TEST BANK for Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care 11th Edition by Donna D. Ignatavicius, All chapters 1 - 74||Complete A+ Guide

,
,Overview of Professional Nursing Concepts for Medical
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- Surgical Nursing
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MULTIPLE z@Q CHOICE

1. A nurse wishes to provide client-
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centered care in all interactions. Which action by the nurse best demonstrates this concept?
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a. Assesses for cultural influences affecting health care
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b. Ensures that all the clients basic needs are met
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c. Tells the client and family about all upcoming tests
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d. Thoroughly orients the client and family to the room
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ANS: A z@Q


Competency in client- z@Q z@Q


focused care is demonstrated when the nurse focuses on communication, culture, respect comp
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assion, client ed ucation, and empowerment. By assessing the effect of the clients culture on
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health care, this nurse is practici ng client-
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focused care. Providing for basic needs does not demonstrate this competence.
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Simply telling the client about all upcoming tests is not providing empowering education. Ori
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enting the client and family to the room is an important safety measure, but not directly r
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elated to demonstrating client- centered care.
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DIF: Understanding/Comprehension REF:
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@ Q3 KEY: Patient-
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centered care| culture MSC: Integrated Process: Caring NOT: C
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lient N eeds Category: Psychosocial Integrity
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2. A nurse is caring for a postoperative client on the surgical unit. The clients blood press
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ure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the n
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urse is best?
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a. Call the Rapid Response Team.
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b. Document and continue to monitor.z@Q z@Q z@Q z@Q


c. Notify the primary care provider.
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d. Repeat blood pressure measurement in 15 minutes.
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ANS: A z@Q


The purpose of the Rapid Response Team (RRT) is to intervene when clients
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are deteriorating before they suffer either respiratory or cardiac arrest. Since the client
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has manifested a significant change, the nurse s hould
z@Q z@Q z@Q call the RRT. Changes in blood p z@Q z@Q z@Q z@Q z@Q z @ Q z@Q z@Q z@Q z@Q z@Q z@Q


ressure, mental status, heart rate, and pain are particularly significant. Documentation is vital,
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Qbut the nurse must do more than document. The primary care provider should be no tified
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, but this is not the priority over calling the RRT. The clients blood pressure should be re
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assessed freq uently, but the priority is getting the rapid care to the client.
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DIF: Applying/Application REF: 3
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KEY: Rapid Response Team (RRT)| medical emergencie
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s MS C: Integrated Process: Communication and Doc
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umentation
NOT: Client Needs Category: Physiological Integrity: Physiological
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3. A nurse is orienting a new client and family to the inpatient unit. What information does the
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nurse provide to
z@Q h elp the client promote his or her own safety?
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a. Encourage the client and family to be active partners.
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b. Have the client monitor hand hygiene in caregivers.
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c. Offer the family the opportunity to stay with the client.
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d. Tell the client to always wear his or her armband.
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ANS: A z@Q


Each action could be important for the client or family to perform. However,
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encouraging the client to be active in his or her health care as a partner is the m
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, ost critical. The other actions are very limited in scope a nd
za z@Q z@Q z@Q z@Q z@Q z@Q z@Q z@Q z@Q z@Q z @ Q do not provide the broad p
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rotection that being active and involved does.
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DIF: Understanding/Comprehension REF: 3
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KEY: Patient safety
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