lOMoARcPSD| 240 zx 0
zx
59 64
Test Bank For Medical Surgical Nursing
10th Edition Ignatavicius Workman
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE zx
1. A new nurse is working with a preceptor on a medical-
zx zx zx zx zx zx zx zx zx zx
surgical unit. The preceptor advises the new nurse that which is the priority when working
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
as a professional nurse?
zx zx zx
a. Attending to holistic client needs zx zx zx zx
b. Ensuring client safety zx zx
c. Not making medication errors zx zx zx
d. Providing client-focused care zx zx
ANS: B zx
All actions are appropriate for the professional nurse. However, ensuring client safety is th
zx zx zx zx zx zx zx zx zx zx zx zx zx
e priority. Health care errors have been widely reported for 25 years, many of which resul
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
t in client injury, death, and increased health care costs. There are several national and int
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ernational organizations that have either recommended or mandated safety initiatives.
zx zx zx zx zx zx zx zx zx
Every nurse has the responsibility to guard the client9s safety. The other actions are importa
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
nt for quality nursing, but they are not as vital as providing safety. Not making medication e
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
rrors does provide safety, but is too narrow in scope to be the best answer.
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
DIF: Understanding
TOP: Integrated Process: Nursing Process: Intervention KEY: Client safety
zx zx zx zx zx zx zx zx
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
z x zx zx zx zx zx zx zx zx zx zx zx
2. A nurse is orienting a new client and family to the medical-
zx zx zx zx zx zx zx zx zx zx zx
surgical unit. What information does the nurse provide to best help the client promote hi
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
s or her own safety?
zx zx zx zx
a. Encourage the client and family to be active partners. zx zx zx zx zx zx zx zx
b. Have the client monitor hand hygiene in caregivers.
zx zx zx zx zx zx zx
c. Offer the family the opportunity to stay with the client.
zx zx zx zx zx zx zx zx zx
d. Tell the client to always wear his or her armband.
zx zx zx zx zx zx zx zx zx
ANS: A zx
Each action could be important for the client or family to perform. However, encouraging th
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
e client to be active in his or her health care as a safety partner is the most critical. The oth
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
er actions are very limited in scope and do not provide the broad protection that being active
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z
and involved does.
x zx zx
DIF: Understanding
TOP: Integrated Process: Teaching/Learning KEY: Client safety
zx zx zx zx zx zx
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
z x zx zx zx zx zx zx zx zx zx zx zx
3. A nurse is caring for a postoperative client on the surgical unit. The client9s blood pressu
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
re was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
nurse take first? zx zx
a. Call the Rapid Response Team. zx zx zx zx
b. Document and continue to monitor. zx zx zx zx
c. Notify the primary health care provider. zx zx zx zx zx
d. Repeat the blood pressure in 15 minutes. zx zx zx zx zx zx
, lOMoARcPSD| 240 zx 0
zx
59 64
ANS: A zx
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deterioratin
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
g before they suffer either respiratory or cardiac arrest. Since the client has manifested a si
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
gnificant change, the nurse would call the RRT. Changes in blood pressure, mental status,
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
heart rate, temperature, oxygen saturation, and last 2 hours9 urine output are particularly si
zx zx zx zx zx zx zx zx zx zx zx zx zx
gnificant and are part of the Modified Early Warning System guide. Documentation is vital,
zx zx zx zx zx zx zx zx zx zx zx zx zx
but the nurse must do more than document. The primary health care provider would be not
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ified, but this is not more important than calling the RRT. The client9s blood pressure woul
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
d be reassessed frequently, but the priority is getting the rapid care to the client.
