FULL TEST BANK
TIMBY'S INTRODUCTORY MEDICAL-SURGICAL NURSING 13TH
EDITION BY LORETTA A. DONNELLY-MORENO, BRIGITTE
MOSELEY
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Table of Contents
Chapter 01 Concepts and Trends in Health Care 1
Chapter 02 Settings and Models for Nursing Care 13
Chapter 03 The Nursing Process 25
Chapter 04 Interviewing and Physical Assessment 35
Chapter 05 Legal and Ethical Issues 46
Chapter 06 Leadership Roles and Management Functions 58
Chapter 07 Nurse–Client Relationships 68
Chapter 08 Cultural Care Considerations 80
Chapter 09 Integrative Medicine and Alternative Therapies 87
Chapter 10 End-of-Life Care 97
Chapter 11 Pain Management 108
Chapter 12 Infection 120
Chapter 13 Intravenous Therapy 132
Chapter 14 Perioperative Care 142
Chapter 15 Disaster Situations 153
Chapter 16 Caring for Clients With Fluid, Electrolyte, and Acid– Base Imbalances 161
Chapter 17 Caring for Clients in Shock 172
Chapter 18 Caring for Clients With Cancer 183
Chapter 19 Introduction to the Respiratory System 192
Chapter 20 Caring for Clients With Upper Respiratory Disorders 204
Chapter 21 Caring for Clients With Lower Respiratory Disorders 216
Chapter 22 Introduction to the Cardiovascular System 226
Chapter 23 Caring for Clients With Infectious and Inflammatory Disorders of the Heart
and Blood Vessels 234
Chapter 24 Caring for Clients With Valvular Disorders of the Heart 244
Chapter 25 Caring for Clients With Disorders of Coronary and Peripheral Blood Vessels 254
Chapter 26 Caring for Clients With Cardiac Arrhythmias 265
Chapter 27 Caring for Clients With Hypertension 275
Chapter 28 Caring for Clients With Heart Failure 286
Chapter 29 Caring for Clients Undergoing Cardiovascular Surgery 297
Chapter 30 Introduction to the Hematopoietic and Lymphatic Systems 308
Chapter 31 Caring for Clients With Disorders of the Hematopoietic System 318
Chapter 32 Caring for Clients With Disorders of the Lymphatic System 328
Chapter 33 Introduction to the Immune System 341
Chapter 34 Caring for Clients With Immune-Mediated Disorders 351
Chapter 35 Caring for Clients With HIV AIDS 362
Chapter 36 Introduction to the Nervous System 374
Chapter 37 Caring for Clients With Central and Peripheral Nervous System Disorders 384
Chapter 38 Caring for Clients With Cerebrovascular Disorders 393
Chapter 39 Caring for Clients With Head and Spinal Cord Trauma 402
Chapter 40 Caring for Clients With Neurologic Deficits 413
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,Chapter 41 Introduction to the Sensory System
Chapter 42 Caring for Clients With Eye Disorders
Chapter 43 Caring for Clients With Ear Disorders
Chapter 44 Introduction to the Gastrointestinal System and Accessory Structures
Chapter 45 Caring for Clients With Disorders of the Upper Gastrointestinal Tract
Chapter 46 Caring for Clients With Disorders of the Lower Gastrointestinal Tract
Chapter 47 Caring for Clients With Disorders of the Liver, Gallbladder, or Pancreas
Chapter 48 Caring for Clients With Ostomies
Chapter 49 Introduction to the Endocrine System
Chapter 50 Caring for Clients With Disorders of the Endocrine System
Chapter 51 Caring for Clients With Diabetes Mellitus
Chapter 52 Introduction to the Female and Male Reproductive Systems
Chapter 53 Caring for Clients With Disorders of the Female Reproductive System
Chapter 54 Caring for Clients With Breast Disorders
Chapter 55 Caring for Clients With Disorders of the Male Reproductive System
Chapter 56 Caring for Clients With Sexually Transmitted Infections
Chapter 57 Introduction to the Urinary System
Chapter 58 Caring for Clients With Disorders of the Kidneys and Ureters
Chapter 59 Caring for Clients With Disorders of the Bladder and Urethra
Chapter 60 Introduction to the Musculoskeletal System
Chapter 61 Caring for Clients Requiring Orthopedic Treatment
Chapter 62 Caring for Clients With Traumatic Musculoskeletal Injuries
Chapter 63 Caring for Clients With Orthopedic and Connective Tissue Disorders
Chapter 64 Introduction to the Integumentary System
Chapter 65 Caring for Clients With Skin, Hair, and Nail Disorders
Chapter 66 Caring for Clients With Burns
Chapter 67 Interaction of Body and Mind
Chapter 68 Caring for Clients With Anxiety Disorders
Chapter 69 Caring for Clients With Mood Disorders
Chapter 70 Caring for Clients With Eating Disorders
Chapter 71 Caring for Clients With Substance Use Disorders
Chapter 72 Caring for Clients With Dementia and Thought Disorders
, ◦ Timby's introductory medical-surgical nursing 13th edition moreno test bank
chapter 1 concepts and trends in healthcare
◦ A new nurse is working with a preceptor on an inpatient medical-surgical unit.
