Overview of Professional Nursing Concepts for Medical- 5% 5% 5% 5% 5% 5%
Surgical Nursing
5% 5%
MULTIPLE CHOICE 5%
1. A nurse wishes to provide client-
5% 5% 5% 5% 5%
centered care in all interactions. Which action by the nurse best demonstrates this concept?
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
a.
b. Assesses for cultural influences affecting health care
5% 5% 5% 5% 5% 5%
c. Ensures that all the clients basic needs are met
5% 5% 5% 5% 5% 5% 5% 5%
d. Tells the client and family about all upcoming tests
5% 5% 5% 5% 5% 5% 5% 5%
e. Thoroughly orients the client and family to the room 5% 5% 5% 5% 5% 5% 5% 5%
ANS: A 5%
Competency in client- 5% 5%
focused care is demonstrated when the nurse focuses on communication, culture, respect compassion, clien
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5 % 5%
t education, and empowerment. By assessing the effect of the clients culture on health care, this nurse i
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5 % 5 % 5 %
s practicing client-focused care. Providing for basic needs does not demonstrate this competence.
5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 %
Simply telling the client about all upcoming tests is not providing empowering education. Orienting the cli
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
ent and family to the room is an important safety measure, but not directly related to demonstrating clie
5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
nt-centered care. 5%
DIF: Understanding/Comprehension REF: 3
5% 5% 5%
KEY: Patient- 5%
centered care| culture MSC: Integrated Process: Caring NOT: Client
5% 5% 5% 5% 5% 5% 5% 5% 5
%Needs Category: Psychosocial Integrity
5% 5% 5%
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
a. Call the Rapid Response Team.
5% 5% 5% 5%
b. Document and continue to monitor. 5% 5% 5% 5%
c. Notify the primary care provider. 5% 5% 5% 5%
d. Repeat blood pressure measurement in 15 minutes.
5% 5% 5% 5% 5% 5%
ANS: A 5%
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating bef
5 % 5% 5% 5 % 5% 5% 5% 5% 5 % 5% 5% 5% 5 % 5 % 5%
ore they suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, th
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
e nurse should call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particular
5% 5% 5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
ly significant.
5%
Documentation is vital, but the nurse must do more than document. The primary care provider should
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
be notified, but this is not the priority over calling the RRT. The clients blood pressure should be reas
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
sessed frequently, but the priority is getting the rapid care to the client.
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
DIF: Applying/Application REF: 3
5% 5% 5%
KEY: Rapid Response Team (RRT)| medical emergencies
5% 5% 5% 5% 5% 5% 5 %
MSC: Integrated Process: Communication and Documentatio
5% 5% 5% 5% 5%
n
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
5% 5% 5% 5% 5% 5% 5%
3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provid
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
e to help the client promote his or her own safety?
5% 5 % 5% 5% 5% 5% 5% 5% 5% 5%
a. Encourage the client and family to be active partners. 5% 5% 5% 5% 5% 5% 5% 5%
b. Have the client monitor hand hygiene in caregivers.
5% 5% 5% 5% 5% 5% 5%
c. Offer the family the opportunity to stay with the client.
5% 5% 5% 5% 5% 5% 5% 5% 5%
d. Tell the client to always wear his or her armband.
5% 5% 5% 5% 5% 5% 5% 5% 5%
ANS: A 5%
Each action could be important for the client or family to perform. However, encouraging the clien
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
t to be active in his or her health care as a partner is the most critical. The other actions are very limite
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
d in scope and do not provide the broad protection that being active and involved does.
5% 5% 5% 5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
,DIF: Understanding/Comprehension REF:
5% 5% 5%
3 KEY: Patient safety
5% 5% 5%
,MSC: Integrated Process: Teaching/Learning
5% 5% 5%
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
4. A new nurse is working with a preceptor on an inpatient medical-
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
surgical unit. The preceptor advises the student that which is the priority when working as a professional
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5
%nurse?
a. Attending to holistic client needs 5% 5% 5% 5%
b. Ensuring client safety 5% 5%
c. Not making medication errors
5% 5% 5%
d. Providing client-focused care 5% 5%
ANS: B 5%
All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up t
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
o 98,000 deaths result each year from errors in hospital care, according to the 2000 Institute of Medicine
5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
report. Many more clients have suffered injuries and less serious outcomes. Every nurse has the
5% 5 % 5 % 5% 5 % 5 % 5 % 5 % 5 % 5% 5 % 5% 5 % 5 % 5 % 5 %
responsibility to guard the clients safety. 5 % 5% 5% 5% 5%
DIF: Understanding/Comprehension REF:
5% 5% 5%
2 KEY: Patient safety
5% 5% 5%
MSC: Integrated Process: Nursing Process: Intervention
5% 5% 5% 5% 5%
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explai
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
n is the most important thing the client can do to protect against errors?
