Test Bank Timby's Introductory Medical-Surgical Nursing 13th Edition MorenoChapter 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 ◦
NOT: Client Needs Category: Safe and Effective CareEnvironment: 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
◦
◦
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 questions is vital, because without full information the client
cannot practice autonomy. Giving accurate information is practicing with veracity.
Keeping promises is upholding fidelity. Treating the
◦
◦
◦
◦
◦
◦
of Care
client fairly is providing social justice.
DIF: Applying/Application REF: 4
KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
NOT: Client Needs Category: Safe and Effective Care Environment:
Management◦
◦ A student nurse asks the faculty to explain best practices when
communicating with a person from the lesbian, gay, bisexual, transgender,
and queer/ questioning (LGBTQ) community. What answer by the faculty is
most accurate?
◦
Avoid embarrassing the client by asking questions.
◦ Dont make assumptions about their health needs.
◦ Most LGBTQ people do not want to share information.
◦ No differences exist in communicating
with this population. ANS: B
◦
Many members of the LGBTQ community have faced
discrimination from health care providers and may be reluctant to seek health
care. The nurse should never make assumptions about the needs of members of
this population. Rather, respectful questions are appropriate. If approached with
sensitivity, the client with any health care need is more likely to answer honestly.
◦
DIF: Understanding/Comprehension
REF: 4 KEY: LGBTQ| diversity MSC: Integrated Process:
Teaching/Learning
◦
NOT: Client Needs Category: Psychosocial Integrity
◦
◦ A nurse is calling the on-call physician about a client who had a
hysterectomy 2 days ago and has pain that is unrelieved by the prescribed
narcotic pain medication. Which statement is part of the SBAR format for
communication?
◦
◦
◦
◦
A: I would like you to order a different pain medication.
B: This client has allergies to morphine and codeine.
R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
S: This client had a vaginal
hysterectomy 2 days ago. ANS:
B
◦
SBAR is a recommended form of communication, and the acronym
stands for Situation, Background, Assessment, and Recommendation.
Appropriate background information includes allergies to medications the on-call
physician might order. Situation describes what is happening right now that must
be communicated; the clients surgery 2 days ago would be considered
background. Assessment would include an analysis of the clients problem; asking
for a different pain medication is a recommendation. Recommendation is a
statement of what is needed or what
◦
◦
outcome is desired; this information about the surgeons
preference might be better placed in background.
◦
DIF:
Applying/ Application REF: 5
KEY: SBAR| communication◦
of Care ◦
◦
◦ A nurse working on a cardiac unit delegated taking vital signs to an
experienced unlicensed assistive personnel (UAP). Four hours later, the
nurse notes the clients blood pressure is much higher than previous
readings, and the clients mental status has changed. What action by the
nurse would most likely have prevented this negative outcome?
Determining if the UAP knew how to take blood pressure
◦
◦ Double-checking the UAP by taking another blood pressure
◦
Providing more appropriate supervision of the UAP
◦
Taking the blood pressure instead
of delegating the task ANS: C
◦
Supervision is one of the five rights of delegation and includes
directing, evaluating, and following up on delegated tasks. The nurse should
either have asked the UAP about the vital signs or instructed the UAP to report
them right away. An experienced UAP should know how to take vital signs and
the nurse should not have to assess this at this point. Double-checking the work
defeats the purpose of delegation. Vital signs are within the scope of practice for a
UAP
and are permissible to delegate. The only appropriate answer is
that the nurse did not provide adequate instruction to the UAP.
◦
DIF: Applying/Application REF: 6
◦
KEY: Supervision| delegation|
unlicensed assistive personnel MSC:
Integrated Process: Communication and
Documentation
◦
NOT: Client Needs Category: Safe and Effective Care Environment:
Management
of Care
◦
◦ A newly graduated nurse in the hospital states that, since she is so new, she
cannot participate in quality improvement (QI) projects. What response
by the precepting nurse is best?
◦
◦
◦
◦
All staff nurses are required to participate in quality improvement here.
Even being new, you can implement activities designed to improve care.
Its easy to identify what indicators should be used to measure quality.
You should ask to be assigned to the research
and quality committee. ANS: B
◦
◦
The preceptor should try to reassure the nurse that implementing
QI measures is not out of line for a newly licensed nurse. Simply stating that all
nurses are required to participate does not help the nurse understand how that is
possible and
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment:
Managementis dismissive. Identifying indicators of quality is not an easy, quick process
and would not be the best place to suggest a new nurse to start.
◦
Asking to be assigned to the QI committee does not give the
nurse information about how to implement QI in daily practice.
◦
DIF:
Applying/ Application REF: 6
KEY:
Quality improvement
◦
MSC: Integrated Process: Communication and Documentation
◦
of Care
◦
◦ A nurse is talking with a client who is moving to a new state and needs to
find a new doctor and hospital there. What advice by the nurse is best?
Ask the hospitals there about standard nurse-client ratios.
◦
◦
Choose the hospital that has the newest technology.
Find a hospital that is accredited by The Joint Commission.
◦ Use a facility affiliated with a medical
or nursing school. ANS: C
◦
Accreditation by The Joint Commission (TJC) or other accrediting
body gives assurance that the facility has a focus on safety. Nurse-client ratios
differ by unit type and change over time. New technology doesnt necessarily
mean the hospital is safe. Affiliation with a health professions school has several
advantages, but safety is most important.
◦
DIF: Understanding/
Comprehension REF: 2 KEY: The
Joint Commission (TJC)|
accreditation
◦
MSC: Integrated Process: Communication and Documentation
◦
NOT: Client Needs Category: Safe and Effective
Care Environment: Safety and Infection Control
◦
MULTIPLE RESPONSE
◦
◦ A nurse manager wishes to ensure that the nurses on the unit are
practicing at their highest levels of competency. Which areas should
the manager assess to determine if the nursing staff demonstrate
competency according to the Institute of Medicine (IOM) report
Health Professions Education: A Bridge to Quality? (Select all that
apply.)
◦
◦
◦
Collaborating with an interdisciplinary team
◦
Implementing evidence-based care
Providing family-focused care
◦
NOT: Client Needs Category: Safe and Effective Care Environment:
Management◦ Routinely using informatics in practice
◦ Using
quality
improvement in client care
ANS: A, B, D, E
◦
The IOM report lists five broad core competencies that all health
care providers should practice. These include collaborating with the
interdisciplinary team, implementing evidence-based practice, providing client-
focused care, using informatics in client care, and using quality improvement in
client care.