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
DIF: Applying
TOP: Integrated Process: Communication and Documentation KEY: Rapid
zx zx zx zx zx zx zx zx
Response Team (RRT), Clinical judgment zx zx zx zx
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
zx zx zx zx zx zx zx
4. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
best demonstrates this concept?
zx zx zx
a. Assesses for cultural influences affecting health care. zx zx zx zx zx zx
b. Ensures that all the client9s basic needs are met. zx zx zx zx zx zx zx zx
c. Tells the client and family about all upcoming tests.
zx zx zx zx zx zx zx zx
d. Thoroughly orients the client and family to the room. zx zx zx zx zx zx zx zx
ANS: A zx
Showing respect for the client and family9s preferences and needs is essential to ensure a h
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
olistic or <whole- zx zx
person= approach to care. By assessing the effect of the client9s culture on health care, this n
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
urse is practicing client-
zx zx zx
focused care. Providing for basic needs does not demonstrate this competence. Simply telli
zx zx zx zx zx zx zx zx zx zx zx zx
ng the client about all upcoming tests is not providing empowering education. Orienting the
zx zx zx zx zx zx zx zx zx zx zx zx zx z
client and family to the room is an important safety measure, but not directly related to dem
x zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
onstrating client-centered care. zx zx
DIF: Understanding
TOP: Integrated Process: Culture and Spirituality KEY: Client-centered care, Culture
zx zx zx zx zx zx z x zx zx
MSC: Client Needs Category: Psychosocial Integrity
zx zx zx zx zx
5. A client is going to be admitted for a scheduled surgical procedure. Which action does t
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
he nurse explain is the most important thing the client can do to protect against errors?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
a. Bring a list of all medications and what they are for.
zx zx zx zx zx zx zx zx zx zx
b. Keep the provider9s phone number by the telephone.
zx zx zx zx zx zx zx
c. Make sure that all providers wash hands before entering the room.
zx zx zx zx zx zx zx zx zx zx
d. Write down the name of each caregiver who comes in the room.
zx zx zx zx zx zx zx zx zx zx zx
ANS: A zx
Medication reconciliation is a formal process in which the client9s actual current medications
zx zx zx zx zx zx zx zx zx zx zx zx z
are compared to the prescribed medications at the time of admission, transfer, or discharge.
x zx zx zx zx zx zx zx zx zx zx zx zx zx
This National client Safety Goal is important to reduce medication errors. The client woul
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
d not have to be responsible for providers washing their hands, and even if the client does s
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
o, this is too narrow to be the most important action to prevent errors. Keeping the provider
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
9s phone number nearby and documenting everyone who enters the room also do not guara
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ntee safety. zx
DIF: Applying
TOP: Integrated Process: Teaching/Learning KEY: Client
zx zx zx zx zx zx
safety, Informatics zx
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
z x zx zx zx zx zx zx zx zx zx zx zx
, lOMoARcPSD| 240 zx 0
zx
59 64
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
zx zx zx zx zx zx zx zx zx zx zx zx zx
a. Asks if the client has questions before signing a consent.
zx zx zx zx zx zx zx zx zx
b. Gives the client accurate information when questioned.
zx zx zx zx zx zx
c. Keeps the promises made to the client and family.
zx zx zx zx zx zx zx zx
d. Treats the client fairly compared to other clients.
zx zx zx zx zx zx zx
ANS: A zx
Autonomy is self- zx zx
determination. The client would make decisions regarding care. When the nurse obtains a sig
zx zx zx zx zx zx zx zx zx zx zx zx zx
nature on the consent form, assessing if the client still has questions is vital, because without
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
full information the client cannot practice autonomy. Giving accurate information is practicin
zx zx zx zx zx zx zx zx zx zx zx
g with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providin
zx zx zx zx zx zx zx zx zx zx zx zx zx
g social justice.
zx zx
DIF: Applying TOP: Integrated Process: Caring z x zx zx
KEY: Ethics, Autonomy MSC: Client Needs Category: Safe and Effective Care E
zx zx zx z x zx zx zx zx zx zx zx
nvironment: Management of Care zx zx zx
7. A nurse asks a more seasoned colleague to explain best practices when communicating with
zx zx zx zx zx zx zx zx zx zx zx zx zx z
a person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) com
x zx zx zx zx zx zx zx zx zx zx zx
munity. What answer by the faculty is most accurate?