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
a. Bring a list of all medications and what they are for.
5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
b. Keep the doctors phone number by the telephone.
5% 5% 5% 5% 5% 5% 5%
c. Make sure all providers wash hands before entering the room.
5% 5% 5% 5% 5% 5% 5% 5% 5%
d. Write down the name of each caregiver who comes in the room.
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
ANS: A 5%
Medication errors are the most common type of health care mistake. The Joint Commissions Speak Up ca
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
mpaign encourages clients to help ensure their safety. One recommendation is for clients to know all their
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
medications and why they take them. This will help prevent medication errors.
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
DIF: Applying/Application REF: 4
5% 5% 5%
KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/Learning
5% 5% 5% 5% 5% 5% 5% 5% 5%
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
a. Asks if the client has questions before signing a consent
5% 5% 5% 5% 5% 5% 5% 5% 5%
b. Gives the client accurate information when questioned
5% 5% 5% 5% 5% 5%
c. Keeps the promises made to the client and family
5% 5% 5% 5% 5% 5% 5% 5%
d. Treats the client fairly compared to other clients
5% 5% 5% 5% 5% 5% 5%
ANS: A 5%
Autonomy is self- 5% 5%
determination. The client should make decisions regarding care. When the nurse obtains a signature on t
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5 % 5% 5%
he consent form, assessing if the client still has questions is vital, because without full information the cl
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
ient cannot practice autonomy. Giving accurate information is practicing with veracity.
5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
DIF: Applying/Application REF: 4
5% 5% 5%
KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
5% 5% 5% 5% 5% 5% 5%
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
7. A student nurse asks the faculty to explain best practices when communicating with a person from
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5
%the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the fac
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
ulty is most accurate?
5% 5 % 5%
a. Avoid embarrassing the client by asking questions.
5% 5% 5% 5% 5% 5%
b. Dont make assumptions about their health needs.
5% 5% 5% 5% 5% 5%
c. Most LGBTQ people do not want to share information.
5% 5% 5% 5% 5% 5% 5% 5%
, d. No differences exist in communicating with this population.
5% 5% 5% 5% 5% 5% 5%
ANS: B 5%
Many members of the LGBTQ community have faced discrimination from health care providers and may
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
be reluctant to seek health care. The nurse should never make assumptions about the needs of members
5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the client
5% 5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
with any health care need is more likely to answer honestly.
5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
DIF: Understanding/Comprehension REF:
5% 5% 5%
4 KEY: LGBTQ| diversity
5% 5% 5%
MSC: Integrated Process: Teaching/Learning
5% 5% 5%
NOT: Client Needs Category: Psychosocial Integrity
5% 5% 5% 5% 5%
8. A nurse is calling the on-
5% 5% 5% 5% 5%
call physician about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5
%prescribed narcotic pain medication. Which statement is part of the SBAR format for communication?
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
a. A: I would like you to order a different pain medication.
5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
b. B: This client has allergies to morphine and codeine.
5% 5% 5% 5% 5% 5% 5% 5%
c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
5% 5% 5% 5% 5% 5% 5%
d. S: This client had a vaginal hysterectomy 2 days ago.
5% 5% 5% 5% 5% 5% 5% 5% 5%
ANS: B 5%
SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Asses
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5 %
sment, and Recommendation. Appropriate background information includes allergies to medications the on-
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5 %
call physician might order. Situation describes what is happening right now that must be communicated; the
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5
%clients surgery 2 days ago would be considered background. Assessment would include an analysis
5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 %
of the clients problem; asking for a different pain medication is a recommendation. Recommendation
5 % 5% 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 %
is a statement of what is needed or what outcome is desired; this information about the surgeons preference
5 % 5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5
%might be better placed in background.
5% 5% 5 % 5% 5%
DIF: Applying/Application REF: 5
5% 5% 5% 5%
KEY: SBAR| communication 5% 5%
MSC: Integrated Process: Communication and Documentation
5% 5% 5% 5% 5%
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
personnel (UAP). Four hours later, the nurse notes the clients blood pressure is much higher than previo
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
us readings, and the clients mental status has changed. What action by the nurse would most likely ha
5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
ve prevented this negative outcome?
