encourage athe aclient aand afamily ato abe aactive apartners.
b. Have athe aclient amonitor ahand ahygiene ain acaregivers.
c. Offer athe afamily athe aopportunity ato astay awith athe aclient.
d. Tell athe aclient ato aalways awear ahis aor aher aarmband.
ACCURATE
aANSWER: a A
Rationale:Each aaction acould abe aimportant afor athe aclient aor afamily ato aperform.
aHowever, aencouraging athea client ato abe aactive ain ahis aor aher ahealth acare aas aa asafety
apartner ais athe amost acritical. aThe aother aactions aare avery alimited ain ascope aand ado
anot aprovide athe abroad aprotection athat abeing aactive aandainvolved adoes.
DIF: Understanding TOP: a Integrated aProcess:
aTeaching/LearningaKEY: a Client asafety
MSC: a Client aNeeds aCategory: aSafe aand aEffective aCare aEnvironment: aSafety aand aInfection
aControl
3. A anurse ais acaring afor aa apostoperative aclient aon athe asurgical aunit. aThe aclient’s
ablood apressure awas a142/76 amm aHg a30 aminutes aago, aand anow ais a88/50 amm
aHg. aWhat aaction awould athe anurseatake afirst?
a. Call athe aRapid aResponse aTeam.
b. Document aand acontinue ato amonitor.
c. Notify athe aprimary ahealth acare aprovider.
d. Repeat athe ablood apressure ain a15 aminutes.
, ACCURATE aANSWER: a A
Rationale:The apurpose aof athe aRapid aResponse aTeam a(RRT) ais ato aintervene awhen
aclients aare adeterioratinga before athey asuffer aeither arespiratory aor acardiac aarrest.
aSince athe aclient ahas amanifested aa asignificant achange, athe anurse awould acall athe
aRRT. aChanges ain ablood apressure, amental astatus, aheart arate, atemperature, aoxygen
asaturation, aand alast a2 ahours’ aurine aoutput aare aparticularly asignificant aand aare
apart aof athe aModified aEarly aWarning aSystem aguide. aDocumentation ais avital, abut
athe anurse amust ado amore athan adocument. aThe aprimary ahealth acare aprovider
awould abe anotified, abut athis ais anot amore aimportant athan acalling athe aRRT. aThe
aclient’s ablood apressure awould abe areassessed afrequently, abut athe apriority ais agetting
athe arapid acare ato athe aclient.
DIF: Applying TOP: a Integrated aProcess: aCommunication aand
aDocumentationa KEY: a Rapid aResponse aTeam a(RRT), aClinical ajudgment
MSC: a Client aNeeds aCategory: aPhysiological aIntegrity: aPhysiological aAdaptation
4. A anurse awishes ato aprovide aclient-centered acare ain aall ainteractions. aWhich aaction aby
athe anurse
best ademonstrates athis aconcept?
a. Assesses afor acultural ainfluences aaffecting ahealth acare.
b. Ensures athat aall athe aclient’s abasic aneeds aare amet.
c. Tells athe aclient aand afamily aabout aall aupcoming atests.
d. Thoroughly aorients athe aclient aand afamily ato athe aroom.
ACCURATE aANSWER: a A
Rationale:Showing arespect afor athe aclient aand afamily’s apreferences aand aneeds ais
aessential ato aensure aa aholistic aor a“whole-person” aapproach ato acare. aBy aassessing
athe aeffect aof athe aclient’s aculture aonahealth acare, athis anurse ais apracticing aclient-
focused acare. aProviding afor abasic aneeds adoes anot ademonstrate athis acompetence.
aSimply atelling athe aclient aabout aall aupcoming atests ais anot aproviding aempowering
aeducation. aOrienting athe aclient aand afamily ato athe aroom ais aan aimportantasafety
ameasure, abut anot adirectly arelated ato ademonstrating aclient-centered acare.