The preceptor advises the student that which is the priority when working as a
professional nurse?
◦ Attending to holistic client needs
◦ Ensuring client safety
◦ Not making medication errors
◦ Providing
client- focused
care
Answer: b
◦ All actions are appropriate for the professional nurse. However,
ensuring client safety is the priority. Up to 98,000 deaths result each year from errors
in hospital care, according to the 2000 institute of medicine report. Many more clients
have suffered injuries and less serious outcomes. Every nurse has the responsibility to
guard the clients safety.
◦ Dif: understanding/comprehension ref: 2
key: patient safety msc: integrated process: nursing
process: intervention
◦ Not: client needs category: safe and effective care
environment: safety and infection control
◦ A nurse is orienting a new client and family to the inpatient unit. What
information does the nurse provide to help the client promote his or her own
safety?
◦ Encourage the client and family to be active partners.
◦ Have the client monitor hand hygiene in caregivers.
◦ Offer the family the opportunity to stay with the client.
◦ Tell the client to always wear his or
her armband. Answer: a
◦ Each action could be important for the client or family to perform.
However, encouraging the client to be active in his or her health care as a partner is
the most critical. The other actions are
◦
◦ Very limited in scope and do not provide the broad protection that
being active and involved does.
◦ Dif: understanding/comprehension ref: 3
key: patient safety msc: integrated process: teaching/
learning
◦ Not: client needs category: safe and effective care
,Environment: safety and infection control
◦ A nurse is caring for a postoperative client on the surgical unit. The clients blood
pressure was 142/76 mm hg 30 minutes ago, and now is 88/50 mm hg. What
action by the nurse is best?
◦ Call the rapid response team.
◦ Document and continue to monitor.
◦ Notify the primary care provider.
◦ Repeat blood pressure
measurement in 15 minutes.
Answer: a
◦ The purpose of the rapid response team (rrt) is to intervene when clients
are deteriorating before they suffer either respiratory or cardiac arrest. Since the client
has manifested a significant change, the nurse should call the rrt. Changes in blood
pressure, mental status, heart rate, and pain are particularly significant. Documentation
is vital, but the nurse must do more than document. The primary care provider should
be notified, but this is not the priority over calling the rrt. The clients blood pressure
should be reassessed frequently, but the priority is getting the
Rapid care to the client.
◦ Dif: applying/application ref: 3
◦ Key: rapid response team (rrt)|
medical emergencies msc: integrated process:
Communication and documentation
◦ Not: client needs category: physiological integrity: physiological adaptation
◦
◦ A nurse wishes to provide client-centered care in all interactions.
Which action by the nurse best demonstrates this concept?
◦ Assesses for cultural influences affecting health care
◦ Ensures that all the clients basic needs are met
◦ Tells the client and family about all upcoming tests
◦ Thoroughly orients the client
and family to the room
answer: a
◦ Competency in client-focused care is demonstrated when the
nurse focuses on communication, culture, respect, compassion, client
education, and empowerment. By assessing the effect of the
◦
◦ Clients culture on health 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 important safety measure, but not
directly related to demonstrating client-centered care.
