Medical-Surgical Nursing: b b
Concepts for Clinical Judgment and Collaborative Care 11th
b b b b b b b
Edition by Ignatavicius
b b b
Chapters 1-69
b
,Concepts for Medical-Surgical NursingIgnatavicius: Medical-Surgical Nursing, 11th
b b b b b b b
Edition
b
MULTIPLE CHOICE b
1. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises
b b b b b b b b b b b b b b
thenew nurse that which is the priority when working as a professional nurse?
b b b b b b b b b b b b b b
a. Attending to holistic client needs b b b b
b. Ensuring client safety b b
c. Not making medication errors b b b
d. Providing client-focused care b b
ACCURATE ANSWER: B
b b
Rationale:All actions are appropriate for the professional nurse. However, ensuring b b b b b b b b b
client safety is thepriority. Health care errors have been widely reported for 25 years,
b b b b b b b b b b b b b b b
many of which result inclient injury, death, and increased health care costs. There are
b b b b b b b b b b b b b b b
several national and international organizations that have either recommended or
b b b b b b b b b b
mandated safety initiatives.
b b b
Every nurse has the responsibility to guard the client’s safety. The other actions are
b b b b b b b b b b b b b
importantfor quality nursing, but they are not as vital as providing safety. Not making
b b b b b b b b b b b b b b b
medication errorsdoes provide safety, but is too narrow in scope to be the best accurate
b b b b b b b b b b b b b b b b
answerwer.
b
DIF: Understanding TOP: Integrated Process: Nursing Process: b b b b
InterventionKEY: Client safety
b b b b
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
b b b b b b b b b b b b
2. A nurse is orienting a new client and family to the medical-surgical unit. What
b b b b b b b b b b b b b
informationdoes the nurse provide to best help the client promote his or her own
b b b b b b b b b b b b b b b
safety?
b
a. Encourage the client and family to be active partners. b b b b b b b b
b. Have the client monitor hand hygiene in caregivers. b b b b b b b
c. Offer the family the opportunity to stay with the client.
b b b b b b b b b
d. Tell the client to always wear his or her armband.
b b b b b b b b b
ACCURATE ANSWER: A
b b
Rationale:Each action could be important for the client or family to perform. However, b b b b b b b b b b b b
b encouraging theclient to be active in his or her health care as a safety partner is the most b b b b b b b b b b b b b b b b b b
b critical. The other actions are very limited in scope and do not provide the broad protection
b b b b b b b b b b b b b b b
b that being active andinvolved does.
b b b b b
DIF: Understanding TOP: Integrated Process: b b
Teaching/LearningKEY: Client safety
b b b b
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
b b b b b b b b b b b b
3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood
b b b b b b b b b b b b b b
pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action
b b b b b b b b b b b b b b b b
would the nursetake first?
b b b b b
a. Call the Rapid Response Team. b b b b
b. Document and continue to monitor. b b b b
, c. Notify the primary health care provider. b b b b b
d. Repeat the blood pressure in 15 minutes. b b b b b b
ACCURATE ANSWER: A b b
Rationale:The purpose of the Rapid Response Team (RRT) is to intervene when clients are b b b b b b b b b b b b b
deterioratingbefore they suffer either respiratory or cardiac arrest. Since the client has
b b b b b b b b b b b b b
manifested a significant change, the nurse would call the RRT. Changes in blood pressure,
b b b b b b b b b b b b b b
mental status, heart rate, temperature, oxygen saturation, and last 2 hours’ urine output
b b b b b b b b b b b b b
are particularly significant and are part of the Modified Early Warning System guide.
b b b b b b b b b b b b b
Documentation is vital, but the nurse must do more than document. The primary health
b b b b b b b b b b b b b b
care provider would be notified, but this is not more important than calling the RRT. The
b b b b b b b b b b b b b b b b
client’s blood pressure would be reassessed frequently, but the priority is getting the rapid
b b b b b b b b b b b b b b
care to the client.
b b b b
DIF: Applying TOP: Integrated Process: Communication and b b b b
DocumentationKEY: Rapid Response Team (RRT), Clinical judgment
b b b b b b b b
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
b b b b b b b
4. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse
b b b b b b b b b b b b b b
best demonstrates this concept?
b b b
a. Assesses for cultural influences affecting health care. b b b b b b
b. Ensures that all the client’s basic needs are met. b b b b b b b b
c. Tells the client and family about all upcoming tests.
b b b b b b b b
d. Thoroughly orients the client and family to the room. b b b b b b b b
ACCURATE ANSWER: A b b
Rationale:Showing respect for the client and family’s preferences and needs is essential to b b b b b b b b b b b b
ensure a holistic or “whole-person” approach to care. By assessing the effect of the client’s
b b b b b b b b b b b b b b b
culture onhealth care, this nurse is practicing client-focused care. Providing for basic
b b b b b b b b b b b b b
needs does not demonstrate this competence. Simply telling the client about all upcoming
b b b b b b b b b b b b b
tests is not providing empowering education. Orienting the client and family to the room is
b b b b b b b b b b b b b b b
an importantsafety measure, but not directly related to demonstrating client-centered
b b b b b b b b b b b
care.
