10/31/23, 5:28AM
v v Testbank - medical surgical nursing 10th edition ignatavicius workman-bte…
v v v v v v v v v
Medical Surgical Nursing 10th Edition v v v v
Ignatavicius Workman Test Bank
v v v v
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing
v v v v v v v v v
Ignatavicius: Medical-Surgical Nursing, 10th Edition
v v v v v
MULTIPLE CHOICE v
1. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new
v v v v v v v v v v v v v v v v
nurse that which is the priority when working as a professional nurse?
v v v v v v v v v v v v
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. Providingclient-focused care v v
ANS: B v
Allactions are appropriate for the professional nurse. However, ensuring client safety is the
v v v v v v v v v v v v v
vpriority. Health care errors have been widely reported for 25 years, many of which result in client
v v v v v v v v v v v v v v v v
injury, death, and increased health care costs. There are several national and international
v v v v v v v v v v v v v
organizations that have either recommended or mandated safety initiatives.
v v v v v v v v v
Every nurse has the responsibility to guard the client’s safety. The other actions are important
v v v v v v v v v v v v v v
for quality nursing, but they are not as vital as providing safety. Not making medication errors does
v v v v v v v v v v v v v v v v
provide safety, but is too narrow in scope to be the best answer.
v v v v v v v v v v v v v
DIF: Understanding v TOP: Integrated Process: Nursing Process: Intervention v v v v v
vKEY: Client safety v v
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
v v v v v v v v v v v v
2. A nurse is orienting a new client and family to the medical-surgical unit. What information does
v v v v v v v v v v v v v v v
the nurse provide to best help the client promote his or her own safety?
v v v v v v v v v v v v v v
a. Encourage the client and family tobe active partners. v v v v v v v v
b. Have theclient monitor hand hygiene in caregivers. v v v v v v v
c. Offer the familythe opportunity to staywith the client. v v v v v v v v v
d. Tell the client to always wear his or her armband. v v v v v v v v v
ANS: A v
Each action could be important for the client or familyto perform. However, encouraging the
v v v v v v v v v v v v v v
vclient to be active in his or her health care as a safety partner is the most critical. The other actions
v v v v v v v v v v v v v v v v v v v v
are very limited in scope and do not provide the broad protection that being active and involved
v v v v v v v v v v v v v v v v v
does.
v
DIF: Understanding v TOP: Integrated Process: Teaching/Learning v v v
vKEY: Client safety v v
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
v v v v v v v v v v v v
3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressure was
v v v v v v v v v v v v v v v v
142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nurse take first?
v v v v v v v v v v v v v v v v v v v
a. Call the Rapid ResponseTeam. v v v v
b. Document and continue to monitor. v v v v
c. Notifythe primary health care provider. v v v v v
d. Repeat the blood pressure in 15 minutes. v v v v v v
Btestbanks.com
about:blank 1/593
,10/31/23, 5:28AM
v v Testbank - medical surgical nursing 10th edition ignatavicius workman-bte…
v v v v v v v v v
ANS: A v
The purpose of theRapid Response Team (RRT)istointervene when clients are deteriorating
v v v v v v v v v v v v v v
vbefore they suffer either respiratory or cardiac arrest. Since the client has manifested a
v v v v v v v v v v v v v
vsignificant change, the nurse would call the RRT. Changes in blood pressure, mental status, v v v v v v v v v v v v v
vheart rate, temperature, oxygen saturation, and last 2 hours’ urine output are particularly
v v v v v v v v v v v v
vsignificant and are part of the Modified Early Warning System guide. Documentation is vital, but v v v v v v v v v v v v v v
the nurse must do more than document. The primary health care provider would be notified, but
v v v v v v v v v v v v v v v v
this is not more important than calling the RRT. The client’s blood pressure would be reassessed
v v v v v v v v v v v v v v v v
frequently, but the priority is getting the rapid care to the client.
v v v v v v v v v v v v
DIF: Applying TOP: Integrated Process: Communication and Documentation
v v v v v v
vKEY: Rapid Response Team (RRT), Clinical judgment
v v v v v v
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
v v v v v v v
4. A nurse wishes to provide client-centeredcare in all interactions. Which action bythe nurse
v v v v v v v v v v v v v v
best demonstrates this concept?