zx zx zx zx zx zx zx zx
a. Avoid embarrassing the client by asking questions.
zx zx zx zx zx zx
b. Don9t make assumptions about his or her health needs.
zx zx zx zx zx zx zx zx
c. Most LGBTQ people do not want to share information.
zx zx zx zx zx zx zx zx
d. No differences exist in communicating with this population.
zx zx zx zx zx zx zx
ANS: B zx
Many members of the LGBTQ community have faced discrimination from health care provi
zx zx zx zx zx zx zx zx zx zx zx zx
ders and may be reluctant to seek health care. The nurse would never make assumptions abo
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ut the needs of members of this population. Rather, respectful questions are appropriate. If ap
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
proached with sensitivity, the client with any health care need is more likely to answer hones
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
tly.
DIF: Understanding TOP: Integrated Process: Teaching/Learning
zx zx zx
KEY: Health care disparities, LGBTQ
z x zx zx zx MSC: Client Needs Category: Psychosocial Integrity
zx zx zx zx zx
8. A nurse is calling the on-
zx zx zx zx zx
call health care provider about a client who had a hysterectomy 2 days ago and has pain
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
that is unrelieved by the prescribed opioid pain medication. Which statement comprises
zx zx zx zx zx zx zx zx zx zx zx zx
the background portion of the SBAR format for communication?
zx zx zx zx zx zx zx zx
a. <I would like you to order a different pain medication.=
zx zx zx zx zx zx zx zx zx
b. <This client has allergies to morphine and codeine.=
zx zx zx zx zx zx zx
c. <Dr. Smith doesn9t like nonsteroidal anti-inflammatory meds.=
zx zx zx zx zx zx
d. <This client had a vaginal hysterectomy 2 days ago.=
zx zx zx zx zx zx zx zx
ANS: B zx
, lOMoARcPSD| 240 zx 0
59 zx 64
SBAR is a recommended form of communication, and the acronym stands for Situation, Ba
zx zx zx zx zx zx zx zx zx zx zx zx zx
ckground, Assessment, and Recommendation. Appropriate background information includes
zx zx zx zx zx zx zx zx
allergies to medications the on- zx zx zx zx
call health care provider might order. Situation describes what is happening right now that m
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ust be communicated; the client9s surgery 2 days ago would be considered background. Asse
zx zx zx zx zx zx zx zx zx zx zx zx zx
ssment would include an analysis of the client9s problem; none of the options has assessme
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
nt information. Asking for a different pain medication is a recommendation. Recommendati
zx zx zx zx zx zx zx zx zx zx zx
on is a statement of what is needed or what outcome is desired.
zx zx zx zx zx zx zx zx zx zx zx zx
DIF: Applying
TOP: Integrated Process: Communication and Documentation KEY: Team
zx zx zx zx zx zx zx
work and collaboration, SBAR
zx zx zx
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
z x zx zx zx zx zx zx zx zx zx zx
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive p
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ersonnel (AP). Four hours later, the nurse notes that the client9s blood pressure taken by th
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
e AP was much higher than previous readings, and the client9s mental status has changed. W
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
hat action by the nurse would most likely have prevented this negative outcome?
zx zx zx zx zx zx zx zx zx zx zx zx
a. Determining if the AP knew how to take blood pressure zx zx zx zx zx zx zx zx zx
b. Double-checking the AP by taking another blood pressure zx zx zx zx zx zx zx
c. Providing more appropriate supervision of the AP zx zx zx zx zx zx
d. Taking the blood pressure instead of delegating the task zx zx zx zx zx zx zx zx
ANS: C zx
Supervision is one of the five rights of delegation and includes directing, evaluating, and fo
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
llowing up on delegated tasks. The nurse would either have asked the AP about the vital si
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
gns or instructed the AP to report them right away. An experienced AP would know how to
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
take vital signs and the nurse would not have to assess this at this point. Double-
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
checking the work defeats the purpose of delegation. Vital signs are within the scope of pra
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ctice for a AP and are permissible to delegate. The only appropriate answer is that the nurse
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z
xdid not provide adequate instruction to the AP.
