,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 nursebest
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
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 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: CaringNOT:
Client Needs Category: Psychosocial Integrity
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was
142/76mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse isbest?
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.
ANS: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before
they suffereitherrespiratoryorcardiacarrest. Sincetheclienthasmanifestedasignificantchange,
thenurseshould call the RRT. Changes in blood pressure, mental status, heart rate, and pain are
,particularly significant. Documentation is vital, but the nursemust 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 theclient.
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.
ANS: A
Each action could be important for the client or family to perform. However, encouraging the client to
beactive 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 involveddoes.
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
4. A new nurse is working with a preceptor on an inpatientmedical-surgical unit. The preceptor
advisesthe student that which is the priority when working as a professionalnurse?
a. Attending to holistic client needs
b. Ensuring client safety
, c. Not making medication errors
d. Providing client-focused care
ANS: B
All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up
to98,000 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
5. 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 againsterrors?
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.
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
theirmedications 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
6. 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
MULTIPLE CHOICE
1. A nurse wishes to provide client-centered care in all interactions. Which action by the nursebest
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
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 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: CaringNOT:
Client Needs Category: Psychosocial Integrity
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was
142/76mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse isbest?
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.
ANS: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before
they suffereitherrespiratoryorcardiacarrest. Sincetheclienthasmanifestedasignificantchange,
thenurseshould call the RRT. Changes in blood pressure, mental status, heart rate, and pain are
,particularly significant. Documentation is vital, but the nursemust 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 theclient.
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.
ANS: A
Each action could be important for the client or family to perform. However, encouraging the client to
beactive 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 involveddoes.
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
4. A new nurse is working with a preceptor on an inpatientmedical-surgical unit. The preceptor
advisesthe student that which is the priority when working as a professionalnurse?
a. Attending to holistic client needs
b. Ensuring client safety
, c. Not making medication errors
d. Providing client-focused care
ANS: B
All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up
to98,000 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
5. 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 againsterrors?
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.
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
theirmedications 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
6. 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