DIF: Understanding TOP: aIntegrated aProcess: aCulture aand
aSpirituality aKEY: a Client-centered acare, aCulture MSC: a Client aNeeds aCategory:
aPsychosocial aIntegrity
5. A aclient ais agoing ato abe aadmitted afor aa ascheduled asurgical aprocedure. aWhich
aaction adoes atheanurse aexplain ais athe amost aimportant athing athe aclient acan ado ato
aprotect aagainst aerrors?
a. Bring aa alist aof aall amedications aand awhat athey aare afor.
b. Keep athe aprovider’s aphone anumber aby athe atelephone.
c. Make asure athat aall aproviders awash ahands abefore aentering athe aroom.
d. Write adown athe aname aof aeach acaregiver awho acomes ain athe aroom.
ACCURATE aANSWER: a A
Rationale:Medication areconciliation ais aa aformal aprocess ain awhich athe aclient’s
aactual acurrent amedicationsaare acompared ato athe aprescribed amedications aat athe
atime aof aadmission, atraccurate aanswerfer, aor adischarge. aThis aNational aclient aSafety
aGoal ais aimportant ato areduce amedication aerrors. aThe aclient awould anot ahave ato abe
aresponsible afor aproviders awashing atheir ahands, aand aeven aif athe aclient adoes aso,
a a
CONCEPTS FOR CLINICAL JUDGMENT AND
a a a a
COLLABORATIVE CARE 11TH EDITION BY
a a a a a
IGNATAVICIUS
a
CHAPTERS 1-69
a
,Concepts for Medical-Surgical NursingIgnatavicius: Medical-Surgical Nursing,
a a a a a a
11th Edition
a a
MULTIPLE aCHOICE
, 1. A anew anurse ais aworking awith aa apreceptor aon aa amedical-surgical aunit. aThe
apreceptor aadvises atheanew anurse athat awhich ais athe apriority awhen aworking aas aa
aprofessional anurse?
a. Attending ato aholistic aclient aneeds
b. Ensuring aclient asafety
c. Not amaking amedication aerrors
d. Providing aclient-focused acare
ACCURATE
aANSWER: a B
Rationale:All aactions aare aappropriate afor athe aprofessional anurse. aHowever,
aensuring aclient asafety ais atheapriority. aHealth acare aerrors ahave abeen awidely
areported afor a25 ayears, amany aof awhich aresult ainaclient ainjury, adeath, aand
aincreased ahealth acare acosts. aThere aare aseveral anational aand ainternational
aorganizations athat ahave aeither arecommended aor amandated asafety ainitiatives.
Every anurse ahas athe aresponsibility ato aguard athe aclient’s asafety. aThe aother aactions
aare aimportanta for aquality anursing, abut athey aare anot aas avital aas aproviding asafety.
aNot amaking amedication aerrorsadoes aprovide asafety, abut ais atoo anarrow ain ascope ato
abe athe abest aaccurate aanswerwer.
DIF: Understanding TOP: a Integrated aProcess: aNursing aProcess:
aInterventiona
KEY: a Client asafety
MSC: a Client aNeeds aCategory: aSafe aand aEffective aCare aEnvironment: aSafety aand aInfection
aControl
2. A anurse ais aorienting aa anew aclient aand afamily ato athe amedical-surgical aunit.
aWhat ainformationadoes athe anurse aprovide ato abest ahelp athe aclient apromote ahis
aor aher aown asafety?
a. Encourage athe aclient aand afamily ato abe aactive apartners.
b. Have athe aclient amonitor ahand ahygiene ain acaregivers.
c. Offer athe afamily athe aopportunity ato astay awith athe aclient.
d. Tell athe aclient ato aalways awear ahis aor aher aarmband.
ACCURATE
aANSWER: a A
Rationale:Each aaction acould abe aimportant afor athe aclient aor afamily ato aperform.
aHowever, aencouraging athea client ato abe aactive ain ahis aor aher ahealth acare aas aa asafety
apartner ais athe amost acritical. aThe aother aactions aare avery alimited ain ascope aand ado
anot aprovide athe abroad aprotection athat abeing aactive aandainvolved adoes.
