,
,
,Chapter 01: Overview of Professional Nursing Concepts for Medical- Surgical
Nursing
MULTIPLE CHOICE
1. 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 clients basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room
CORRECT ANSWER: A
Rationale: 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
2. 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?
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.
CORRECT ANSWER: A
Rationale: 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
3. 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.
CORRECT ANSWER: A
Rationale: 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/Comprehensio
n REF: 3 KEY: Patient safety
MSC: Integrated Process:
Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and
Infection Control
4. 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
CORRECT ANSWER: B
Rationale: 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/Comprehensio
n REF: 2 KEY: Patient safety
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and
Infection Control
,
,Chapter 01: Overview of Professional Nursing Concepts for Medical- Surgical
Nursing
MULTIPLE CHOICE
1. 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 clients basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room
CORRECT ANSWER: A
Rationale: 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
2. 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?
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.
CORRECT ANSWER: A
Rationale: 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
3. 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.
CORRECT ANSWER: A
Rationale: 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/Comprehensio
n REF: 3 KEY: Patient safety
MSC: Integrated Process:
Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and
Infection Control
4. 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
CORRECT ANSWER: B
Rationale: 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/Comprehensio
n REF: 2 KEY: Patient safety
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and
Infection Control