◦ Dif: understanding/comprehension ref: 3
, ◦ Key: patient-centered care| culture
msc: integrated process: caring not: client needs
category:
Psychosocial integrity
◦ A client is going to be admitted for a scheduled surgical procedure. Which
action does the nurse explain is the most important thing the client can do
to protect against errors?
◦ Bring a list of all medications and what they are for.
◦ Keep the doctors phone number by the telephone.
◦ Make sure all providers wash hands before entering the room.
◦ Write down the name of each caregiver
who comes in the room. Answer: a
◦ Medication errors are the most common type of health care mistake.
The joint commissions speak up campaign encourages clients to help ensure their
safety. One recommendation is for clients to know all their medications and why
they take them. This will help prevent medication errors.
◦ Dif: applying/application ref: 4
◦ Key: speak up campaign| patient safety msc: integrated
process: teaching/learning not: client needs category: safe and effective care
environment: safety and infection control
◦ Which action by the nurse working with a client best demonstrates
respect for autonomy?
◦ Asks if the client has questions before signing a consent
◦ Gives the client accurate information when questioned
◦ Keeps the promises made to the client and family
◦ Treats the client fairly
compared to other
clients answer: a
◦ Autonomy is self-determination. The client should 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/application ref: 4
◦ Key: autonomy| ethical principles msc: integrated process: caring
◦ Not: client needs category: safe and effective care environment: management of
care
, ◦
◦ A student nurse asks the faculty to explain best practices when communicating
with a person from the lesbian, gay, bisexual, transgender, and queer/
questioning (lgbtq) community. What answer by the faculty is most accurate?
◦ Avoid embarrassing the client by asking questions.
◦ Dont make assumptions about their health needs.
◦ Most lgbtq people do not want to share information.
◦ No differences exist in communicating
with this population. Answer: b
◦ Many members of the lgbtq community have faced discrimination
from health care providers and may be reluctant to seek health care. The nurse should
never make assumptions about the needs of members of this population. Rather,
respectful questions are appropriate. If approached with sensitivity, the client with
any health care need is more likely to answer honestly.
◦ Dif: understanding/comprehension ref: 4
key: lgbtq| diversity msc: integrated process:
teaching/learning
◦ Not: client needs category: psychosocial integrity
◦
◦ A nurse is calling the on-call physician about a client who had a hysterectomy
2 days ago and has pain that is unrelieved by the prescribed narcotic pain
medication. Which statement is part 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.
◦ R: dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
◦ S: this client had a vaginal
hysterectomy 2 days ago.
Answer: b
◦ Sbar is a recommended form of communication, and the acronym
stands for situation, background, assessment, and recommendation. Appropriate
background information includes allergies to medications the on-call physician might
order. Situation describes what is happening right now that must be communicated;
the clients surgery 2 days ago would be considered background. Assessment would
include an analysis of the clients problem; asking for a different pain medication is a
recommendation. Recommendation is a statement of what is needed or what
◦
◦ Outcome is desired; this information about the surgeons
preference might be better placed in background.
◦ Dif: applying/
application ref: 5 key: sbar|
communication
, ◦ msc: integrated process: communication and documentation
◦ Not: client needs category: safe and effective care environment: management
Of
care ◦
◦ A nurse working on a cardiac unit delegated taking vital signs to an
experienced unlicensed assistive personnel (uap). Four hours later, the nurse
notes the clients blood pressure is much higher than previous readings, and
the clients mental status has changed. What action by the nurse would most
likely have prevented this negative outcome?
◦ Determining if the uap knew how to take blood pressure
◦ Double-checking the uap by taking another blood pressure
◦ Providing more appropriate supervision of the uap
◦ Taking the blood pressure instead of
delegating the task answer:
C
◦ Supervision is one of the five rights of delegation and includes
directing, evaluating, and following up on delegated tasks. The nurse should either
have asked the uap about the vital signs or instructed the uap to report them right
away. An experienced uap should know how to take vital signs and the nurse should
not have to assess this at this point. Double- checking the work defeats the purpose of
delegation. Vital signs are within the scope of practice for a uap and are
permissible to delegate. The only appropriate answer is that the nurse did not provide
adequate instruction to the uap.