◦
◦
DIF: Remembering/Knowledge REF: 3
KEY: Competencies| Institute
of Medicine (IOM) MSC: Integrated
Process:
Nursing Process: Assessment
◦
NOT: Client Needs Category: Safe and Effective
Care Environment: Safety and Infection Control
◦ A nurse is interested in making interdisciplinary work a high
priority. Which actions by the nurse best demonstrate this skill?
(Select all that apply.)
◦
◦
◦
Consults with other disciplines on client care
Coordinates discharge planning for home safety
Participates in comprehensive client rounding
◦ Routinely asks other disciplines about client progress
◦
Shows the nursing care plans to
other disciplines ANS: A, B, C, D
◦
Collaborating with the interdisciplinary team involves planning,
implementing, and evaluating client care as a team with all other disciplines
included. Simply showing other caregivers the nursing care plan is not actively
involving them or collaborating with them.
◦
◦
◦
◦
of Care
◦
◦
The nurse utilizing evidence-based practice (EBP) considers
which factors when planning care? (Select all that apply.)
◦
Cost-saving measures
◦ Nurses expertise
◦
◦
Client preferences
DIF: Applying/Application REF: 4
KEY: Collaboration| interdisciplinary team
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment:
Management◦ Research findings
◦ Value
s of
the
client
ANS:
B, C,
D, E
◦
EBP consists of utilizing current evidence, the clients values and
preferences, and the nurses expertise when planning care. It does not include
cost- saving measures.
◦
DIF:
Remembering/Knowledge REF:
6 KEY: Evidence-based
practice (EBP)
◦
MSC: Integrated Process: Nursing Process: Planning
◦
of Care
◦
◦ A nurse manager wants to improve hand-off communication among
the staff. What actions by the manager would best help achieve this
goal? (Select all that apply.)
◦
◦
◦
Attend hand-off rounds to coach and mentor.
Conduct audits of staff using a new template.
Create a template of topics to include in report.
◦ Encourage staff to ask questions during hand-off.
◦ Give raises based on
compliance with reporting.
ANS: A, B, C, D
◦
NOT: Client Needs Category: Safe and Effective Care Environment:
Management
A good tool for standardizing hand-off reports and other critical
communication is the SHARE model. SHARE stands for standardize critical
information, hardwire within your system, allow opportunities to ask questions,
reinforce quality and measurement, and educate and coach.
◦
Attending hand-off report gives the manager opportunities to
educate and coach. Conducting audits is part of reinforcing quality. Creating a
template is hardwiring within the system.
◦
Encouraging staff to ask questions and think critically about the
information is allowing opportunities to ask questions. The manager may need
to tie raises into compliance if the staff is resistive and other measures have
failed, but this is not part of the SHARE model.
◦
◦
Chapter 2
Care MULTIPLE CHOICE
Settings and Models for Nursing•
The nurse ensures that a clients bedspace is neat and clean
with the call light within easy reach. The nurse is focusing on
which nursing theorist who realized the importance of the
environment for care?
•
•
Florence Nightingale
Sister Callista Roy
• Dorothea Orem
• Martha Rogers
ANS: 1
Florence Nightingales theory focused on the environment for care.
Sister Callista Roys model is based in systems theory and an
individuals ability to adapt. Dorothea Orems model is the self- care
deficit theory. Martha Rogers model is the science of unitary human
beings.
PTS:1DIF:Apply
REF:Emergence of Contemporary Nursing in the United States
•
The nurse is instructing a client on self-administration of
insulin so that the client will not need a health care provider to
do this activity. The nurse is implementing which of the
following aspects of Virginia Hendersons theory of nursing?
• A caring relationship
• Helping the client achieve independence from the nurses assistance as
quickly as possible
•
•
ANS: 2
Integration of objective and subjective data
Application of critical thinkingVirginia Hendersons theory of nursing is to help people achieve
health or a peaceful death so that they can be independent from the
nurses assistance as quickly as possible. A caring relationship,
integration of objective and subjective data, and application of critical
thinking are included in the American Nurses Associations essential
features of professional nursing.
PTS:1DIF:Analyze
REF:Emergence of Contemporary Nursing in the United States
3.A client tells the nurse that he has an HMO for his health insurance.
The nurse understands that the purpose of this type of health plan is to:
•
ensure payment is made to Medicare for services rendered.
• maximize the utilization of health care resources.
•
efficiently manage costs while providing quality care.
•
ANS: 3
Health maintenance organizations (HMOs) were created to efficiently
manage health care costs while providing quality care. An HMO is a
type of managed care plan with the goal of providing wellness care and
not focusing on the illness during the provision of care. HMOs do not
ensure payment is made to Medicare for services rendered. HMOs also
do not maximize the utilization of health care resources but rather
uses financial incentives to decrease care costs.
PTS: 1 DIF: Understand REF: Cost of Care
•
client tells the nurse that he does not have a primary
care physician but rather makes an appointment
with a doctor who specializes in the area in which he
is experiencing a problem. The nurse realizes this
client is at risk for which of the following?
•
Fragmented care
focus on the illness when providing care.• Overpayment of services
•
Inability to sustain health
•
ANS: 1
In the 1980s, the close and trusting relationship between an individual
and the individuals physician waned and was replaced by
acquaintances with specialists based upon particular health care
problems. These episodes of care cause fragmentation of care. The
client who utilizes specialists is not at risk for overpayment of services,
the inability to sustain health, or finding an appropriate general
practitioner.
PTS:1DIF:AnalyzeREFroviders of Care
•
The nurse is attending a masters degree
program in efforts to be educationally
prepared to serve as a hospital leader. The
nurse realizes that this educational
preparation will:
•
•
hinder the nurses ability to work with physicians.
be viewed as not supporting the profession of nursing by
other nurses.
•
ensure the nurse is biased towards clinicians interests.
prepare the nurse to serve as strong clinical support with the ability to integrate
business and
•
ANS: 4
The nurse is attending an educational program to serve as a hospital
leader. This education will prepare the nurse to serve as strong
clinical support with the ability to integrate business and caring. This
education will not hinder the nurses ability to work with physicians.
This education will not be viewed as unsupportive to the profession of
nursing. The
caring.
Finding an appropriate general practitionereducation will ensure that the nurse is not biased towards
clinicians interests.
PTS: 1 DIF: Analyze REF: Clinical Systems Leadership
•
client tells the nurse that all hospitals care about is
doing the minimum for a client regardless of the
outcome. Which of the following should the nurse
respond to this client?