v v v
a. Assesses for cultural influences affecting health care. v v v v v v
b. Ensures that all the client’s basic needs are met. v v v v v v v v
c. Tells the client and family about all upcoming tests. v v v v v v v v
d. Thoroughly orients the client and familyto the room. v v v v v v v v
ANS: A v
Showing respect for the client and family’s preferences and needs is essential to ensure a
v v v v v v v v v v v v v v
holistic or “whole-person” approach to care. By assessing the effect of the client’s culture on health
v v v v v v v v v v v v v v v
care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate
v v v v v v v v v v v v v v
this competence. Simply telling the client about all upcoming tests is not providing empowering
v v v v v v v v v v v v v v
education. Orienting the client and family to theroom is an important safety measure, but not
v v v v v v v v v v v v v v v v
directly related to demonstrating client-centered care.
v v v v v v
DIF: Understanding v TOP: Integrated Process: Culture and Spirituality v v v v v
vKEY: Client-centered care, Culture v v v MSC: Client Needs Category: Psychosocial Integrity v v v v v
5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse
v v v v v v v v v v v v v v v v
explain is the most important thing the client can do to protect against errors?
v v v v v v v v v v v v v v
a. Bring a list of all medications and what they are for. v v v v v v v v v v
b. Keep the provider’s phone number by the telephone. v v v v v v v
c. Make surethat all providers wash hands before entering the room. v v v v v v v v v v
d. Write down the name ofeach caregiver who comes in the room. v v v v v v v v v v v
ANS: A v
Medication reconciliation is a formal processinwhich the client’sactual current medications are v v v v v v v v v v v v v
compared to the prescribed medications at the time of admission, transfer, or discharge. This
v v v v v v v v v v v v v v
National client Safety Goal is important to reduce medication errors. The client would not have
v v v v v v v v v v v v v v v
to be responsible for providers washing their hands, and even if the client does so,
v v v v v v v v v v v v v v v
this is too narrow to be the most important action to prevent errors. Keeping the provider’s phone
v v v v v v v v v v v v v v v v
number nearby and documenting everyone who entersthe room also do not guarantee safety.
v v v v v v v v v v v v v v
DIF: Applying TOP: Integrated Process: Teaching/Learning
v v v v
vKEY: Client safety, Informatics v v v
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
v v v v v v v v v v v v
Btestbanks.com
about:blank 2/593
,10/31/23, 5:28AM
v v Testbank - medical surgical nursing 10th edition ignatavicius workman-bte…
v v v v v v v v v
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
v v v v v v v v v v v v v
a. Asks if the client has questions before signing a consent.
v v v v v v v v v
b. Gives the client accurate information when questioned. v v v v v v
c. Keeps the promises made to the client and family. v v v v v v v v
d. Treatsthe client fairly compared to other clients. v v v v v v v
ANS: A v
Autonomy is self-determination. The client would make decisions regarding care. When the
v v v v v v v v v v v
nurse obtains a signature onthe consent form, assessing if the client still has questions is vital,
v v v v v v v v v v v v v v v v v
because without full information the client cannot practice autonomy. Giving accurate
v v v v v v v v v v v
information is practicing with veracity. Keeping promises is upholding fidelity. Treating the
v v v v v v v v v v v v
client fairly is providing social justice.
v v v v v v
DIF: Applying TOP: Integrated Process: Caring
v KEY:Ethics,Autonomy v v v v v
vMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
v v v v v v v v v v v
7. A nurse asks a more seasoned colleague to explain best practices when communicating with a
v v v v v v v v v v v v v v
vperson from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ)
v v v v v v v v v
vcommunity. What answer by the faculty is most accurate? v v v v v v v v
a. Avoid embarrassing theclient by asking questions. v v v v v v
b. Don’t make assumptions about his or her health needs. v v v v v v v v
c. Most LGBTQ peopledo not want to share information.v v v v v v v v
d. No differences exist in communicating with this population.
v v v v v v v
ANS: B v
Many members of the LGBTQ community have faced discrimination from health care providers
v v v v v v v v v v v v
and may be reluctant to seek health care. The nurse would never make assumptions about the needs
v v v v v v v v v v v v v v v v v
of members of this population. Rather, respectful questionsare appropriate. If approached with
v v v v v v v v v v v v v
sensitivity, the client with any health care need is more likely to answer honestly.
v v v v v v v v v v v v v v
DIF: Understanding v TOP: Integrated Process:Teaching/Learning v v v
KEY: Healthcare disparities, LGBTQ
v v v v MSC: Client Needs Category: Psychosocial Integrity v v v v v
8. A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days
v v v v v v v v v v v v v v v v v
ago and has pain that is unrelieved by the prescribed opioid pain medication. Which
v v v v v v v v v v v v v v
vstatement comprises the background portion of the SBAR format for communication?