◦ Dif: applying/application ref: 6
◦ Key: supervision| delegation|
unlicensed assistive personnel msc:
Integrated process: communication and
documentation
◦ Not: client needs category: safe and effective care environment: management
Of care
◦
◦ A newly graduated nurse in the hospital states that, since she is so new, she
cannot participate in quality improvement (qi) projects. What response by the
precepting nurse is best?
◦ All staff nurses are required to participate in quality improvement here.
◦ Even being new, you can implement activities designed to improve care.
◦ Its easy to identify what indicators should be used to measure quality.
◦ You should ask to be assigned to the research
and quality committee. Answer: b
◦
◦ The preceptor should try to reassure the nurse that implementing qi
measures is not out of line for a newly licensed nurse. Simply stating that all nurses
are required to participate does not help the nurse understand how that is possible
and
,Is dismissive. Identifying indicators of quality is not an easy, quick process and would not
be the best place to suggest a new nurse to start.
◦ Asking to be assigned to the qi committee does not give the nurse
information about how to implement qi in daily practice.
◦ Dif: applying/
application ref: 6 key:
Quality improvement
◦ Msc: integrated process: communication and documentation
◦ Not: client needs category: safe and effective care environment: management
Of care
◦
◦ A nurse is talking with a client who is moving to a new state and needs to find
a new doctor and hospital there. What advice by the nurse is best?
◦ Ask the hospitals there about standard nurse-client ratios.
◦ Choose the hospital that has the newest technology.
◦ Find a hospital that is accredited by the joint commission.
◦ Use a facility affiliated with a medical or
nursing school. Answer: c
◦ Accreditation by the joint commission (tjc) or other accrediting body
gives assurance that the facility has a focus on safety. Nurse-client ratios differ by
unit type and change over time. New technology doesnt necessarily mean the hospital
is safe. Affiliation with a health professions school has several advantages, but safety
is most important.
◦ Dif: understanding/
comprehension ref: 2 key: the joint
commission (tjc)| accreditation
◦ Msc: integrated process: communication and documentation
◦ Not: client needs category: safe and effective care
environment: safety and infection control
◦ Multiple response
◦
◦ A nurse manager wishes to ensure that the nurses on the unit are
practicing at their highest levels of competency. Which areas should
the manager assess to determine if the nursing staff demonstrate
competency according to the institute of medicine (iom) report health
professions education: a bridge to quality? (select all that apply.)
◦ Collaborating with an interdisciplinary team
◦
◦ Implementing evidence-based care
◦ Providing family-focused care
, ◦ Routinely using informatics in practice
◦ Using quality improvement
in client care answer:
A, b, d, e
◦ The iom report lists five broad core competencies that all health care
providers should practice. These include collaborating with the interdisciplinary
team, implementing evidence-based practice, providing client- focused care, using
informatics in client care, and using quality improvement in client care.
◦ Dif: remembering/knowledge ref: 3
◦ Key: competencies| institute of
medicine (iom) msc: integrated process:
Nursing process: assessment
◦ Not: client needs category: safe and effective care
environment: safety and infection control
◦ A nurse is interested in making interdisciplinary work a high
priority. Which actions by the nurse best demonstrate this skill?
(select all that apply.)
◦ Consults with other disciplines on client care
◦ Coordinates discharge planning for home safety
◦ Participates in comprehensive client rounding
◦ Routinely asks other disciplines about client progress
◦ Shows the nursing care plans to
other disciplines answer:
A, b, c, d
◦ Collaborating with the interdisciplinary team involves planning,
implementing, and evaluating client care as a team with all other disciplines
included. Simply showing other caregivers the nursing care plan is not actively
involving them or collaborating with them.
◦ Dif: applying/application ref: 4
◦ Key: collaboration| interdisciplinary team
◦ Msc: integrated process: communication and documentation
◦ Not: client needs category: safe and effective care environment: management
Of care
◦
◦ The nurse utilizing evidence-based practice (ebp) considers
which factors when planning care? (select all that apply.)
◦ Cost-saving measures
◦ Nurses expertise
◦
◦ Client preferences
TIMBY'S INTRODUCTORY MEDICAL-SURGICAL NURSING 13TH
EDITION BY LORETTA A. DONNELLY-MORENO, BRIGITTE
MOSELEY
PRINTED PDF | ORIGINAL DIRECTLY FROM THE PUBLISHER | 100%
VERIFIED ANSWERS | DOWNLOAD IMMEDIATELY AFTER THE ORDER
Complete Test bank, All Chapters are included.