DIF: Understanding TOP: a Integrated aProcess:
aTeaching/LearningaKEY: a Client asafety
MSC: a Client aNeeds aCategory: aSafe aand aEffective aCare aEnvironment: aSafety aand aInfection
aControl
3. A anurse ais acaring afor aa apostoperative aclient aon athe asurgical aunit. aThe aclient’s
ablood apressure awas a142/76 amm aHg a30 aminutes aago, aand anow ais a88/50 amm
aHg. aWhat aaction awould athe anurseatake afirst?
a. Call athe aRapid aResponse aTeam.
b. Document aand acontinue ato amonitor.
c. Notify athe aprimary ahealth acare aprovider.
d. Repeat athe ablood apressure ain a15 aminutes.
, ACCURATE aANSWER: a A
Rationale:The apurpose aof athe aRapid aResponse aTeam a(RRT) ais ato aintervene awhen
aclients aare adeterioratinga before athey asuffer aeither arespiratory aor acardiac aarrest.
aSince athe aclient ahas amanifested aa asignificant achange, athe anurse awould acall athe
aRRT. aChanges ain ablood apressure, amental astatus, aheart arate, atemperature, aoxygen
asaturation, aand alast a2 ahours’ aurine aoutput aare aparticularly asignificant aand aare
apart aof athe aModified aEarly aWarning aSystem aguide. aDocumentation ais avital, abut
athe anurse amust ado amore athan adocument. aThe aprimary ahealth acare aprovider
awould abe anotified, abut athis ais anot amore aimportant athan acalling athe aRRT. aThe
aclient’s ablood apressure awould abe areassessed afrequently, abut athe apriority ais agetting
athe arapid acare ato athe aclient.
DIF: Applying TOP: a Integrated aProcess: aCommunication aand
aDocumentationa KEY: a Rapid aResponse aTeam a(RRT), aClinical ajudgment
MSC: a Client aNeeds aCategory: aPhysiological aIntegrity: aPhysiological aAdaptation
4. A anurse awishes ato aprovide aclient-centered acare ain aall ainteractions. aWhich aaction aby
athe anurse
best ademonstrates athis aconcept?
a. Assesses afor acultural ainfluences aaffecting ahealth acare.
b. Ensures athat aall athe aclient’s abasic aneeds aare amet.
c. Tells athe aclient aand afamily aabout aall aupcoming atests.
d. Thoroughly aorients athe aclient aand afamily ato athe aroom.
ACCURATE aANSWER: a A
Rationale:Showing arespect afor athe aclient aand afamily’s apreferences aand aneeds ais
aessential ato aensure aa aholistic aor a“whole-person” aapproach ato acare. aBy aassessing
athe aeffect aof athe aclient’s aculture aonahealth acare, athis anurse ais apracticing aclient-
focused acare. aProviding afor abasic aneeds adoes anot ademonstrate athis acompetence.
aSimply atelling athe aclient aabout aall aupcoming atests ais anot aproviding aempowering
aeducation. aOrienting athe aclient aand afamily ato athe aroom ais aan aimportantasafety
ameasure, abut anot adirectly arelated ato ademonstrating aclient-centered acare.
DIF: Understanding TOP: aIntegrated aProcess: aCulture aand
aSpirituality aKEY: a Client-centered acare, aCulture MSC: a Client aNeeds aCategory:
aPsychosocial aIntegrity
5. A aclient ais agoing ato abe aadmitted afor aa ascheduled asurgical aprocedure. aWhich
aaction adoes atheanurse aexplain ais athe amost aimportant athing athe aclient acan ado ato
aprotect aagainst aerrors?
a. Bring aa alist aof aall amedications aand awhat athey aare afor.
b. Keep athe aprovider’s aphone anumber aby athe atelephone.
c. Make asure athat aall aproviders awash ahands abefore aentering athe aroom.
d. Write adown athe aname aof aeach acaregiver awho acomes ain athe aroom.
ACCURATE aANSWER: a A
Rationale:Medication areconciliation ais aa aformal aprocess ain awhich athe aclient’s
aactual acurrent amedicationsaare acompared ato athe aprescribed amedications aat athe
atime aof aadmission, atraccurate aanswerfer, aor adischarge. aThis aNational aclient aSafety
aGoal ais aimportant ato areduce amedication aerrors. aThe aclient awould anot ahave ato abe
aresponsible afor aproviders awashing atheir ahands, aand aeven aif athe aclient adoes aso,