•
It does feel like that sometimes.
• Health insurance companies have caused this problem.
•
The doctors will get paid regardless of the clients outcomes.
There are quality programs in place to make sure clients receive the best
quality of care regardless
•
of the cost.
ANS: 4
In response to concerns about safety and quality of care voiced by
clients and providers, total quality management and continuous
quality improvement programs were initiated. These programs
ensure society that cost management is not compromising safety or
quality. This is what the nurse should respond to the client. The other
choices do not address the clients concerns nor do they explain
quality management programs.
PTS: 1 DIF: Apply REF: Quality Measure Shift
•
The nurse is providing care at a time that is the most
beneficial to the client. The nurse is implementing which of
the following Joint Commission Dimensions of Quality
Performance?
•
•
•
Safety
Timeliness
Efficiency•
ANS: 2
The dimension of timeliness means the degree in which interventions
are provided at the most beneficial time to the client. Safety means the
degree in which the risk of an intervention and risk to the environment
are reduced for both client and health care provider. Efficiency means
the degree in which care has the desired effect with a minimum of
effort, waste, or expense.
Availability means the degree in which appropriate interventions
are available to meet the clients needs.
PTS:1DIF:Analyze
REF:Box 1-1 Joint Commission Dimensions of Quality Performance
•
The nurse is providing care while adhering to safety as a
Joint Commission Dimension of Quality Performance.
Which of the following did the nurse provide to the
client?
• Using a needleless device when providing intravenous medications
•
Availability
Keeping the siderails of the bed in the down position after providing a
pain medication to a client
• Having the client sit in a wheelchair with the wheels in the unlocked position
•
Placing cloth towels over a spill in the room of an ambulatory client
ANS: 1
The dimension of safety means the degree in which the risk of an
intervention and risk to the environment are reduced for both client
and health care provider. The nurse who uses a needleless device when
providing intravenous medications is adhering to this dimension.
Keeping the siderails in the down position is not a safe practice.
Having a client sit in a wheelchair with the wheels unlocked is not a
safe practice. Placing cloth towels over a spill in the room of an
ambulatory client is not a safe practice.
PTS:1DIF:Analyze
REF:Box 1-1 Joint Commission Dimensions of Quality Performance
•
The nurse is planning and providing care while adhering to theAmerican Nurses Association definition of professional
nursing. Which of the following does the nurse include when
implementing client care?
•
•
Follows the NANDA nursing diagnoses process
Integrates objective and subjective data
• Respects cultural diversity of peers
•
Acknowledges the experience and training of physicians
ANS: 2
The American Nurses Association acknowledges six essential features
of professional nursing. These include: 1) a caring relationship, 2)
attention to the full range of human health and illness experiences, 3)
integrates objective and subjective data, 4) applies scientific
knowledge and critical thinking, 5) advances nursing knowledge
through scholarly inquiry, and
6) promotes social justice. The nurse integrating objective and
subjective data is implementing one of the six essential features of
professional nursing. The other choices are not essential features of
professional nursing.
PTS:1DIF:Analyze
•
The nurse has shifted her practice from an illness focus
to a health focus. Which of the following has this nurse
implemented?
•
•
•
Standardized care plans
Critical pathways
Instructing a client on relaxation techniques to aid with sleep
• Holding around-the-clock medication when a client is asleepANS: 3
The use of client education as a strategy to attain and maintain the
potential for health is an example of the shift of care from an illness
focus to a health focus. The nurse instructing a client on relaxation
techniques to aid with sleep is implementing a health focus of care.
The other choices do not support the shift from an illness focus to a
health focus.
PTS: 1 DIF: Analyze REF: Leadership
•
client is admitted with a highly communicable
disease. The nurses do not want to participate in the
care of this client. Which of the following should be
done to ensure the client receives the highest quality
of care?
• Adhere to strict standard precautions.
•
Plan to have the client transferred to another health care organization.
•
•
ANS: 1
When providing care in a highly global environment, the risks of
communicable diseases increases. In the event that a client is
admitted with a highly communicable disease and the nurses are
fearing for their own health and safety, the only safe approach is to
ensure all staff adhere to strict standard precautions. The other
choices do not ensure that the client will receive the highest quality of
care. The nurses must learn emotional intelligence and resolve issues
under fire.
•
The nurse has been an employee of an organization
for 2 years and is considering a job change. Which of
the following does this nurses plan suggest to any
future employers?
•
The nurse moves to other jobs too frequently.
Ask the physician if the client can be cared for in the home.
Suspend the nurses without pay who refuse to care for the client.•
•
The nurse is inflexible.
The nurse is searching for a more challenging environment with
career opportunities.
•
ANS: 3
At one point in time, job changes every 2 or 3 years was considered a
red flag for employers. This does not hold true today. The nurse who
changes jobs every 2 or 3 years is interested in career advancement
and success. Creativity is valued and opportunities are desired.
Moving to another job in 2 to 3 years does not mean the nurse is
inflexible. The new generation of nurses does not want to sacrifice
home and personal life for a job.
PTS: 1 DIF: Analyze REF: Care Delivery Models
•
The nurse is experiencing pain and fatigue in both arms
when using the computer to document client care. Which
of the following can the nurse do to reduce these
symptoms?
• Refuse to use the computer and document using a pen and paper.
•
Stand up when using the computer.
• Adjust the keyboard and chair to reduce the pressure on the wrists and arms.
•
Ask another nurse to input the information for client care activities.
ANS: 3
Ergonomic hazards are increasing with health care providers and
nurses in particular. Many of these hazards are because of the
implementation of computers for documentation. The nurse should
adjust the keyboard and chair to reduce the pressure on the wrists
and arms when documenting with the computer. The nurse cannot
refuse to use the computer. Standing up may not reduce the nurses
symptoms. The nurse cannot legally ask another nurse to document
client care.
The nurse is willing to sacrifice home and personal life for a job.MULTIPLE RESPONSE
•
The nurse is planning care for a client and reviewing
appropriate educational materials to use for discharge
instructions. Which domains of nursing is this nurse
implementing? (Select all that apply.)
• Nursing process
•
Clinical practice
•
•
Education
Literature
• Administration
• Researc
h ANS: 2, 3
The four domains of nursing are: 1) clinical practice, 2) education, 3)
administration, and 4) research. When the nurse plans care for a
client, the domain being implemented is clinical practice. When
reviewing appropriate educational materials to use for discharge
instructions, the domain being implemented is education. The nurse
is not utilizing the domains of research or administration. Nursing
process and literature are not domains of nursing.