v v v v v v v v v v
a. “Iwould like you to order a different pain medication.”
v v v v v v v v v
b. “This client has allergies to morphine and codeine.” v v v v v v v
c. “Dr. Smith doesn’t like nonsteroidalanti-inflammatory meds.”
v v v v v v
d. “This client had a vaginal hysterectomy 2 days ago.” v v v v v v v v
ANS: B v
Btestbanks.com
about:blank 3/593
, 10/31/23, 5:28AM
v v Testbank - medical surgical nursing 10th edition ignatavicius workman-bte…
v v v v v v v v v
SBAR is a recommended form of communication, and the acronym stands for Situation,
v v v v v v v v v v v v
vBackground, Assessment, and Recommendation. Appropriate background information v v v v v v
vincludes allergies to medications the on-call health care provider might order. Situation
v v v v v v v v v v v
describes what is happening right now that must be communicated; the client’s surgery 2 days
v v v v v v v v v v v v v v
ago would be considered background. Assessment would include an analysis of the client’s
v v v v v v v v v v v v
problem; none of the options has assessment information. Asking for a different pain medication
v v v v v v v v v v v v v
is a recommendation. Recommendation is a statement of what is needed or what outcome is
v v v v v v v v v v v v v v v
desired.
v
DIF: Applying TOP: Integrated Process: Communication and Documentation
v v v v v v
vKEY: Teamwork and collaboration, SBAR v v v v
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
v v v v v v v v v v v
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive
v v v v v v v v v v v v v v
vpersonnel (AP). Four hours later, the nurse notes that the client’s blood pressure taken by the AP
v v v v v v v v v v v v v v v v
was much higher than previous readings, and the client’s mental status has changed. What action
v v v v v v v v v v v v v v v
by the nurse would most likely have prevented this negative outcome?
v v v v v v v v v v v
a. Determiningif the AP knew how to take blood pressure v v v v v v v v v
b. Double-checking the AP by taking another blood pressure v v v v v v v
c. Providingmore appropriate supervision of the AP v v v v v v
d. Taking the blood pressure instead ofdelegating the task v v v v v v v v
ANS: C v
Supervision is one of the five rights of delegation and includes directing, evaluating, and v v v v v v v v v v v v v
vfollowing up on delegated tasks. The nurse would either have asked the AP about the vital signs
v v v v v v v v v v v v v v v v
or instructed the APto report them right away. An experienced AP would know how to take vital
v v v v v v v v v v v v v v v v v v
signs and the nurse would not have to assess this at this point. Double-checking the work defeats the
v v v v v v v v v v v v v v v v v v
purpose of delegation. Vital signs are within the scope of practice for a AP and are permissible to
v v v v v v v v v v v v v v v v v v
delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the
v v v v v v v v v v v v v v v v
AP.
v
DIF: Analyzing TOP: Integrated Process: Communication and Documentation
v v v v v v
vKEY: Teamwork and collaboration, Delegation v v v v
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
v v v v v v v v v v v
10. A newly graduated nurse in the hospital states that because of being so new, participation in
v v v v v v v v v v v v v v v
vquality improvement (QI) projects is not wise. What response bythe precepting nurseis best?
v v v v v v v v v v v v v v
a. “Allstaff nurses are required to participate in quality improvement here.”
v v v v v v v v v v
b. “Even being new, you can implement activities designed toimprove care.” v v v v v v v v v v
c. “It’s easyto identify what indicators would be used to measure quality.”
v v v v v v v v v v v
d. “You should ask to be assigned to theresearch and quality committee.”
v v v v v v v v v v v
ANS: B v
The preceptor would try to reassure the nurse that implementing QI measures is not out of line for a
v v v v v v v v v v v v v v v v v v
newly licensed nurse. Simply stating that all nurses are required to participate does not help the
v v v v v v v v v v v v v v v v
nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an
v v v v v v v v v v v v v v v v
easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be
v v v v v v v v v v v v v v v v v v v v
assigned to the QI committee does not give the nurse information about how to implement QI in
v v v v v v v v v v v v v v v v v
daily practice.