b
DIF: Understanding TOP: Integrated Process: Culture and Spirituality
b b b b b
KEY: Client-centered care, Culture
b b b b MSC: Client Needs Category: Psychosocial b b b b
Integrity
b
5. A client is going to be admitted for a scheduled surgical procedure. Which action does
b b b b b b b b b b b b b b
b thenurse explain is the most important thing the client can do to protect against errors?
b b b b b b b b b b b b b b b
a. Bring a list of all medications and what they are for.
b b b b b b b b b b
b. Keep the provider’s phone number by the telephone.
b b b b b b b
c. Make sure that all providers wash hands before entering the room.
b b b b b b b b b b
d. Write down the name of each caregiver who comes in the room.
b b b b b b b b b b b
ACCURATE ANSWER: A b b
Rationale:Medication reconciliation is a formal process in which the client’s actual current b b b b b b b b b b b
medicationsare compared to the prescribed medications at the time of admission,
b b b b b b b b b b b b
traccurate answerfer, or discharge. This National client Safety Goal is important to reduce
b b b b b b b b b b b b b
medication errors. The client would not have to be responsible for providers washing their
b b b b b b b b b b b b b b
hands, and even if the client does so, this is too narrow to be the most important action to
b b b b b b b b b b b b b b b b b b b
prevent errors. Keeping the provider’s phone number nearby and documenting everyone
b b b b b b b b b b b
who enters the room also do not guarantee safety.
b b b b b b b b b
DIF: Applying TOP: Integrated Process: b b
, Teaching/LearningKEY: Client safety, Informatics
b b b b b
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
b b b b b b b b b b b b
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
b b b b b b b b b b b b b
a. Asks if the client has questions before signing a consent.
b b b b b b b b b
b. Gives the client accurate information when questioned.b b b b b b
c. Keeps the promises made to the client and family. b b b b b b b b
d. Treats the client fairly compared to other clients. b b b b b b b
ACCURATE ANSWER: A b b
Rationale:Autonomy is self-determination. The client would make decisions regarding b b b b b b b b
care. When the nurse obtains a signature on the consent form, assessing if the client still has
b b b b b b b b b b b b b b b b b
questions is vital,because without full information the client cannot practice autonomy.
b b b b b b b b b b b b
Giving accurate information is practicing with veracity. Keeping promises is upholding
b b b b b b b b b b b
fidelity. Treating the client fairly is providing social justice.
b b b b b b b b b
DIF: Applying TOP: Integrated Process: Caring KEY: Ethics, Autonomy b b b b b
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
b b b b b b b b b b b b
7. A nurse asks a more seasoned colleague to explain best practices when communicating
b b b b b b b b b b b b
with aperson from the lesbian, gay, bisexual, traccurate answergender, and
b b b b b b b b b b b
questioning/queer (LGBTQ) community. What accurate answerwer by the faculty is most
b b b b b b b b b b b
accurate?
b
a. Avoid embarrassing the client by asking questions. b b b b b b
b. Don’t make assumptions about his or her health needs. b b b b b b b b
c. Most LGBTQ people do not want to share information.
b b b b b b b b
d. No differences exist in communicating with this population.
b b b b b b b
ACCURATE ANSWER: B b b
Rationale:Many members of the LGBTQ community have faced discrimination from health b b b b b b b b b b
b care providers and may be reluctant to seek health care. The nurse would never make
b b b b b b b b b b b b b b
b assumptions about the needs of members of this population. Rather, respectful questions b b b b b b b b b b b
b are appropriate. Ifapproached with sensitivity, the client with any health care need is more
b b b b b b b b b b b b b b
b likely to accurate answerwer honestly.
b b b b
DIF: Understanding TOP: Integrated Process: Teaching/Learning b b b
KEY: Health care disparities, LGBTQ
b b b b MSC: Client Needs Category: Psychosocial Integrity
b b b b b
8. A nurse is calling the on-call health care provider about a client who had a hysterectomy
b b b b b b b b b b b b b b b
2days ago and has pain that is unrelieved by the prescribed opioid pain medication.
b b b b b b b b b b b b b b b
Which statement comprises the background portion of the SBAR format for
b b b b b b b b b b b
communication?
b
a. “I would like you to order a different pain medication.”
b b b b b b b b b
b. “This client has allergies to morphine and codeine.” b b b b b b b
c. “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.”