PTS:1DIF:Apply
REF:Emergence of Contemporary Nursing in the United States
•
The nurse suspects that another health care colleague
may be chemically dependent when which of the following
is assessed? (Select all that apply.)
•
Prolonged work breaks
•
Clinical care omissions• Mood stability
•
Extraordinary accomplishments
• Heavy use of fragrances
•
Inability to recall recent
events ANS: 1, 2, 4, 5, 6
Clues of possible chemical dependency include tardiness, late sick
calls, frequent or prolonged work breaks, inability to recall recent
events, heavy use of fragrances, clinical care omissions or errors,
patient complaints or requests for a change in care provider, mood
instability, and extraordinary accomplishments. Mood stability is not
a characteristic of a colleague who is experiencing chemical
dependency.
PTS:1DIF:Apply
REF:Box 1-6 Clues to the Possibility of Chemical Dependence
•
The nurse is a member of a health care team that includes a
physician and other health care providers. These providers
work together to ensure the client is relieved of suffering,
has diseases cured, and experiences enhanced health and
performance. Which of the following are the levels of care
represented by this team of health care providers? (Select all
that apply.)
•
Sustain life
• Maintain health
• Regain health
• Minimize injury• Maximize cost
•
Attain enhanced health
ANS: 1, 2, 3, 6
The medical teams mission is to relieve suffering and cure disease.
This involved the three levels of care: 1) sustain life, 2) regain health,
and 3) maintain health. Once the shift toward health care occurred,
the fourth level of attaining enhanced health was added. Minimize
injury and maximize cost is not a level of care.
PTS:1DIF:AnalyzeREFroviders of Care
•
client tells the nurse that she is disappointed that her
employer is offering a health maintenance
organization for a health care benefit. Which of the
following can the nurse use as responses to the client
as advantages of this type of health plan? (Select all
that apply.)
•
•
Since there is a nursing shortage, clients need to stay out of the hospital.
This type of plan provides wellness care at a minimal cost to keep
people healthy.
•
This type of plan helps clients avoid illnesses with high costs.
• An HMO standardizes diagnostic and treatment decisions across
the nation.
•
This type of plan ensures coordinated services from wellness to death.
This type of plan costs as much as the traditional plans, but the insurance
companies get the extra
• money from premiums.
ANS: 2, 3, 4, 5There are several missions and visions of managed care. The first is to
provide wellness care at a minimal cost to keep people healthy and
avoid providing illness care at a higher cost. Another mission is to
standardize diagnostic and treatment decisions across the nation.
Managed care emphasizes the delivery of coordinated services across
the care spectrum from wellness to death and uses financial
incentives to decrease length of stay and achieve cost efficiency.
Managed care was not implemented to address the nursing shortage.
This type of plan does not cost as much as a traditional health plan
nor do the insurance companies receive the extra money from
premiums.
PTS: 1 DIF: Apply REF: Cost of Care
•
The nurse has incorporated several criteria that are
essential for being a member of a profession. Which
of the following has this nurse done? (Select all that
apply.)
• Has passed the licensure examination
• Works regularly scheduled shifts
•
Completed a bachelors degree in nursing
•
•
Limits absences from work
Joined the American Nurses Association
• Reads evidenced-based information to incorporate into planning client
care ANS: 1, 3, 5, 6
There are seven essential criteria for a profession. The nurse has
incorporated four of these criteria by passing the licensure
examination, the nurse has implemented a code of ethics; by
completing a bachelors degree in nursing, the nurse has been
educated in an institution of higher education; by joining the
American Nurses Association and reading evidenced-based
information, the nurse is affiliated with a professional association that
promotes and ensures quality practice. Working regularlyscheduled shifts and limiting absences from work are not
essential criteria for a profession.
◦
◦
•
Chapter 4-Chapter 6
Chapter 5
Interviewing and Physical Assessment
Legal and Ethical Issues Chapter 6
and Management Functions
When a nurse becomes involved in a legal action, the first step
to occur is that a document is filed in an appropriate court.
What is this document called?
Leadership Roles
a.
b.
c.
d.
ANS: C
A document called a complaint is filed in an appropriate court as the first step in litigation. A
deposition is when witnesses are required to undergo questioning by the attorneys. An appeal
is a request for a review of a decision by a higher court. A summons is a court order that
notifies the defendant of the legal action.
PTS: 1 DIF: Cognitive Level: Knowledge REF:
Page 23 OBJ: 1 TOP: Legal KEY: Nursing
Process Step: N/A MSC:NCLEX: N/A
•
Deposition
Appeal
Complaint
Summons
The nurse caring for a patient in the acute care
setting assumes responsibility for a patients care.
What is this legally binding situation?
a.
b.
c.
d.
ANS: A
When the nurse assumes responsibility for a patients care, the nurse-patient
relationship is formed. This is a legally binding contract for which the nurse
must take responsibility.
Accountability is being responsible for ones own actions. An advocate is one who
defends or pleads a cause or issue on behalf of another. Standards of care define
acts whose performance is required, permitted, or prohibited.
Nurse-patient relationship
Accountability
Advocacy
Standard of carePTS: 1 DIF: Cognitive Level: Comprehension
REF: Page 24 OBJ: 3 TOP: Legal KEY: Nursing
Process Step: N/A MSC:NCLEX: N/A
• What are the universal guidelines that define
appropriate measures for all nursing
interventions?
a.
b.
c.
d.
ANS: C
Standards of care define actions that are permitted or prohibited in most nursing
interventions. These standards are accepted as legal guidelines for
appropriateness of performance. The laws that formally define and limit the scope
of nursing practice are called nurse practice acts. An advocate is one who defends
or pleads a cause or issue on behalf of another. Prudent is a term that refers to
careful and/or wise practice.
PTS: 1 DIF: Cognitive Level: Knowledge REF:
Page 25 OBJ: 4 TOP: Legal KEY: Nursing
Process Step: N/A MSC:NCLEX: N/A
• An LPN/LVN is asked by the RN to administer an IV
chemotherapeutic agent to a patient in the acute care
setting. What law should this nurse refer to before
initiating this intervention?
a.
b.
c.
d.
ANS: D
It is the nurses responsibility to know the nurse practice act in his or her state. Standards of
care, regulation of practice, and the American Nurses code are not laws that the nurse should
refer to
before initiating this treatment.
