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2026/27 Update
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 - ANSWERS ANS: 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 client's 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.
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 by the nurse is best?
a. Call the Rapid Response Team.
b. Document and continue to monitor.
,c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes. - ANSWERS ANS: 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.
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?
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. - ANSWERS ANS: 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.
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?
, a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care - ANSWERS ANS: 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.
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?
a. Bring a list of all medications and what they are for.
b. Keep the doctors phone number by the telephone.
c. Make sure all providers wash hands before entering the room.
d. Write down the name of each caregiver who comes in the room. - ANSWERS
ANS: 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.
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