b b b b b b
d. “This client had a vaginal hysterectomy 2 days ago.” b b b b b b b b
ACCURATE ANSWER: B b b
Concepts for Clinical Judgment and Collaborative Care 11th
b b b b b b b
Edition by Ignatavicius
b b b
Chapters 1-69
b
,Concepts for Medical-Surgical NursingIgnatavicius: Medical-Surgical Nursing, 11th
b b b b b b b
Edition
b
MULTIPLE CHOICE b
1. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises
b b b b b b b b b b b b b b
thenew nurse that which is the priority when working as a professional nurse?
b b b b b b b b b b b b b b
a. Attending to holistic client needs b b b b
b. Ensuring client safety b b
c. Not making medication errors b b b
d. Providing client-focused care b b
ACCURATE ANSWER: B
b b
Rationale:All actions are appropriate for the professional nurse. However, ensuring b b b b b b b b b
client safety is thepriority. Health care errors have been widely reported for 25 years,
b b b b b b b b b b b b b b b
many of which result inclient injury, death, and increased health care costs. There are
b b b b b b b b b b b b b b b
several national and international organizations that have either recommended or
b b b b b b b b b b
mandated safety initiatives.
b b b
Every nurse has the responsibility to guard the client’s safety. The other actions are
b b b b b b b b b b b b b
importantfor quality nursing, but they are not as vital as providing safety. Not making
b b b b b b b b b b b b b b b
medication errorsdoes provide safety, but is too narrow in scope to be the best accurate
b b b b b b b b b b b b b b b b
answerwer.
b
DIF: Understanding TOP: Integrated Process: Nursing Process: b b b b
InterventionKEY: Client safety
b b b b
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
b b b b b b b b b b b b
2. A nurse is orienting a new client and family to the medical-surgical unit. What
b b b b b b b b b b b b b
informationdoes the nurse provide to best help the client promote his or her own
b b b b b b b b b b b b b b b
safety?
b
a. Encourage the client and family to be active partners. b b b b b b b b
b. Have the client monitor hand hygiene in caregivers. b b b b b b b
c. Offer the family the opportunity to stay with the client.
b b b b b b b b b
d. Tell the client to always wear his or her armband.
b b b b b b b b b
ACCURATE ANSWER: A
b b
Rationale:Each action could be important for the client or family to perform. However, b b b b b b b b b b b b
b encouraging theclient to be active in his or her health care as a safety partner is the most b b b b b b b b b b b b b b b b b b
b critical. The other actions are very limited in scope and do not provide the broad protection
b b b b b b b b b b b b b b b
b that being active andinvolved does.
b b b b b
DIF: Understanding TOP: Integrated Process: b b
Teaching/LearningKEY: Client safety
b b b b
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
b b b b b b b b b b b b
3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood
b b b b b b b b b b b b b b
pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action
b b b b b b b b b b b b b b b b
would the nursetake first?
b b b b b
a. Call the Rapid Response Team. b b b b
b. Document and continue to monitor. b b b b
, c. Notify the primary health care provider. b b b b b
d. Repeat the blood pressure in 15 minutes. b b b b b b
ACCURATE ANSWER: A b b
Rationale:The purpose of the Rapid Response Team (RRT) is to intervene when clients are b b b b b b b b b b b b b
deterioratingbefore they suffer either respiratory or cardiac arrest. Since the client has
b b b b b b b b b b b b b
manifested a significant change, the nurse would call the RRT. Changes in blood pressure,
b b b b b b b b b b b b b b
mental status, heart rate, temperature, oxygen saturation, and last 2 hours’ urine output
b b b b b b b b b b b b b
are particularly significant and are part of the Modified Early Warning System guide.
b b b b b b b b b b b b b
Documentation is vital, but the nurse must do more than document. The primary health
b b b b b b b b b b b b b b
care provider would be notified, but this is not more important than calling the RRT. The
b b b b b b b b b b b b b b b b
client’s blood pressure would be reassessed frequently, but the priority is getting the rapid
b b b b b b b b b b b b b b
care to the client.
b b b b
DIF: Applying TOP: Integrated Process: Communication and b b b b
DocumentationKEY: Rapid Response Team (RRT), Clinical judgment
b b b b b b b b
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
b b b b b b b
4. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse
b b b b b b b b b b b b b b
best demonstrates this concept?
b b b
a. Assesses for cultural influences affecting health care. b b b b b b
b. Ensures that all the client’s basic needs are met. b b b b b b b b
c. Tells the client and family about all upcoming tests.
b b b b b b b b
d. Thoroughly orients the client and family to the room. b b b b b b b b
ACCURATE ANSWER: A b b
Rationale:Showing respect for the client and family’s preferences and needs is essential to b b b b b b b b b b b b
ensure a holistic or “whole-person” approach to care. By assessing the effect of the client’s
b b b b b b b b b b b b b b b
culture onhealth care, this nurse is practicing client-focused care. Providing for basic
b b b b b b b b b b b b b
needs does not demonstrate this competence. Simply telling the client about all upcoming
b b b b b b b b b b b b b
tests is not providing empowering education. Orienting the client and family to the room is
b b b b b b b b b b b b b b b
an importantsafety measure, but not directly related to demonstrating client-centered
b b b b b b b b b b b
care.