PTS: 1 DIF: Cognitive Level: Application REF:
Page 25 OBJ: 5 TOP: Legal KEY: Nursing
Standards of care
Regulation of practice
American Nurses Association Code
Nurse practice act
Scope of practice
Advocacy
Standard of care
Prudent practiceProcess Step: N/A MSC:NCLEX: N/A
5.A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the
patient. This nurse could be found guilty of:
a.
b.
c.
d.
ANS: A
The nurse can be held liable for malpractice for acts of omission. Failure to
meet a legal duty, thus causing harm to another, is malpractice. The nurse
practice act has general guidelines that can support the charge of malpractice.
PTS: 1 DIF: Cognitive Level: Application REF: Pages
22-23 OBJ: 2 TOP: Legal KEY: Nursing Process
Step:
N/A MSC:NCLEX: N/A
•
malpractice.
harm to the patient.
negligence.
failure to follow the nurse practice act.
Patients have expectations regarding the health care services they
receive. To protect these expectations, which of the following has
become law?
a.
b.
c.
d.
ANS: A
Patients have expectations regarding the health care services they receive. In 1972, the
American Hospital Association (AHA) developed the Patients Bill of Rights. The Self-
determination act, American Hospital Associations Standards of Care, and The Joint
Commissions rights and responsibilities do not address patients expectations regarding health
care.
PTS: 1 DIF: Cognitive Level: Comprehension REF:
Page 26 OBJ: 3 | 4 TOP: Legal KEY: Nursing
Process Step: N/A MSC:NCLEX: N/A
•
American Hospital Associations Patients Bill of Rights
Self-determination act
American Hospital Associations Standards of Care
The Joint Commissions rights and responsibilities of patients
The nurse is preparing the patient for a thoracentesis. What
must be completed before the procedure may be performed?
a.
Physical assessmentb.
c.
d.
ANS: C
The doctrine of informed consent refers to full disclosure of the facts the patient
needs to make an intelligent (informed) decision before any invasive treatment
or procedure is performed. A physical assessment, interview, and surgical
checklist are not required before this procedure.
PTS: 1 DIF: Cognitive Level: Application REF: Pages
26-27 OBJ: 8 TOP: Legal KEY: Nursing Process
Step:
N/A MSC:NCLEX: N/A
• When a nurse protects the information in a patients record what
ethical responsibility is the nurse fulfilling?
a.
b.
c.
d.
ANS: C
The nurse has an ethical and legal duty to protect information about a patient and preserve
confidentiality. Some disclosures are legal and anticipated, and may not be subject to the rules
of confidentiality. None of the information in a chart is considered secret.
PTS: 1 DIF: Cognitive Level: Comprehension REF:
Page 28 OBJ: 9 TOP: Confidentiality KEY: Nursing
Process Step: N/A MSC:NCLEX: N/A
• An older adult is admitted to the hospital with numerous bodily bruises,
and the nurse suspects elder abuse. What is the best nursing action?
a.
b.
c.
d.
ANS: D
The law stipulates that the health care professional is required to report certain
information to the appropriate authorities. The report should be given to a
supervisor
Cover the bruises with bandages.
Take photographs of the bruises.
Ask the patient if anyone has hit her.
Report the bruises to the charge nurse.
Privacy
Disclosure
Confidentiality
Absolute secrecy
Interview
Informed consent
Surgical checklistor directly to the police, according to agency policy. When acting in good faith
to report mandated information (e.g., certain communicable diseases or
gunshot wounds), the health care professional is protected from liability.
PTS: 1 DIF: Cognitive Level: Application REF:
Page 29 OBJ: 9 TOP: Elder abuse KEY: Nursing
Process Step: N/A
MSC:NCLEX: N/A
• What is the best way for a nurse to avoid a lawsuit?
a.
b.
c.
d.
ANS: C
The best defense against a lawsuit is to provide compassionate and competent
nursing care. Carrying malpractice insurance is prudent, but it will not avoid a
lawsuit.
Spending time with patients and answering call lights quickly will not necessarily
help avoid a lawsuit.
PTS: 1 DIF: Cognitive Level: Comprehension REF:
Pages 29-30 OBJ: 8 TOP: Avoiding a lawsuit KEY:
Nursing Process Step: N/A MSC:NCLEX: N/A
•
Carry malpractice insurance
Spend time with the patient
Provide compassionate, competent care
Answer all call lights quickly
The nurse is caring for a patient with a do-not-resuscitate (DNR)
order. Although the nurse may disagree with this order, what is his
or her legal obligation?
a.
b.
c.
d.
ANS: D
When a DNR order is written in the chart, the nurse has a duty to follow the
order. Questioning the doctor, seeking advice from the family, and discussing it
with the patient are not legal obligations of the nurse.
•
Although the patient denies pain, the nurse observes the patient
breathing rapidly with clenched fists and facial grimacing.
What is
To question the doctor
To seek advice from the family
To discuss it with the patient
To follow the orderthe nurses best response to these observations?
a
.
I am glad you are feeling better and have no
discomfort.
b
.
c
.
d
.
Where do you hurt?
What you are saying and what I am
observing dont seem to match.
It makes me uncomfortable when you are
not honest with me.
ANS: C
The nonverbal communication should be clarified to prevent
miscommunication. PTS: 1 DIF: Cognitive Level: Application REF: Pages
59-61 OBJ:2 | 3TOP:Communication
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
•
The nurse considers the feelings and needs of a patient by
stating, I know you are concerned about your surgery tomorrow.
How can I help you? What type of communication is this?
a.
b.
c.
d.
ANS: D
Assertive communication takes a patients feelings and needs into account, yet honors the
patients rights as an individual.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page
61 OBJ:4TOP:Communication
KEY:Nursing Process Step:
Implementation MSC: NCLEX:
Psychosocial Integrity
•
Intrusive
Aggressive
Closed
Assertive
If the nurse aggressively says to a patient, Why couldnt you
have asked me to give you your pain medication when I was in
hereearlier? what feeling is the patient most likely to demonstrate?
a.
b.
c.
d.
ANS: C
Aggressive communication is highly destructive. Although anger may
eventually come, the patient most likely feels humiliated first.
PTS: 1 DIF: Cognitive Level: Application REF: Page 62
OBJ:7TOP:Communication
KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial
Integrity 4.What does therapeutic communication accomplish?
a
.
b
.
c
.
d
.