For more Test banks, ATI, HESI exams, and more contact us.
, Stuvia.com - TThheeMarketplace tooB u y aannddSell yyoouur Study Material
Table of Contents
Chapter 01 Concepts and Trends in Health Care 1
Chapter 02 Settings and Models for Nursing Care 13
Chapter 03 The Nursing Process 25
Chapter 04 Interviewing and Physical Assessment 35
Chapter 05 Legal and Ethical Issues 46
Chapter 06 Leadership Roles and Management Functions 58
Chapter 07 Nurse–Client Relationships 68
Chapter 08 Cultural Care Considerations 80
Chapter 09 Integrative Medicine and Alternative Therapies 87
Chapter 10 End-of-Life Care 97
Chapter 11 Pain Management 108
Chapter 12 Infection 120
Chapter 13 Intravenous Therapy 132
Chapter 14 Perioperative Care 142
Chapter 15 Disaster Situations 153
Chapter 16 Caring for Clients With Fluid, Electrolyte, and Acid– Base Imbalances 161
Chapter 17 Caring for Clients in Shock 172
Chapter 18 Caring for Clients With Cancer 183
Chapter 19 Introduction to the Respiratory System 192
Chapter 20 Caring for Clients With Upper Respiratory Disorders 204
Chapter 21 Caring for Clients With Lower Respiratory Disorders 216
Chapter 22 Introduction to the Cardiovascular System 226
Chapter 23 Caring for Clients With Infectious and Inflammatory Disorders of the Heart
and Blood Vessels 234
Chapter 24 Caring for Clients With Valvular Disorders of the Heart 244
Chapter 25 Caring for Clients With Disorders of Coronary and Peripheral Blood Vessels 254
Chapter 26 Caring for Clients With Cardiac Arrhythmias 265
Chapter 27 Caring for Clients With Hypertension 275
Chapter 28 Caring for Clients With Heart Failure 286
Chapter 29 Caring for Clients Undergoing Cardiovascular Surgery 297
Chapter 30 Introduction to the Hematopoietic and Lymphatic Systems 308
Chapter 31 Caring for Clients With Disorders of the Hematopoietic System 318
Chapter 32 Caring for Clients With Disorders of the Lymphatic System 328
Chapter 33 Introduction to the Immune System 341
Chapter 34 Caring for Clients With Immune-Mediated Disorders 351
Chapter 35 Caring for Clients With HIV AIDS 362
Chapter 36 Introduction to the Nervous System 374
Chapter 37 Caring for Clients With Central and Peripheral Nervous System Disorders 384
Chapter 38 Caring for Clients With Cerebrovascular Disorders 393
Chapter 39 Caring for Clients With Head and Spinal Cord Trauma 402
Chapter 40 Caring for Clients With Neurologic Deficits 413
Downloaded by: AlmaStudyGuides | Want to earn $1.236
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,Chapter 41 Introduction to the Sensory System
Chapter 42 Caring for Clients With Eye Disorders
Chapter 43 Caring for Clients With Ear Disorders
Chapter 44 Introduction to the Gastrointestinal System and Accessory Structures
Chapter 45 Caring for Clients With Disorders of the Upper Gastrointestinal Tract
Chapter 46 Caring for Clients With Disorders of the Lower Gastrointestinal Tract
Chapter 47 Caring for Clients With Disorders of the Liver, Gallbladder, or Pancreas
Chapter 48 Caring for Clients With Ostomies
Chapter 49 Introduction to the Endocrine System
Chapter 50 Caring for Clients With Disorders of the Endocrine System
Chapter 51 Caring for Clients With Diabetes Mellitus
Chapter 52 Introduction to the Female and Male Reproductive Systems
Chapter 53 Caring for Clients With Disorders of the Female Reproductive System
Chapter 54 Caring for Clients With Breast Disorders
Chapter 55 Caring for Clients With Disorders of the Male Reproductive System
Chapter 56 Caring for Clients With Sexually Transmitted Infections
Chapter 57 Introduction to the Urinary System
Chapter 58 Caring for Clients With Disorders of the Kidneys and Ureters
Chapter 59 Caring for Clients With Disorders of the Bladder and Urethra
Chapter 60 Introduction to the Musculoskeletal System
Chapter 61 Caring for Clients Requiring Orthopedic Treatment
Chapter 62 Caring for Clients With Traumatic Musculoskeletal Injuries
Chapter 63 Caring for Clients With Orthopedic and Connective Tissue Disorders
Chapter 64 Introduction to the Integumentary System
Chapter 65 Caring for Clients With Skin, Hair, and Nail Disorders
Chapter 66 Caring for Clients With Burns
Chapter 67 Interaction of Body and Mind
Chapter 68 Caring for Clients With Anxiety Disorders
Chapter 69 Caring for Clients With Mood Disorders
Chapter 70 Caring for Clients With Eating Disorders
Chapter 71 Caring for Clients With Substance Use Disorders
Chapter 72 Caring for Clients With Dementia and Thought Disorders
, ◦ Timby's introductory medical-surgical nursing 13th edition moreno test bank
chapter 1 concepts and trends in healthcare
◦ A new nurse is working with a preceptor on an inpatient medical-surgical unit.