b
DIF: Understanding TOP: Integrated Process: Culture and Spirituality
b b b b b
KEY: Client-centered care, Culture
b b b b MSC: Client Needs Category: Psychosocial b b b b
Integrity
b
5. A client is going to be admitted for a scheduled surgical procedure. Which action does
b b b b b b b b b b b b b b
b thenurse explain is the most important thing the client can do to protect against errors?
b b b b b b b b b b b b b b b
a. Bring a list of all medications and what they are for.
b b b b b b b b b b
b. Keep the provider’s phone number by the telephone.
b b b b b b b
c. Make sure that all providers wash hands before entering the room.
b b b b b b b b b b
d. Write down the name of each caregiver who comes in the room.
b b b b b b b b b b b
ACCURATE ANSWER: A b b
Rationale:Medication reconciliation is a formal process in which the client’s actual current b b b b b b b b b b b
medicationsare compared to the prescribed medications at the time of admission,
b b b b b b b b b b b b
traccurate answerfer, or discharge. This National client Safety Goal is important to reduce
b b b b b b b b b b b b b
medication errors. The client would not have to be responsible for providers washing their
b b b b b b b b b b b b b b
hands, and even if the client does so, this is too narrow to be the most important action to
b b b b b b b b b b b b b b b b b b b
prevent errors. Keeping the provider’s phone number nearby and documenting everyone
b b b b b b b b b b b
who enters the room also do not guarantee safety.
b b b b b b b b b
DIF: Applying TOP: Integrated Process: b b
, Teaching/LearningKEY: Client safety, Informatics
b b b b b
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
b b b b b b b b b b b b
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
b b b b b b b b b b b b b
a. Asks if the client has questions before signing a consent.
b b b b b b b b b
b. Gives the client accurate information when questioned.b b b b b b
c. Keeps the promises made to the client and family. b b b b b b b b
d. Treats the client fairly compared to other clients. b b b b b b b
ACCURATE ANSWER: A b b
Rationale:Autonomy is self-determination. The client would make decisions regarding b b b b b b b b
care. When the nurse obtains a signature on the consent form, assessing if the client still has
b b b b b b b b b b b b b b b b b
questions is vital,because without full information the client cannot practice autonomy.
b b b b b b b b b b b b
Giving accurate information is practicing with veracity. Keeping promises is upholding
b b b b b b b b b b b
fidelity. Treating the client fairly is providing social justice.
b b b b b b b b b
DIF: Applying TOP: Integrated Process: Caring KEY: Ethics, Autonomy b b b b b
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
b b b b b b b b b b b b
7. A nurse asks a more seasoned colleague to explain best practices when communicating
b b b b b b b b b b b b
with aperson from the lesbian, gay, bisexual, traccurate answergender, and
b b b b b b b b b b b
questioning/queer (LGBTQ) community. What accurate answerwer by the faculty is most
b b b b b b b b b b b
accurate?
b
a. Avoid embarrassing the client by asking questions. b b b b b b
b. Don’t make assumptions about his or her health needs. b b b b b b b b
c. Most LGBTQ people do not want to share information.
b b b b b b b b
d. No differences exist in communicating with this population.
b b b b b b b
ACCURATE ANSWER: B b b
Rationale:Many members of the LGBTQ community have faced discrimination from health b b b b b b b b b b
b care providers and may be reluctant to seek health care. The nurse would never make
b b b b b b b b b b b b b b
b assumptions about the needs of members of this population. Rather, respectful questions b b b b b b b b b b b
b are appropriate. Ifapproached with sensitivity, the client with any health care need is more
b b b b b b b b b b b b b b
b likely to accurate answerwer honestly.
b b b b
DIF: Understanding TOP: Integrated Process: Teaching/Learning b b b
KEY: Health care disparities, LGBTQ
b b b b MSC: Client Needs Category: Psychosocial Integrity
b b b b b
8. A nurse is calling the on-call health care provider about a client who had a hysterectomy
b b b b b b b b b b b b b b b
2days ago and has pain that is unrelieved by the prescribed opioid pain medication.
b b b b b b b b b b b b b b b
Which statement comprises the background portion of the SBAR format for
b b b b b b b b b b b
communication?
b
a. “I would like you to order a different pain medication.”
b b b b b b b b b
b. “This client has allergies to morphine and codeine.” b b b b b b b
c. “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.”
b b b b b b
d. “This client had a vaginal hysterectomy 2 days ago.” b b b b b b b b
ACCURATE ANSWER: B b b