ANS: A
A positive nurse-patient relationship is facilitated by therapeutic
communication. PTS: 1 DIF: Cognitive Level: Comprehension REF:
Page 62
OBJ: 10 TOP: Communication KEY: Nursing
Process Step: N/A MSC:NCLEX: N/A
•
Facilitates the formation of a
positive nurse-patient relationship
Manipulates the patient
Assigns the patient a passive role
Requires the patient to accept what the
nurse says
Anger
Satisfaction that his needs are met
Humiliation and worthlessness
Confidence that his request will be granted
The nurse is sitting in a chair near the patients bed, leaning forward to
hear what the patient is saying, and does not interrupt. What is the
nurse demonstrating?
a.
b.
Support
Caringc.
d.
ANS: C
When demonstrating active listening, the nurse must give his or her full attention
and make an effort to understand both the verbal and nonverbal message.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page
63 OBJ:5TOP:Communication
KEY:Nursing Process Step:
Implementation MSC: NCLEX:
Psychosocial Integrity
• What therapeutic communication technique requires a great deal of
skill and is not used as frequently as other communication
techniques?
a.
b.
c.
d.
ANS: B
Silence is an extremely effective therapeutic communication skill that is frequently underused
because the nurse feels uncomfortable applying it.
PTS: 1 DIF: Cognitive Level: Comprehension REF:
Page 63 OBJ: 5 TOP: Communication KEY: Nursing
Process Step: N/A MSC:NCLEX: N/A
7.A patient does not speak English; therefore, the nurse cannot use words to
provide comfort during a painful procedure. What is another intervention that
may provide comfort to this
patient?
a.
b.
c.
d.
ANS: C
Holding the hand of a nonEnglish-speaking patient is effective and
comforting. PTS: 1 DIF: Cognitive Level: Application REF: Page 63
Silence
Listening
Touch
Restating
Touch
Silence
Listening
Summarizing
Active listening
InterestOBJ:9TOP:Communication
KEY:Nursing Process Step:
Implementation MSC: NCLEX:
Psychosocial Integrity
8.A patient states, I do cocaine when I feel things are out of my control. The nurse responds by
asking, What else does cocaine do for you? What communication skill does this exemplify?
a.
b.
c.
d.
ANS: C
Acceptance is the willingness to listen and respond to what the patient is saying without
passing judgment.
PTS: 1 DIF: Cognitive Level: Application REF: Page 64-65
OBJ:5TOP:Communication
KEY:Nursing Process Step:
Implementation MSC: NCLEX:
Psychosocial Integrity
9.A patient states, Im really strung out about this pregnancy. The nurse responds by asking,
What about this pregnancy worries you? What communication technique is this?
a.
b.
c.
Closed inquiry
Restating
Open-ended question
d. Minimal encouraging
ANS: C
Open-ended questions convey interest and do not require a
specific response. PTS: 1 DIF: Cognitive Level: Application REF:
Pages 65 OBJ:5TOP:Communication
KEY:Nursing Process Step:
Implementation MSC: NCLEX:
Psychosocial Integrity
10.A grieving young widow cries out, Why was my husband killed? Why wasnt it
me? What is the nurses best response?
Summarization
Restating
Showing acceptance
Stating observationsa
.
Stating You need to be strong for
your children.
b
.
c
.
d
.
ANS: B
The ability to listen and assist those who are newly grieving through the use of
silence and a quiet presence is very effective. Stating You need to be strong for
your children is a clich.
Asking if there is anyone the widow needs to have notified and stating You are
feeling overwhelmed about your husbands death are not therapeutic in this
immediate grieving time.
•
The nurse is implementing evidence-based practice. Which of
the following is not a component of this process?
1.
2.
3.
4.
ANS: 4
Evidence-based practice is the combination of applying research findings, creating
clinical guidelines, and the individualization of the plan of care to meet the
patients needs and desired. Leader practice is not a component of the evidence-
based process.
PTS:1DIF:AnalyzeREF:The Process of EBP
•
The nurse is planning the care for a client using an
unstructured approach. Which of the following approaches
did the nurse most likely use?
Patient preference
Clinical expertise
Research evidence
Leader practice
Silently placing her hand on the widows
arm.
Asking if there is anyone the widow
needs to have notified.
Stating You are feeling
overwhelmed about your husbands
death.1.
2.
3.
4.
ANS: 2
Examples of unstructured approaches to plan client care include trial and
error, tradition, and authority. The approaches of research, nursing theory,
and validated order all represent a structured approach to planning client care.
PTS: 1 DIF: Analyze REF: Knowledge Bases for Clinical Decisions
•
The nurse is participating in an activity that is the first step
of the ACE Star Model of Knowledge Transformation.
Which of the following is the nurse doing?
1.
2.
3.
4.
ANS: 4
The ACE Star Model of Knowledge Transformation depicts the transfer of
knowledge according to five sequential steps. The first step is primary research.
Subsequent steps are: 2) evidence summary, 3) translation, 4) integration, and 5)
evaluation.
PTS:1DIF:AnalyzeREF:EBP in Nursing
4.A committee has been developed to implement knowledge transformation
when providing client care. The members realize that the purpose of
knowledge transformation is to:
1.
2.
3.
4.
reduce length of stay.
convert research findings to impact health outcomes.
reduce the cost of care.
increase the number of patients with health insurance.
Creating evidence summaries
Evaluating outcomes
Integrating findings into practice
Participating in research
Research
Trial and error
Nursing theory
Validated orderANS: 2
The core concept of the ACE Star Model is knowledge transformation. Knowledge
transformation is the conversion of research findings to have an impact on health
outcomes by way of evidence-based care. Knowledge transformation is not a
method to reduce length of stay, reduce the cost of care, or increase the number of
patients with health insurance.
PTS: 1 DIF: Analyze REF: Definition of Knowledge Transformation
• An advance practice nurse is being consulted to participate during the
translation phase of the ACE Star Model of Knowledge Transformation.
During this phase, which of the following will the nurse create?
1.
2.
3.
4.
ANS: 3
In the third step of the ACE Star Model of Knowledge Transformation, experts are
consulted to consider the evidence summaries, fill in gaps, and merge research
knowledge with expertise to produce clinical practice guidelines. The nurse is not
creating standardized care plans, critical pathways, or checklists to streamline
documentation since these items are not a part of the ACE Star Model of
Knowledge Transformation.
PTS: 1 DIF: Apply REF: Star Point 3: Translation
•
The nurse leaders of a health care organization are creating plans to change
clinical and organizational practices to support evidence-based practice.
Which phase of the ACE Star Model of Knowledge Transformation are the
leaders implementing?
1.
2.
3.
4.