zx zx zx zx zx zx zx
DIF: Analyzing
TOP: Integrated Process: Communication and Documentation KEY: Team
zx zx zx zx zx zx zx
work and collaboration, Delegation
zx zx zx
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
z x zx zx zx zx zx zx zx zx zx zx
10. A newly graduated nurse in the hospital states that because of being so new, participation i
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
n quality improvement (QI) projects is not wise. What response by the precepting nurse is b
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
est?
a. <All staff nurses are required to participate in quality improvement here.=
zx zx zx zx zx zx zx zx zx zx
b. <Even being new, you can implement activities designed to improve care.=
zx zx zx zx zx zx zx zx zx zx
c. <It9s easy to identify what indicators would be used to measure quality.=
zx zx zx zx zx zx zx zx zx zx zx
d. <You should ask to be assigned to the research and quality committee.=
zx zx zx zx zx zx zx zx zx zx zx
ANS: B zx
The preceptor would try to reassure the nurse that implementing QI measures is not out of li
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ne for a newly licensed nurse. Simply stating that all nurses are required to participate does
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z
not help the nurse understand how that is possible and is dismissive. Identifying indicators
x zx zx zx zx zx zx zx zx zx zx zx zx zx zx
of quality is not an easy, quick process and would not be the best place to suggest a new nu
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
rse to start. Asking to be assigned to the QI committee does not give the nurse information
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
about how to implement QI in daily practice.
zx zx zx zx zx zx zx
DIF: Applying TOP: Integrated Process: Communication and Documentation
zx zx zx zx zx
zx
59 64
Test Bank For Medical Surgical Nursing
10th Edition Ignatavicius Workman
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE zx
1. A new nurse is working with a preceptor on a medical-
zx zx zx zx zx zx zx zx zx zx
surgical unit. The preceptor advises the new nurse that which is the priority when working
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
as a professional nurse?
zx zx zx
a. Attending to holistic client needs zx zx zx zx
b. Ensuring client safety zx zx
c. Not making medication errors zx zx zx
d. Providing client-focused care zx zx
ANS: B zx
All actions are appropriate for the professional nurse. However, ensuring client safety is th
zx zx zx zx zx zx zx zx zx zx zx zx zx
e priority. Health care errors have been widely reported for 25 years, many of which resul
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
t in client injury, death, and increased health care costs. There are several national and int
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ernational organizations that have either recommended or mandated safety initiatives.
zx zx zx zx zx zx zx zx zx
Every nurse has the responsibility to guard the client9s safety. The other actions are importa
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
nt for quality nursing, but they are not as vital as providing safety. Not making medication e
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
rrors does provide safety, but is too narrow in scope to be the best answer.
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
DIF: Understanding
TOP: Integrated Process: Nursing Process: Intervention KEY: Client safety
zx zx zx zx zx zx zx zx
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
z x zx zx zx zx zx zx zx zx zx zx zx
2. A nurse is orienting a new client and family to the medical-
zx zx zx zx zx zx zx zx zx zx zx
surgical unit. What information does the nurse provide to best help the client promote hi
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
s or her own safety?
zx zx zx zx
a. Encourage the client and family to be active partners. zx zx zx zx zx zx zx zx
b. Have the client monitor hand hygiene in caregivers.
zx zx zx zx zx zx zx
c. Offer the family the opportunity to stay with the client.
zx zx zx zx zx zx zx zx zx
d. Tell the client to always wear his or her armband.
