Test Bank for Medical-Surgical Nursing: Patient-Centered Collaborative Care 8th Edition, Donna D. Ignatavicius

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,Chapter 1: Introduction to Medical-Surgical Nursing Practice
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Ignatavicius: Medical-Surgical Nursing, 8th Edition
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MULTIPLE CHOICE v




1. A new nurse is working with a preceptor on an inpatient medical-
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surgical unit. The preceptor advises the student that which is the priority when working a
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s a professional nurse?
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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 v v v


d. Providing client-focused care v v




ANS: B vv


All actions are appropriate for the professional nurse. However, ensuring client safety is the pri
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ority. Up to 98,000 deaths result each year from errors in hospital care, according to the 2000 I
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nstitute of Medicine report. Many more clients have suffered injuries and less serious outcome
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s. Every nurse has the responsibility to guard the client’s safety.
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DIF: Understanding/Comprehension REF: 2
KEY: Patient safety MSC: Integrated Process: Nursing Process: Intervention v v v v v v v v


NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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2. A nurse is orienting a new client and family to the inpatient unit. What information does the nur
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se 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.v v v v v v v


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 vv


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

DIF: Understanding/Comprehension REF: 3
KEY: Patient safety MSC: Integrated Process: Teaching/Learning v v v v v v


NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressure wa
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s 142/76 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. v v v v


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. v v v v v v

, ANS: A vv


The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating
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before they suffer either respiratory or cardiac arrest. Since the client has manifested a significa
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nt change, the nurse should call the RRT. Changes in blood pressure, mental status, heart rate, a
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nd pain are particularly significant. Documentation is vital, but the nurse must do more than doc
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ument. The primary care provider should be notified, but this is not the priority over calling the
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RRT. The client’s blood pressure should be reassessed frequently, but the priority is getting the
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rapid care to the client.
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DIF: Applying/Application REF:
3 KEY: Rapid Response Team (RRT)| medical emev v v v v v v


rgencies
MSC: Integrated Process: Communication and Documentation
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NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
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4. 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 v v v v v v


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 vv


Competency in client- v v


focused care is demonstrated when the nurse focuses on communication, culture, respect, com
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passion, client education, and empowerment. By assessing the effect of the client’s culture on
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health care, this nurse is practicing
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client-
focused care. Providing for basic needs does not demonstrate this competence. Simply telling
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the client about all upcoming tests is not providing empowering education. Orienting the clien
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t and family to the room is an important safety measure, but not directly related to demonstrati
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ng client-centered care.
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DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture
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MSC: Integrated Process: Caring v v v v


NOT: Client Needs Category: Psychosocial Integrity
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5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nu
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rse explain is the most important thing the client can do to protect against errors?
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a. Bring a list of all medications and what they are for.
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b. Keep the doctor’s phone number by the telephone. v v v v v v v


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 vv


Medication errors are the most common type of health care mistake. The Joint Commission’s
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Speak Up campaign encourages clients to help ensure their safety. One recommendation is for
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clients to know all their medications and why they take them. This will help prevent medicatio
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n errors.
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DIF: Applying/Application REF: 4
KEY: Speak Up campaign| patient safety
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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 v v v v v v v v


d. Treats the client fairly compared to other clients v v v v v v v




ANS: A vv


Autonomy is self- v v


determination. The client should make decisions regarding care. When the nurse obtains a sign
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ature 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 wit
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h veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social
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justice.

DIF: Applying/Application REF: 4
KEY: Autonomy| ethical principles
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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 pe
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rson from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) com
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munity. What answer by the faculty is most accurate?
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a. Avoid embarrassing the client by asking questions. v v v v v v


b. Don’t make assumptions about their health needs. v v v v v v


c. Most LGBTQ people do not want to share information.
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d. No differences exist in communicating with this population.
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ANS: B vv


Many members of the LGBTQ community have faced discrimination from health care provide
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rs and may be reluctant to seek health care. The nurse should never make assumptions about th
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e needs of members of this population. Rather, respectful questions are appropriate. If approac
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hed with sensitivity, the client with any health care need is more likely to answer honestly.
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DIF: Understanding/Comprehension REF: 4
KEY: LGBTQ| diversity MSC: Integrated Process: Teaching/Learning v v v v v v


NOT: Client Needs Category: Psychosocial Integrity
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8. A nurse is calling the on-
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call physician about a client who had a hysterectomy 2 days ago and has pain that is unrelieved
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by the prescribed narcotic pain medication. Which statement is part of the SBAR format for c
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ommunication?
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 doesn’t 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 vv