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Introductory Medical-Surgical Nursing 13th
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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 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.
◦ 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. 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.
◦ DIF: Understanding/Comprehension REF: 3 KEY: Patient safety MSC: Integrated
Process: Teaching/ Learning
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◦ 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. 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.
◦ 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 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
◦
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◦ 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. 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.
◦ 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 ANS: 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
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