The preceptor advises the student that which is the priority when working as a
professional nurse?
◦ Attending to holistic client needs
◦ Ensuring client safety
◦ Not making medication errors
◦ Providing
client- focused
care
Answer: b
◦ All actions are appropriate for the professional nurse. However,
ensuring client safety is the priority. Up to 98,000 deaths result each year from errors
in hospital care, according to the 2000 institute of medicine report. Many more clients
have suffered injuries and less serious outcomes. Every nurse has the responsibility to
guard the clients safety.
◦ Dif: understanding/comprehension ref: 2
key: patient safety msc: integrated process: nursing
process: intervention
◦ Not: client needs category: safe and effective care
environment: safety and infection control
◦ A nurse is orienting a new client and family to the inpatient unit. What
information does the nurse provide to help the client promote his or her own
safety?
◦ Encourage the client and family to be active partners.
◦ Have the client monitor hand hygiene in caregivers.
◦ Offer the family the opportunity to stay with the client.
◦ Tell the client to always wear his or
her armband. Answer: a
◦ Each action could be important for the client or family to perform.
However, encouraging the client to be active in his or her health care as a partner is
the most critical. The other actions are
◦
◦ Very limited in scope and do not provide the broad protection that
being active and involved does.
◦ Dif: understanding/comprehension ref: 3
key: patient safety msc: integrated process: teaching/
learning
◦ Not: client needs category: safe and effective care
,Environment: safety and infection control
◦ A nurse is caring for a postoperative client on the surgical unit. The clients blood
pressure was 142/76 mm hg 30 minutes ago, and now is 88/50 mm hg. What
action by the nurse is best?
◦ Call the rapid response team.
◦ Document and continue to monitor.
◦ Notify the primary care provider.
◦ Repeat blood pressure
measurement in 15 minutes.
Answer: a
◦ The purpose of the rapid response team (rrt) is to intervene when clients
are deteriorating before they suffer either respiratory or cardiac arrest. Since the client
has manifested a significant change, the nurse should call the rrt. Changes in blood
pressure, mental status, heart rate, and pain are particularly significant. Documentation
is vital, but the nurse must do more than document. The primary care provider should
be notified, but this is not the priority over calling the rrt. The clients blood pressure
should be reassessed frequently, but the priority is getting the
Rapid care to the client.
◦ Dif: applying/application ref: 3
◦ Key: rapid response team (rrt)|
medical emergencies msc: integrated process:
Communication and documentation
◦ Not: client needs category: physiological integrity: physiological adaptation
◦
◦ A nurse wishes to provide client-centered care in all interactions.
Which action by the nurse best demonstrates this concept?
◦ Assesses for cultural influences affecting health care
◦ Ensures that all the clients basic needs are met
◦ Tells the client and family about all upcoming tests
◦ Thoroughly orients the client
and family to the room
answer: a
◦ Competency in client-focused care is demonstrated when the
nurse focuses on communication, culture, respect, compassion, client
education, and empowerment. By assessing the effect of the
◦
◦ Clients culture on health 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 important safety measure, but not
directly related to demonstrating client-centered care.