5% 5% 5% 5%
a. Determining if the UAP knew how to take blood pressure 5% 5% 5% 5% 5% 5% 5% 5% 5%
b. Double-checking the UAP by taking another blood pressure 5% 5% 5% 5% 5% 5% 5%
c. Providing more appropriate supervision of the UAP5% 5% 5% 5% 5% 5%
d. Taking the blood pressure instead of delegating the task
5% 5% 5% 5% 5% 5% 5% 5%
ANS: C 5%
Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
delegated tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP t
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
o report them right away. An experienced UAP should know how to take vital signs and the nurs
5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
e should not have to assess this at this point. Double-
5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a U
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5 % 5% 5% 5% 5% 5% 5% 5%
AP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequat
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5 % 5% 5% 5% 5%
e instruction to the UAP.
5% 5% 5% 5%
DIF: Applying/Application REF: 6
5% 5% 5%
KEY: Supervision| delegation| unlicensed assistive personnel
5% 5% 5% 5% 5% 5
MSC: Integrated Process: Communication and Documentatio
% 5% 5% 5% 5% 5%
n
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
10. A nurse is talking with a client who is moving to a new state and needs to find a new doctor and hos
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
pital there. What advice by the nurse is best?
5% 5% 5% 5% 5% 5% 5% 5%
Surgical Nursing
5% 5%
MULTIPLE CHOICE 5%
1. A nurse wishes to provide client-
5% 5% 5% 5% 5%
centered care in all interactions. Which action by the nurse best demonstrates this concept?
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
a.
b. Assesses for cultural influences affecting health care
5% 5% 5% 5% 5% 5%
c. Ensures that all the clients basic needs are met
5% 5% 5% 5% 5% 5% 5% 5%
d. Tells the client and family about all upcoming tests
5% 5% 5% 5% 5% 5% 5% 5%
e. Thoroughly orients the client and family to the room 5% 5% 5% 5% 5% 5% 5% 5%
ANS: A 5%
Competency in client- 5% 5%
focused care is demonstrated when the nurse focuses on communication, culture, respect compassion, clien
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5 % 5%
t education, and empowerment. By assessing the effect of the clients culture on health care, this nurse i
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5 % 5 % 5 %
s practicing client-focused care. Providing for basic needs does not demonstrate this competence.
5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 %
Simply telling the client about all upcoming tests is not providing empowering education. Orienting the cli
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
ent and family to the room is an important safety measure, but not directly related to demonstrating clie
5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
nt-centered care. 5%
DIF: Understanding/Comprehension REF: 3
5% 5% 5%
KEY: Patient- 5%
centered care| culture MSC: Integrated Process: Caring NOT: Client
5% 5% 5% 5% 5% 5% 5% 5% 5
%Needs Category: Psychosocial Integrity
5% 5% 5%
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
a. Call the Rapid Response Team.
5% 5% 5% 5%
b. Document and continue to monitor. 5% 5% 5% 5%
c. Notify the primary care provider. 5% 5% 5% 5%
d. Repeat blood pressure measurement in 15 minutes.
5% 5% 5% 5% 5% 5%
ANS: A 5%
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating bef
5 % 5% 5% 5 % 5% 5% 5% 5% 5 % 5% 5% 5% 5 % 5 % 5%
ore they suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, th
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
e nurse should call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particular
5% 5% 5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
ly significant.
5%
Documentation is vital, but the nurse must do more than document. The primary care provider should
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
be notified, but this is not the priority over calling the RRT. The clients blood pressure should be reas
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
sessed frequently, but the priority is getting the rapid care to the client.
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
DIF: Applying/Application REF: 3
5% 5% 5%
KEY: Rapid Response Team (RRT)| medical emergencies
5% 5% 5% 5% 5% 5% 5 %
MSC: Integrated Process: Communication and Documentatio
5% 5% 5% 5% 5%
n
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
5% 5% 5% 5% 5% 5% 5%
3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provid
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
e to help the client promote his or her own safety?
5% 5 % 5% 5% 5% 5% 5% 5% 5% 5%
a. Encourage the client and family to be active partners. 5% 5% 5% 5% 5% 5% 5% 5%
b. Have the client monitor hand hygiene in caregivers.
5% 5% 5% 5% 5% 5% 5%
c. Offer the family the opportunity to stay with the client.
5% 5% 5% 5% 5% 5% 5% 5% 5%
d. Tell the client to always wear his or her armband.
5% 5% 5% 5% 5% 5% 5% 5% 5%
ANS: A 5%
Each action could be important for the client or family to perform. However, encouraging the clien
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
t to be active in his or her health care as a partner is the most critical. The other actions are very limite
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
d in scope and do not provide the broad protection that being active and involved does.