v v
DIF: v Applying TOP: Integrated Process: Communication and Documentation v v v v v
Btestbanks.com
about:blank 4/593
v v Testbank - medical surgical nursing 10th edition ignatavicius workman-bte…
v v v v v v v v v
Medical Surgical Nursing 10th Edition v v v v
Ignatavicius Workman Test Bank
v v v v
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing
v v v v v v v v v
Ignatavicius: Medical-Surgical Nursing, 10th Edition
v v v v v
MULTIPLE CHOICE v
1. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new
v v v v v v v v v v v v v v v v
nurse that which is the priority when working as a professional nurse?
v v v v v v v v v v v v
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. Providingclient-focused care v v
ANS: B v
Allactions are appropriate for the professional nurse. However, ensuring client safety is the
v v v v v v v v v v v v v
vpriority. Health care errors have been widely reported for 25 years, many of which result in client
v v v v v v v v v v v v v v v v
injury, death, and increased health care costs. There are several national and international
v v v v v v v v v v v v v
organizations that have either recommended or mandated safety initiatives.
v v v v v v v v v
Every nurse has the responsibility to guard the client’s safety. The other actions are important
v v v v v v v v v v v v v v
for quality nursing, but they are not as vital as providing safety. Not making medication errors does
v v v v v v v v v v v v v v v v
provide safety, but is too narrow in scope to be the best answer.
v v v v v v v v v v v v v
DIF: Understanding v TOP: Integrated Process: Nursing Process: Intervention v v v v v
vKEY: Client safety v v
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
v v v v v v v v v v v v
2. A nurse is orienting a new client and family to the medical-surgical unit. What information does
v v v v v v v v v v v v v v v
the nurse provide to best help the client promote his or her own safety?
v v v v v v v v v v v v v v
a. Encourage the client and family tobe active partners. v v v v v v v v
b. Have theclient monitor hand hygiene in caregivers. v v v v v v v
c. Offer the familythe opportunity to staywith the client. v v v v v v v v v
d. Tell the client to always wear his or her armband. v v v v v v v v v
ANS: A v
Each action could be important for the client or familyto perform. However, encouraging the
v v v v v v v v v v v v v v
vclient to be active in his or her health care as a safety partner is the most critical. The other actions
v v v v v v v v v v v v v v v v v v v v
are very limited in scope and do not provide the broad protection that being active and involved
v v v v v v v v v v v v v v v v v
does.
v
DIF: Understanding v TOP: Integrated Process: Teaching/Learning v v v
vKEY: Client safety v v
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
v v v v v v v v v v v v
3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressure was
v v v v v v v v v v v v v v v v
142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nurse take first?
v v v v v v v v v v v v v v v v v v v
a. Call the Rapid ResponseTeam. v v v v
b. Document and continue to monitor. v v v v
c. Notifythe primary health care provider. v v v v v
d. Repeat the blood pressure in 15 minutes. v v v v v v
Btestbanks.com
about:blank 1/593
,10/31/23, 5:28AM
v v Testbank - medical surgical nursing 10th edition ignatavicius workman-bte…
v v v v v v v v v
ANS: A v
The purpose of theRapid Response Team (RRT)istointervene when clients are deteriorating
v v v v v v v v v v v v v v
vbefore they suffer either respiratory or cardiac arrest. Since the client has manifested a
v v v v v v v v v v v v v
vsignificant change, the nurse would call the RRT. Changes in blood pressure, mental status, v v v v v v v v v v v v v
vheart rate, temperature, oxygen saturation, and last 2 hours’ urine output are particularly
v v v v v v v v v v v v
vsignificant and are part of the Modified Early Warning System guide. Documentation is vital, but v v v v v v v v v v v v v v
the nurse must do more than document. The primary health care provider would be notified, but
v v v v v v v v v v v v v v v v
this is not more important than calling the RRT. The client’s blood pressure would be reassessed
v v v v v v v v v v v v v v v v
frequently, but the priority is getting the rapid care to the client.
v v v v v v v v v v v v
DIF: Applying TOP: Integrated Process: Communication and Documentation
v v v v v v
vKEY: Rapid Response Team (RRT), Clinical judgment
v v v v v v
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
v v v v v v v
4. A nurse wishes to provide client-centeredcare in all interactions. Which action bythe nurse
v v v v v v v v v v v v v v
best demonstrates this concept?