zx zx zx zx zx zx zx zx zx
ANS: A zx
Each action could be important for the client or family to perform. However, encouraging th
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
e client to be active in his or her health care as a safety partner is the most critical. The oth
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
er actions are very limited in scope and do not provide the broad protection that being active
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z
and involved does.
x zx zx
DIF: Understanding
TOP: Integrated Process: Teaching/Learning KEY: Client safety
zx zx zx zx zx zx
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
z x zx zx zx zx zx zx zx zx zx zx zx
3. A nurse is caring for a postoperative client on the surgical unit. The client9s blood pressu
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
re was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
nurse take first? zx zx
a. Call the Rapid Response Team. zx zx zx zx
b. Document and continue to monitor. zx zx zx zx
c. Notify the primary health care provider. zx zx zx zx zx
d. Repeat the blood pressure in 15 minutes. zx zx zx zx zx zx
, lOMoARcPSD| 240 zx 0
zx
59 64
ANS: A zx
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deterioratin
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
g before they suffer either respiratory or cardiac arrest. Since the client has manifested a si
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
gnificant change, the nurse would call the RRT. Changes in blood pressure, mental status,
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
heart rate, temperature, oxygen saturation, and last 2 hours9 urine output are particularly si
zx zx zx zx zx zx zx zx zx zx zx zx zx
gnificant and are part of the Modified Early Warning System guide. Documentation is vital,
zx zx zx zx zx zx zx zx zx zx zx zx zx
but the nurse must do more than document. The primary health care provider would be not
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ified, but this is not more important than calling the RRT. The client9s blood pressure woul
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
d be reassessed frequently, but the priority is getting the rapid care to the client.
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
DIF: Applying
TOP: Integrated Process: Communication and Documentation KEY: Rapid
zx zx zx zx zx zx zx zx
Response Team (RRT), Clinical judgment zx zx zx zx
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
zx zx zx zx zx zx zx
4. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
best demonstrates this concept?
zx zx zx
a. Assesses for cultural influences affecting health care. zx zx zx zx zx zx
b. Ensures that all the client9s basic needs are met. zx zx zx zx zx zx zx zx
c. Tells the client and family about all upcoming tests.
zx zx zx zx zx zx zx zx
d. Thoroughly orients the client and family to the room. zx zx zx zx zx zx zx zx
ANS: A zx
Showing respect for the client and family9s preferences and needs is essential to ensure a h
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
olistic or <whole- zx zx
person= approach to care. By assessing the effect of the client9s culture on health care, this n
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
urse is practicing client-
zx zx zx
focused care. Providing for basic needs does not demonstrate this competence. Simply telli
zx zx zx zx zx zx zx zx zx zx zx zx
ng the client about all upcoming tests is not providing empowering education. Orienting the
zx zx zx zx zx zx zx zx zx zx zx zx zx z
client and family to the room is an important safety measure, but not directly related to dem
x zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
onstrating client-centered care. zx zx
DIF: Understanding
TOP: Integrated Process: Culture and Spirituality KEY: Client-centered care, Culture
zx zx zx zx zx zx z x zx zx
MSC: Client Needs Category: Psychosocial Integrity
zx zx zx zx zx
5. A client is going to be admitted for a scheduled surgical procedure. Which action does t
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
he nurse explain is the most important thing the client can do to protect against errors?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
a. Bring a list of all medications and what they are for.
zx zx zx zx zx zx zx zx zx zx
b. Keep the provider9s phone number by the telephone.
zx zx zx zx zx zx zx
c. Make sure that all providers wash hands before entering the room.
zx zx zx zx zx zx zx zx zx zx
d. Write down the name of each caregiver who comes in the room.
zx zx zx zx zx zx zx zx zx zx zx
ANS: A zx
Medication reconciliation is a formal process in which the client9s actual current medications
zx zx zx zx zx zx zx zx zx zx zx zx z
are compared to the prescribed medications at the time of admission, transfer, or discharge.