◦ Dif: understanding/comprehension ref: 3
, ◦ Key: patient-centered care| culture
msc: integrated process: caring not: client needs
category:
Psychosocial integrity
◦ A client is going to be admitted for a scheduled surgical procedure. Which
action does the nurse explain is the most important thing the client can do
to protect against errors?
◦ Bring a list of all medications and what they are for.
◦ Keep the doctors phone number by the telephone.
◦ Make sure all providers wash hands before entering the room.
◦ Write down the name of each caregiver
who comes in the room. Answer: a
◦ Medication errors are the most common type of health care mistake.
The joint commissions speak up campaign encourages clients to help ensure their
safety. One recommendation is for clients to know all their medications and why
they take them. This will help prevent medication errors.
◦ Dif: applying/application ref: 4
◦ Key: speak up campaign| patient safety msc: integrated
process: teaching/learning not: client needs category: safe and effective care
environment: safety and infection control
◦ Which action by the nurse working with a client best demonstrates
respect for autonomy?
◦ Asks if the client has questions before signing a consent
◦ Gives the client accurate information when questioned
◦ Keeps the promises made to the client and family
◦ Treats the client fairly
compared to other
clients answer: a
◦ Autonomy is self-determination. The client should 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/application ref: 4
◦ Key: autonomy| ethical principles msc: integrated process: caring
◦ Not: client needs category: safe and effective care environment: management of
care
, ◦
◦ A student nurse asks the faculty to explain best practices when communicating
with a person from the lesbian, gay, bisexual, transgender, and queer/
questioning (lgbtq) community. What answer by the faculty is most accurate?
◦ Avoid embarrassing the client by asking questions.
◦ Dont make assumptions about their health needs.
◦ Most lgbtq people do not want to share information.
◦ No differences exist in communicating
with this population. Answer: b
◦ Many members of the lgbtq community have faced discrimination
from health care providers and may be reluctant to seek health care. The nurse should
never make assumptions about the needs of members of this population. Rather,
respectful questions are appropriate. If approached with sensitivity, the client with
any health care need is more likely to answer honestly.
◦ Dif: understanding/comprehension ref: 4
key: lgbtq| diversity msc: integrated process:
teaching/learning
◦ Not: client needs category: psychosocial integrity
◦
◦ A nurse is calling the on-call physician about a client who had a hysterectomy
2 days ago and has pain that is unrelieved by the prescribed narcotic pain
medication. Which statement is part 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.
◦ R: dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
◦ S: this client had a vaginal
hysterectomy 2 days ago.
Answer: b
◦ Sbar is a recommended form of communication, and the acronym
stands for situation, background, assessment, and recommendation. Appropriate
background information includes allergies to medications the on-call physician might
order. Situation describes what is happening right now that must be communicated;
the clients surgery 2 days ago would be considered background. Assessment would
include an analysis of the clients problem; asking for a different pain medication is a
recommendation. Recommendation is a statement of what is needed or what
◦
◦ Outcome is desired; this information about the surgeons
preference might be better placed in background.
◦ Dif: applying/
application ref: 5 key: sbar|
communication
, ◦ msc: integrated process: communication and documentation
◦ Not: client needs category: safe and effective care environment: management
Of
care ◦
◦ A nurse working on a cardiac unit delegated taking vital signs to an
experienced unlicensed assistive personnel (uap). Four hours later, the nurse
notes the clients blood pressure is much higher than previous readings, and
the clients mental status has changed. What action by the nurse would most
likely have prevented this negative outcome?
◦ Determining if the uap knew how to take blood pressure
◦ Double-checking the uap by taking another blood pressure
◦ Providing more appropriate supervision of the uap
◦ Taking the blood pressure instead of
delegating the task answer:
C
◦ Supervision is one of the five rights of delegation and includes
directing, evaluating, and following up on delegated tasks. The nurse should either
have asked the uap about the vital signs or instructed the uap to report them right
away. An experienced uap should know how to take vital signs and the nurse should
not have to assess this at this point. Double- checking the work defeats the purpose of
delegation. Vital signs are within the scope of practice for a uap and are
permissible to delegate. The only appropriate answer is that the nurse did not provide
adequate instruction to the uap.
