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