x zx zx zx zx zx zx zx zx zx zx zx zx zx
This National client Safety Goal is important to reduce medication errors. The client woul
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
d not have to be responsible for providers washing their hands, and even if the client does s
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
o, this is too narrow to be the most important action to prevent errors. Keeping the provider
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
9s phone number nearby and documenting everyone who enters the room also do not guara
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ntee safety. zx
DIF: Applying
TOP: Integrated Process: Teaching/Learning KEY: Client
zx zx zx zx zx zx
safety, Informatics zx
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
z x zx zx zx zx zx zx zx zx zx zx zx
, lOMoARcPSD| 240 zx 0
zx
59 64
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
zx zx zx zx zx zx zx zx zx zx zx zx zx
a. Asks if the client has questions before signing a consent.
zx zx zx zx zx zx zx zx zx
b. Gives the client accurate information when questioned.
zx zx zx zx zx zx
c. Keeps the promises made to the client and family.
zx zx zx zx zx zx zx zx
d. Treats the client fairly compared to other clients.
zx zx zx zx zx zx zx
ANS: A zx
Autonomy is self- zx zx
determination. The client would make decisions regarding care. When the nurse obtains a sig
zx zx zx zx zx zx zx zx zx zx zx zx zx
nature on the consent form, assessing if the client still has questions is vital, because without
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
full information the client cannot practice autonomy. Giving accurate information is practicin
zx zx zx zx zx zx zx zx zx zx zx
g with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providin
zx zx zx zx zx zx zx zx zx zx zx zx zx
g social justice.
zx zx
DIF: Applying TOP: Integrated Process: Caring z x zx zx
KEY: Ethics, Autonomy MSC: Client Needs Category: Safe and Effective Care E
zx zx zx z x zx zx zx zx zx zx zx
nvironment: Management of Care zx zx zx
7. A nurse asks a more seasoned colleague to explain best practices when communicating with
zx zx zx zx zx zx zx zx zx zx zx zx zx z
a person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) com
x zx zx zx zx zx zx zx zx zx zx zx
munity. What answer by the faculty is most accurate?
zx zx zx zx zx zx zx zx
a. Avoid embarrassing the client by asking questions.
zx zx zx zx zx zx
b. Don9t make assumptions about his or her health needs.
zx zx zx zx zx zx zx zx
c. Most LGBTQ people do not want to share information.
zx zx zx zx zx zx zx zx
d. No differences exist in communicating with this population.
zx zx zx zx zx zx zx
ANS: B zx
Many members of the LGBTQ community have faced discrimination from health care provi
zx zx zx zx zx zx zx zx zx zx zx zx
ders and may be reluctant to seek health care. The nurse would never make assumptions abo
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ut the needs of members of this population. Rather, respectful questions are appropriate. If ap
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
proached with sensitivity, the client with any health care need is more likely to answer hones
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
tly.
DIF: Understanding TOP: Integrated Process: Teaching/Learning
zx zx zx
KEY: Health care disparities, LGBTQ
z x zx zx zx MSC: Client Needs Category: Psychosocial Integrity
zx zx zx zx zx
8. A nurse is calling the on-
zx zx zx zx zx
call health care provider about a client who had a hysterectomy 2 days ago and has pain
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
that is unrelieved by the prescribed opioid pain medication. Which statement comprises
zx zx zx zx zx zx zx zx zx zx zx zx
the background portion of the SBAR format for communication?