◦ Dif: applying/application ref: 6
◦ Key: supervision| delegation|
unlicensed assistive personnel msc:
Integrated process: communication and
documentation
◦ Not: client needs category: safe and effective care environment: management
Of care
◦
◦ A newly graduated nurse in the hospital states that, since she is so new, she
cannot participate in quality improvement (qi) projects. What response by the
precepting nurse is best?
◦ All staff nurses are required to participate in quality improvement here.
◦ Even being new, you can implement activities designed to improve care.
◦ Its easy to identify what indicators should be used to measure quality.
◦ You should ask to be assigned to the research
and quality committee. Answer: b
◦
◦ The preceptor should try to reassure the nurse that implementing qi
measures is not out of line for a newly licensed nurse. Simply stating that all nurses
are required to participate does not help the nurse understand how that is possible
and
,Is dismissive. Identifying indicators of quality is not an easy, quick process and would not
be the best place to suggest a new nurse to start.
◦ Asking to be assigned to the qi committee does not give the nurse
information about how to implement qi in daily practice.
◦ Dif: applying/
application ref: 6 key:
Quality improvement
◦ Msc: integrated process: communication and documentation
◦ Not: client needs category: safe and effective care environment: management
Of care
◦
◦ A nurse is talking with a client who is moving to a new state and needs to find
a new doctor and hospital there. What advice by the nurse is best?
◦ Ask the hospitals there about standard nurse-client ratios.
◦ Choose the hospital that has the newest technology.
◦ Find a hospital that is accredited by the joint commission.
◦ Use a facility affiliated with a medical or
nursing school. Answer: c
◦ Accreditation by the joint commission (tjc) or other accrediting body
gives assurance that the facility has a focus on safety. Nurse-client ratios differ by
unit type and change over time. New technology doesnt necessarily mean the hospital
is safe. Affiliation with a health professions school has several advantages, but safety
is most important.
◦ Dif: understanding/
comprehension ref: 2 key: the joint
commission (tjc)| accreditation
◦ Msc: integrated process: communication and documentation
◦ Not: client needs category: safe and effective care
environment: safety and infection control
◦ Multiple response
◦
◦ A nurse manager wishes to ensure that the nurses on the unit are
practicing at their highest levels of competency. Which areas should
the manager assess to determine if the nursing staff demonstrate
competency according to the institute of medicine (iom) report health
professions education: a bridge to quality? (select all that apply.)
◦ Collaborating with an interdisciplinary team
◦
◦ Implementing evidence-based care
◦ Providing family-focused care
, ◦ Routinely using informatics in practice
◦ Using quality improvement
in client care answer:
A, b, d, e
◦ The iom report lists five broad core competencies that all health care
providers should practice. These include collaborating with the interdisciplinary
team, implementing evidence-based practice, providing client- focused care, using
informatics in client care, and using quality improvement in client care.
◦ Dif: remembering/knowledge ref: 3
◦ Key: competencies| institute of
medicine (iom) msc: integrated process:
Nursing process: assessment
◦ Not: client needs category: safe and effective care
environment: safety and infection control
◦ A nurse is interested in making interdisciplinary work a high
priority. Which actions by the nurse best demonstrate this skill?
(select all that apply.)
◦ Consults with other disciplines on client care
◦ Coordinates discharge planning for home safety
◦ Participates in comprehensive client rounding
◦ Routinely asks other disciplines about client progress
◦ Shows the nursing care plans to
other disciplines answer:
A, b, c, d
◦ Collaborating with the interdisciplinary team involves planning,
implementing, and evaluating client care as a team with all other disciplines
included. Simply showing other caregivers the nursing care plan is not actively
involving them or collaborating with them.
◦ Dif: applying/application ref: 4
◦ Key: collaboration| interdisciplinary team
◦ Msc: integrated process: communication and documentation
◦ Not: client needs category: safe and effective care environment: management
Of care
◦
◦ The nurse utilizing evidence-based practice (ebp) considers
which factors when planning care? (select all that apply.)
◦ Cost-saving measures
◦ Nurses expertise
◦
◦ Client preferences