v v v
a. Assesses for cultural influences affecting health care. v v v v v v
b. Ensures that all the client’s basic needs are met. v v v v v v v v
c. Tells the client and family about all upcoming tests. v v v v v v v v
d. Thoroughly orients the client and familyto the room. v v v v v v v v
ANS: A v
Showing respect for the client and family’s preferences and needs is essential to ensure a
v v v v v v v v v v v v v v
holistic or “whole-person” approach to care. By assessing the effect of the client’s culture on health
v v v v v v v v v v v v v v v
care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate
v v v v v v v v v v v v v v
this competence. Simply telling the client about all upcoming tests is not providing empowering
v v v v v v v v v v v v v v
education. Orienting the client and family to theroom is an important safety measure, but not
v v v v v v v v v v v v v v v v
directly related to demonstrating client-centered care.
v v v v v v
DIF: Understanding v TOP: Integrated Process: Culture and Spirituality v v v v v
vKEY: Client-centered care, Culture v v v MSC: Client Needs Category: Psychosocial Integrity v v v v v
5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse
v v v v v v v v v v v v v v v v
explain is the most important thing the client can do to protect against errors?
v v v v v v v v v v v v v v
a. Bring a list of all medications and what they are for. v v v v v v v v v v
b. Keep the provider’s phone number by the telephone. v v v v v v v
c. Make surethat all providers wash hands before entering the room. v v v v v v v v v v
d. Write down the name ofeach caregiver who comes in the room. v v v v v v v v v v v
ANS: A v
Medication reconciliation is a formal processinwhich the client’sactual current medications are v v v v v v v v v v v v v
compared to the prescribed medications at the time of admission, transfer, or discharge. This
v v v v v v v v v v v v v v
National client Safety Goal is important to reduce medication errors. The client would not have
v v v v v v v v v v v v v v v
to be responsible for providers washing their hands, and even if the client does so,
v v v v v v v v v v v v v v v
this is too narrow to be the most important action to prevent errors. Keeping the provider’s phone
v v v v v v v v v v v v v v v v
number nearby and documenting everyone who entersthe room also do not guarantee safety.
v v v v v v v v v v v v v v
DIF: Applying TOP: Integrated Process: Teaching/Learning
v v v v
vKEY: Client safety, Informatics v v v
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
v v v v v v v v v v v v
Btestbanks.com
about:blank 2/593
,10/31/23, 5:28AM
v v Testbank - medical surgical nursing 10th edition ignatavicius workman-bte…
v v v v v v v v v
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
v v v v v v v v v v v v v
a. Asks if the client has questions before signing a consent.
v v v v v v v v v
b. Gives the client accurate information when questioned. v v v v v v
c. Keeps the promises made to the client and family. v v v v v v v v
d. Treatsthe client fairly compared to other clients. v v v v v v v
ANS: A v
Autonomy is self-determination. The client would make decisions regarding care. When the
v v v v v v v v v v v
nurse obtains a signature onthe consent form, assessing if the client still has questions is vital,
v v v v v v v v v v v v v v v v v
because without full information the client cannot practice autonomy. Giving accurate
v v v v v v v v v v v
information is practicing with veracity. Keeping promises is upholding fidelity. Treating the
v v v v v v v v v v v v
client fairly is providing social justice.
v v v v v v
DIF: Applying TOP: Integrated Process: Caring
v KEY:Ethics,Autonomy v v v v v
vMSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
v v v v v v v v v v v
7. A nurse asks a more seasoned colleague to explain best practices when communicating with a
v v v v v v v v v v v v v v
vperson from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ)
v v v v v v v v v
vcommunity. What answer by the faculty is most accurate? v v v v v v v v
a. Avoid embarrassing theclient by asking questions. v v v v v v
b. Don’t make assumptions about his or her health needs. v v v v v v v v
c. Most LGBTQ peopledo not want to share information.v v v v v v v v
d. No differences exist in communicating with this population.
v v v v v v v
ANS: B v
Many members of the LGBTQ community have faced discrimination from health care providers
v v v v v v v v v v v v
and may be reluctant to seek health care. The nurse would never make assumptions about the needs
v v v v v v v v v v v v v v v v v
of members of this population. Rather, respectful questionsare appropriate. If approached with
v v v v v v v v v v v v v
sensitivity, the client with any health care need is more likely to answer honestly.
v v v v v v v v v v v v v v
DIF: Understanding v TOP: Integrated Process:Teaching/Learning v v v
KEY: Healthcare disparities, LGBTQ
v v v v MSC: Client Needs Category: Psychosocial Integrity v v v v v
8. A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days
v v v v v v v v v v v v v v v v v
ago and has pain that is unrelieved by the prescribed opioid pain medication. Which
v v v v v v v v v v v v v v
vstatement comprises the background portion of the SBAR format for communication?