Integration
Evaluation
Translation
Evidence summaries
Standardized care plans
Critical pathways
Clinical practice guidelines
Checklists to streamline documentationANS: 1
During the Integration phase of the ACE Star Model of Knowledge
Transformation, implementation plans are put into action to change the
individual clinician practices, organizational practices, and environmental
policies. Implementation plans are not a part of the evidence summaries,
translation, or evaluation of the ACE Star Model of Knowledge Transformation.
PTS: 1 DIF: Apply REF: Star Point 4: Integration
•
The advance practice nurse is writing clinical practice guidelines. Prior to writing
these guidelines which of the following will the nurse need?
1.
Current client census
2.
3.
4.
ANS: 2
The ideal base for writing clinical guidelines are evidence summaries because
they increase the power and validity of the cause-and-effect relationship between
interventions and outcomes.
Current client census, nursing department budgets, and staffing ratios are not
used to write clinical practice guidelines.
PTS:1DIF:ApplyREF:Evidence Summaries
•
The nurse is writing a systematic review. After the nurse formulates
questions and locates relevant studies, the nurse thing the nurse will
do is:
Evidence summaries
Nursing department budget
Staffing ratios
1.
2.
3.
4.
ANS: 4
The next step in the systematic review writing process is selecting and
appraising the studies. Afterwards, the nurse will complete, in order, summarize
and synthesize
update the reviews.
interpret the findings.
summarize and synthesize results.
select and appraise the ts, interpret the findings, and regularly update the reviews.
PTS: 1 DIF: Apply REF: Method for Producing Systematic
Reviews
•
The nurse is using the scale for rating the strength of research evidence for
one research article for potential inclusion in a clinical practice guideline.
Which of the following is considered the
strongest evidence?
1.
Individual cohort study
2. Meta-analysis of randomized clinical trials
3.
Expert opinion
4.
ANS: 2
When utilizing the Scale for Rating the Strength of Research Evidence, the level
with the strongest evidence is level I, meta-analysis of randomized clinical trials.
Level III is individual cohort studies. Expert opinion is Level VII or the weakest
evidence. Case studies are Level VI.
PTS:1DIF:Analyze
REF:Table 2-1 Scale for Rating the Strength of Research Evidence
•
Case studies
The nurse is considering a research study for inclusion in a clinical
practice guideline that has been identified as being sufficient to
determine effects on health outcomes. This research study would be
considered as being:
1.
2.
3.
4.
ANS: 1
Research studies are rated according to the Scale for Rating the Quality of
Research Evidence. According to this scale, a research study that is sufficient to
determine the effects on health outcomes is considered fair. A good study has
consistent results for well-designed, well- conducted studies that directly assess
effects on health outcomes.
fair.
passable.
poor.
good.A poor study has insufficient results to assess the affects on health outcomes.
Passable is not a category of this rating scale.
PTS:1DIF:Analyze
REF:Table 2-2 Scale for Rating the Quality of Research Evidence
•
The nurse is reviewing evidence-based clinical practice guidelines to use
when planning care for a client. One guideline has been graded by the U.S.
Preventive Services Task Force as being an A. According to this grade, the
nurse should do which of the following?
1
.
2
.
3
.
4
.
ANS: 3
The U.S. Preventive Services Task Force grades clinical practice guidelines from A
to D plus I. A grade A guideline is recommended for care since there is high
certainty that the benefit to the client is substantial. A grade C guideline has a
small net benefit to the client. A grade D guideline has harms that outweigh the
benefits. A grade I guideline has benefits and harms that cannot be determined.
PTS:1DIF:Apply
REF: Box 2-6 Strength of Recommendations from the U.S. Preventive Services Task Force
•
The nurse identifies errors and hazards in a care environment and
implements basic safety to reduce the likelihood of an adverse event. Which
of the following core competencies is this nurse implementing?
Do not use this guideline because the
harm outweighs the benefits.
Do not use this guideline because the
benefits and harms cannot be
determined.
Use this guideline because the benefit is
substantial.
Use this guideline but understand that
the net benefit to the client is small.
1.
2.
3.
Provide patient-centered care
Apply quality improvement
Employ evidence-based practice4.
ANS: 2
Of the five Core Competencies for Health Professions, the competency that
focuses on the identification of errors and hazards with implementation of basic
safety is apply quality improvement. Provide patient-centered care focuses on
direct care activities. Employ evidence- based practice focuses on the integration
of research with clinical expertise. Utilize informatics to focus on communication
and the use of information technology to support decision making.
PTS: 1 DIF: Apply REF: Box 2-1 Core Competencies for Health Professions
•
The nurse is participating on a committee to select evidence-based
practice guidelines.Which of the following statements by the nurse
indicate a clear understanding of the purpose of these guidelines?
Utilize informatics
1
.
They provide the best evidence to make
decisions about the care of individual
clients.
2
.
3
.
4
.
ANS: 1
Evidence-based practice guidelines provide the best evidence to make decisions
about the care of individual clients. The use of a single research study to make
changes in client care is a concept within research utilization and not evidence-
based practice.
Evidence-based practice does impact the costs of client care but their intent is
not to ensure cost-effective care but rather to improve
the overall quality of
care.
Evidence-based guidelines do not provide staffing ratios for client
care.
PTS:1DIF:AnalyzeREF:The Process of EBP
MULTIPLE RESPONSE
•
The nurse is determining the best way to ensure adherence to the core
competencies for health professions. Which of the following competencies
will the nurse implement when providing client care? (Select all that apply.)
They promote changes in client care
according to a research study.
They ensure cost-effective care to
the client.
They identify safe staffing ratios for
client care.1.
2.
3.
4.
5.
6.
Work in interdisciplinary teams
Utilize informatics
Implement basic safety principles
Employ evidence-based practice
Apply quality improvement
Provide patient-centered care
ANS: 1, 2, 4, 5, 6
Core competencies for health professions include providing patient-centered
care, working in interdisciplinary teams, employing evidence-based practice,
applying quality improvement, and utilizing informatics. Implementing basic
safety principles is only one part of a quality improvement program.
PTS:1DIF:Apply
REF: Box 2-1 Core Competencies for Health Professions.
•
There are impediments that make the practice of evidence-based practice
difficult. Which of the following are impediments to evidence-based
practice? (Select all that apply.)
1.
2.
3.
4.
5.
6.
Complexity of science and technology
Difficulty of nowledge transformation
Variety of knowledge forms
Number of patient diagnoses
Evidence summary
Application of quality improvement
ANS: 1, 3
Hurdles to evidence-based practice are the increasing complexity of science and
technology and the variety of knowledge forms, many of which are not suitable
for direct practice. Knowledge transformation, number of patient diagnoses,
evidence summary, application of quality improvement are not considered
impediments to the implementation of evidence-based practice.