5% 5% 5% 5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
,DIF: Understanding/Comprehension REF:
5% 5% 5%
3 KEY: Patient safety
5% 5% 5%
,MSC: Integrated Process: Teaching/Learning
5% 5% 5%
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
4. A new nurse is working with a preceptor on an inpatient medical-
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
surgical unit. The preceptor advises the student that which is the priority when working as a professional
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5
%nurse?
a. Attending to holistic client needs 5% 5% 5% 5%
b. Ensuring client safety 5% 5%
c. Not making medication errors
5% 5% 5%
d. Providing client-focused care 5% 5%
ANS: B 5%
All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up t
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
o 98,000 deaths result each year from errors in hospital care, according to the 2000 Institute of Medicine
5 % 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
report. Many more clients have suffered injuries and less serious outcomes. Every nurse has the
5% 5 % 5 % 5% 5 % 5 % 5 % 5 % 5 % 5% 5 % 5% 5 % 5 % 5 % 5 %
responsibility to guard the clients safety. 5 % 5% 5% 5% 5%
DIF: Understanding/Comprehension REF:
5% 5% 5%
2 KEY: Patient safety
5% 5% 5%
MSC: Integrated Process: Nursing Process: Intervention
5% 5% 5% 5% 5%
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explai
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
n is the most important thing the client can do to protect against errors?
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
a. Bring a list of all medications and what they are for.
5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
b. Keep the doctors phone number by the telephone.
5% 5% 5% 5% 5% 5% 5%
c. Make sure all providers wash hands before entering the room.
5% 5% 5% 5% 5% 5% 5% 5% 5%
d. Write down the name of each caregiver who comes in the room.
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
ANS: A 5%
Medication errors are the most common type of health care mistake. The Joint Commissions Speak Up ca
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
mpaign encourages clients to help ensure their safety. One recommendation is for clients to know all their
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
medications and why they take them. This will help prevent medication errors.
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
DIF: Applying/Application REF: 4
5% 5% 5%
KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/Learning
5% 5% 5% 5% 5% 5% 5% 5% 5%
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%
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
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d. Treats the client fairly compared to other clients
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ANS: A 5%
Autonomy is self- 5% 5%
determination. The client should make decisions regarding care. When the nurse obtains a signature on t
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he consent form, assessing if the client still has questions is vital, because without full information the cl
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ient cannot practice autonomy. Giving accurate information is practicing with veracity.
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Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.
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DIF: Applying/Application REF: 4
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KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
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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 person from
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%the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the fac
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ulty is most accurate?
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a. Avoid embarrassing the client by asking questions.
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b. Dont make assumptions about their health needs.
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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 5%
Many members of the LGBTQ community have faced discrimination from health care providers and may
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be reluctant to seek health care. The nurse should never make assumptions about the needs of members
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of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the client
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with any health care need is more likely to answer honestly.
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DIF: Understanding/Comprehension REF:
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4 KEY: LGBTQ| diversity
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MSC: Integrated Process: Teaching/Learning
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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 by the
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%prescribed narcotic pain medication. Which statement is part of the SBAR format for communication?
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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 doesnt 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 5%
SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Asses
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sment, and Recommendation. Appropriate background information includes allergies to medications the on-
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call physician might order. Situation describes what is happening right now that must be communicated; the
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%clients surgery 2 days ago would be considered background. Assessment would include an analysis
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of the clients problem; asking for a different pain medication is a recommendation. Recommendation
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is a statement of what is needed or what outcome is desired; this information about the surgeons preference
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%might be better placed in background.
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DIF: Applying/Application REF: 5
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KEY: SBAR| communication 5% 5%
MSC: Integrated Process: Communication and Documentation
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NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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9. A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive
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personnel (UAP). Four hours later, the nurse notes the clients blood pressure is much higher than previo
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us readings, and the clients mental status has changed. What action by the nurse would most likely ha
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ve prevented this negative outcome?
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a. Determining if the UAP knew how to take blood pressure 5% 5% 5% 5% 5% 5% 5% 5% 5%
b. Double-checking the UAP by taking another blood pressure 5% 5% 5% 5% 5% 5% 5%
c. Providing more appropriate supervision of the UAP5% 5% 5% 5% 5% 5%
d. Taking the blood pressure instead of delegating the task
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ANS: C 5%
Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on
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delegated tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP t
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o report them right away. An experienced UAP should know how to take vital signs and the nurs
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e should not have to assess this at this point. Double-
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checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a U
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AP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequat
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e instruction to the UAP.
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DIF: Applying/Application REF: 6
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KEY: Supervision| delegation| unlicensed assistive personnel
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MSC: Integrated Process: Communication and Documentatio
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n
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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10. A nurse is talking with a client who is moving to a new state and needs to find a new doctor and hos
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pital there. What advice by the nurse is best?
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