FOR Medical-Surgical Nursing: Concepts for Clinical Judgment and
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Nursestar1 Stuvia
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Collaborative Care (Evolve) 11th Edition by Donna D. Ignatavicius, Cherie
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b2 R. Rebar& Nicole M. Heimgartner |ISBN: 9780323878265| Complete Guide
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Geniusexpert stuvia
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, Chapter 01: Overview of Professional Nursing Concepts for
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b2 Medical- Surgical Nursing b2 b2
MULTIPLE CHOICE b2
1. A nurse wishes to provide client-centered care in all interactions. Which
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b2 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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CORRECT ANSWER: A b2 b2
Competency in client-focused care is demonstrated when the nurse focuses on
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b2 communication, culture, respect compassion, client education, and empowerment. By
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assessing the effect of the clients culture on health care, this nurse is practicing
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b2 client-focused care. Providing for basic needs does not demonstrate this
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b2 competence. Simply telling the client about all upcoming tests is not providing
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empowering education. Orienting the client and family to the room is an important
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b2 safety measure, but not directly related to demonstrating client-centered care.
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DIF: Understanding/Comprehension REF: 3
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KEY: Patient-centered care| culture MSC: Integrated
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b2 Process: Caring NOT: Client Needs Category:
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b2 Psychosocial Integrity b2
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood
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b2 pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What
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b2 action by the nurse is best?
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a. Call the Rapid Response Team.
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b. Document and continue to monitor. b2 b2 b2 b2
c. Notify the primary care provider.
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d. Repeat blood pressure measurement in 15 minutes.
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CORRECT ANSWER: A b2 b2
The purpose of the Rapid Response Team (RRT) is to intervene when clients are
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b2 deteriorating before they suffer either respiratory or cardiac arrest. Since the client
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b2 has manifested a significant change, the nurse should call the RRT. Changes in
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b2 blood pressure, mental status, heart rate, and pain are particularly significant.
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Documentation is vital, but the nurse must do more than document. The primary
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care provider should be notified, but this is not the priority over calling the
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b2 RRT. The clients blood pressure should be reassessed frequently, but the
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b2 priority is getting the rapid care to the client.
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