v v v v v v v v v v
a. “Iwould like you to order a different pain medication.”
v v v v v v v v v
b. “This client has allergies to morphine and codeine.” v v v v v v v
c. “Dr. Smith doesn’t like nonsteroidalanti-inflammatory meds.”
v v v v v v
d. “This client had a vaginal hysterectomy 2 days ago.” v v v v v v v v
ANS: B v
Btestbanks.com
about:blank 3/593
, 10/31/23, 5:28AM
v v Testbank - medical surgical nursing 10th edition ignatavicius workman-bte…
v v v v v v v v v
SBAR is a recommended form of communication, and the acronym stands for Situation,
v v v v v v v v v v v v
vBackground, Assessment, and Recommendation. Appropriate background information v v v v v v
vincludes allergies to medications the on-call health care provider might order. Situation
v v v v v v v v v v v
describes what is happening right now that must be communicated; the client’s surgery 2 days
v v v v v v v v v v v v v v
ago would be considered background. Assessment would include an analysis of the client’s
v v v v v v v v v v v v
problem; none of the options has assessment information. Asking for a different pain medication
v v v v v v v v v v v v v
is a recommendation. Recommendation is a statement of what is needed or what outcome is
v v v v v v v v v v v v v v v
desired.
v
DIF: Applying TOP: Integrated Process: Communication and Documentation
v v v v v v
vKEY: Teamwork and collaboration, SBAR v v v v
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
v v v v v v v v v v v
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive
v v v v v v v v v v v v v v
vpersonnel (AP). Four hours later, the nurse notes that the client’s blood pressure taken by the AP
v v v v v v v v v v v v v v v v
was much higher than previous readings, and the client’s mental status has changed. What action
v v v v v v v v v v v v v v v
by the nurse would most likely have prevented this negative outcome?
v v v v v v v v v v v
a. Determiningif the AP knew how to take blood pressure v v v v v v v v v
b. Double-checking the AP by taking another blood pressure v v v v v v v
c. Providingmore appropriate supervision of the AP v v v v v v
d. Taking the blood pressure instead ofdelegating the task v v v v v v v v
ANS: C v
Supervision is one of the five rights of delegation and includes directing, evaluating, and v v v v v v v v v v v v v
vfollowing up on delegated tasks. The nurse would either have asked the AP about the vital signs
v v v v v v v v v v v v v v v v
or instructed the APto report them right away. An experienced AP would know how to take vital
v v v v v v v v v v v v v v v v v v
signs and the nurse would not have to assess this at this point. Double-checking the work defeats the
v v v v v v v v v v v v v v v v v v
purpose of delegation. Vital signs are within the scope of practice for a AP and are permissible to
v v v v v v v v v v v v v v v v v v
delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the
v v v v v v v v v v v v v v v v
AP.
v
DIF: Analyzing TOP: Integrated Process: Communication and Documentation
v v v v v v
vKEY: Teamwork and collaboration, Delegation v v v v
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
v v v v v v v v v v v
10. A newly graduated nurse in the hospital states that because of being so new, participation in
v v v v v v v v v v v v v v v
vquality improvement (QI) projects is not wise. What response bythe precepting nurseis best?
v v v v v v v v v v v v v v
a. “Allstaff nurses are required to participate in quality improvement here.”
v v v v v v v v v v
b. “Even being new, you can implement activities designed toimprove care.” v v v v v v v v v v
c. “It’s easyto identify what indicators would be used to measure quality.”
v v v v v v v v v v v
d. “You should ask to be assigned to theresearch and quality committee.”
v v v v v v v v v v v
ANS: B v
The preceptor would try to reassure the nurse that implementing QI measures is not out of line for a
v v v v v v v v v v v v v v v v v v
newly licensed nurse. Simply stating that all nurses are required to participate does not help the
v v v v v v v v v v v v v v v v
nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an
v v v v v v v v v v v v v v v v
easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be
v v v v v v v v v v v v v v v v v v v v
assigned to the QI committee does not give the nurse information about how to implement QI in
v v v v v v v v v v v v v v v v v
daily practice.
v v
DIF: v Applying TOP: Integrated Process: Communication and Documentation v v v v v
Btestbanks.com
about:blank 4/593