zx zx zx zx zx zx zx zx
a. <I would like you to order a different pain medication.=
zx zx zx zx zx zx zx zx zx
b. <This client has allergies to morphine and codeine.=
zx zx zx zx zx zx zx
c. <Dr. Smith doesn9t like nonsteroidal anti-inflammatory meds.=
zx zx zx zx zx zx
d. <This client had a vaginal hysterectomy 2 days ago.=
zx zx zx zx zx zx zx zx
ANS: B zx
, lOMoARcPSD| 240 zx 0
59 zx 64
SBAR is a recommended form of communication, and the acronym stands for Situation, Ba
zx zx zx zx zx zx zx zx zx zx zx zx zx
ckground, Assessment, and Recommendation. Appropriate background information includes
zx zx zx zx zx zx zx zx
allergies to medications the on- zx zx zx zx
call health care provider might order. Situation describes what is happening right now that m
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ust be communicated; the client9s surgery 2 days ago would be considered background. Asse
zx zx zx zx zx zx zx zx zx zx zx zx zx
ssment would include an analysis of the client9s problem; none of the options has assessme
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
nt information. Asking for a different pain medication is a recommendation. Recommendati
zx zx zx zx zx zx zx zx zx zx zx
on is a statement of what is needed or what outcome is desired.
zx zx zx zx zx zx zx zx zx zx zx zx
DIF: Applying
TOP: Integrated Process: Communication and Documentation KEY: Team
zx zx zx zx zx zx zx
work and collaboration, SBAR
zx zx zx
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
z x zx zx zx zx zx zx zx zx zx zx
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive p
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ersonnel (AP). Four hours later, the nurse notes that the client9s blood pressure taken by th
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
e AP was much higher than previous readings, and the client9s mental status has changed. W
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
hat action by the nurse would most likely have prevented this negative outcome?
zx zx zx zx zx zx zx zx zx zx zx zx
a. Determining if the AP knew how to take blood pressure zx zx zx zx zx zx zx zx zx
b. Double-checking the AP by taking another blood pressure zx zx zx zx zx zx zx
c. Providing more appropriate supervision of the AP zx zx zx zx zx zx
d. Taking the blood pressure instead of delegating the task zx zx zx zx zx zx zx zx
ANS: C zx
Supervision is one of the five rights of delegation and includes directing, evaluating, and fo
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
llowing up on delegated tasks. The nurse would either have asked the AP about the vital si
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
gns or instructed the AP to report them right away. An experienced AP would know how to
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
take vital signs and the nurse would not have to assess this at this point. Double-
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
checking the work defeats the purpose of delegation. Vital signs are within the scope of pra
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ctice for a AP and are permissible to delegate. The only appropriate answer is that the nurse
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z
xdid not provide adequate instruction to the AP.
zx zx zx zx zx zx zx
DIF: Analyzing
TOP: Integrated Process: Communication and Documentation KEY: Team
zx zx zx zx zx zx zx
work and collaboration, Delegation
zx zx zx
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
z x zx zx zx zx zx zx zx zx zx zx
10. A newly graduated nurse in the hospital states that because of being so new, participation i
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
n quality improvement (QI) projects is not wise. What response by the precepting nurse is b
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
est?
a. <All staff nurses are required to participate in quality improvement here.=
zx zx zx zx zx zx zx zx zx zx
b. <Even being new, you can implement activities designed to improve care.=
zx zx zx zx zx zx zx zx zx zx
c. <It9s easy to identify what indicators would be used to measure quality.=
zx zx zx zx zx zx zx zx zx zx zx
d. <You should ask to be assigned to the research and quality committee.=
zx zx zx zx zx zx zx zx zx zx zx
ANS: B zx
The preceptor would try to reassure the nurse that implementing QI measures is not out of li
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ne for a newly licensed nurse. Simply stating that all nurses are required to participate does
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z
not help the nurse understand how that is possible and is dismissive. Identifying indicators
x zx zx zx zx zx zx zx zx zx zx zx zx zx zx
of quality is not an easy, quick process and would not be the best place to suggest a new nu
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
rse to start. Asking to be assigned to the QI committee does not give the nurse information
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
about how to implement QI in daily practice.
zx zx zx zx zx zx zx
DIF: Applying TOP: Integrated Process: Communication and Documentation
zx zx zx zx zx