Chapter 3. Overview of Health Concepts for Medical-Surgical
Nursing MULTIPLE CHOICE•
The nurse ensures that a clients bedspace is neat and clean with the call
light within easy reach. The nurse is focusing on which nursing theorist who
realized the importance of the environment for care?
1.
2.
3.
Florence Nightingale
Sister Callista Roy
Dorothea Orem
4. Martha Rogers
ANS: 1
Florence Nightingales theory focused on the environment for care. Sister Callista
Roys model is based in systems theory and an individuals ability to adapt.
Dorothea Orems model is the self- care deficit theory. Martha Rogers model is
the science of unitary human beings.
PTS:1DIF:Apply
REF:Emergence of Contemporary Nursing in the United States
•
The nurse is instructing a client on self-administration of insulin so that
the client will not need a health care provider to do this activity. The nurse
is implementing which of the following aspects of Virginia Hendersons
theory of nursing?
1
.
A caring relationship
2
.
3
.
4
.
ANS: 2
Virginia Hendersons theory of nursing is to help people achieve health or a
peaceful death so that they can be independent from the nurses assistance as
quickly as possible. A caring relationship, integration of objective and subjective
data, and
Helping the client achieve
independence from the nurses
assistance as quickly as possible
Integration of objective and subjective
data
Application of critical thinkingapplication of critical thinking are included in the American Nurses
Associations essential features of professional nursing.
PTS:1DIF:Analyze
REF:Emergence of Contemporary Nursing in the United States
3.A client tells the nurse that he has an HMO for his health insurance. The
nurse understands that the purpose of this type of health plan is to:
1.
2.
3.
4.
ANS: 3
Health maintenance organizations (HMOs) were created to efficiently manage
health care costs while providing quality care. An HMO is a type of managed care
plan with the goal of providing wellness care and not focusing on the illness
during the provision of care. HMOs do not ensure payment is made to Medicare
for services rendered. HMOs also do not maximize the utilization of health care
resources but rather uses financial incentives to decrease care costs.
PTS: 1 DIF: Understand REF: Cost of Care
4.A client tells the nurse that he does not have a primary care physician but
rather makes an appointment with a doctor who specializes in the area in
which he is experiencing a problem. The nurse realizes this client is at risk for
which of the following?
ensure payment is made to Medicare for services rendered.
maximize the utilization of health care resources.
efficiently manage costs while providing quality care.
focus on the illness when providing care.
1.
2.
3.
4.
Fragmented care
Overpayment of services
Inability to sustain health
Finding an appropriate general practitioner
ANS: 1
In the 1980s, the close and trusting relationship between an individual and theindividuals physician waned and was replaced by acquaintances with specialists
based upon particular health care problems. These episodes of care cause
fragmentation of care. The client who utilizes specialists is not at risk for
overpayment of services, the inability to sustain health, or finding an appropriate
general practitioner.
PTS:1DIF:AnalyzeREFroviders of Care
5. The nurse is attending a masters degree program in efforts to be
educationally prepared to serve as a hospital leader. The nurse realizes that
this educational preparation will:
1
.
2
.
3
.
4
.
ANS: 4
The nurse is attending an educational program to serve as a hospital leader. This
education will prepare the nurse to serve as strong clinical support with the ability
to integrate business and caring. This education will not hinder the nurses ability
to work with physicians. This education will not be viewed as unsupportive to the
profession of nursing. The education will ensure that the nurse is not biased
towards clinicians interests.
PTS: 1 DIF: Analyze REF: Clinical Systems Leadership
6.A client tells the nurse that all hospitals care about is doing the minimum for a
client regardless of the outcome. Which of the following should the nurse respond
to this client?
be viewed as not supporting the
profession of nursing by other nurses.
ensure the nurse is biased towards
clinicians interests.
prepare the nurse to serve as strong
clinical support with the ability to
integrate business and caring.
hinder the nurses ability to work with physicians.
1
.
It does feel like that sometimes.2
.
Health insurance companies have
caused this problem.
3
.
4
.
ANS: 4
In response to concerns about safety and quality of care voiced by clients and
providers, total quality management and continuous quality improvement
programs were initiated. These programs ensure society that cost management is
not compromising safety or quality. This is
what the nurse should respond to the client. The other choices do not
address the clients concerns nor do they explain quality management
programs.
PTS: 1 DIF: Apply REF: Quality Measure Shift
•
The nurse is providing care at a time that is the most beneficial to the
client. The nurse is implementing which of the following Joint
Commission Dimensions of Quality Performance?
1.
2.
3.
4.
ANS: 2
The dimension of timeliness means the degree in which interventions are
provided at the most beneficial time to the client. Safety means the degree in
which the risk of an intervention and risk to the environment are reduced for both
client and health care provider. Efficiency means the degree in which care has the
desired effect with a minimum of effort, waste, or expense.
Availability means the degree in which appropriate interventions are available to meet the
clients needs.
PTS:1DIF:Analyze
Safety
Timeliness
Efficiency
Availability
The doctors will get paid regardless of the
clients outcomes.
There are quality programs in place to
make sure clients receive the best
quality of care regardless of the cost.REF:Box 1-1 Joint Commission Dimensions of Quality Performance •
The nurse is providing care while adhering to safety as a Joint Commission Dimension of Quality Performance. Which of the following did the nurse provide to the client?
1 . 2 .
3 .
4 .
ANS: 1
The dimension of safety means the degree in which the risk of an intervention and risk to the environment are reduced for both client and health care provider. The nurse who uses a needleless device when providing intravenous medications is adhering to this dimension. Keeping the siderails in the down position is not a safe practice. Having a client sit in a wheelchair with the wheels unlocked is not a safe practice. Placing cloth towels over a spill in the room of an ambulatory client is not a safe practice.
PTS:1
Content preview
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 clientshave suffered injuries and less serious outcomes. Every nurse has the
responsibility to guard the clients safety.
◦ DIF: Understanding/Comprehension REF:
2KEY: Patient safety MSC: Integrated Process: Nursing
Process: Intervention
◦ NOT: Client Needs Category: Safe and Effective
CareEnvironment: 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
ownsafety?
◦ 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
orher 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 isthe most critical. The other actions are
◦
◦ very limited in scope and do not provide the broad protection
thatbeing active and involved does.
◦ DIF: Understanding/Comprehension REF:
3KEY: Patient safety MSC: Integrated Process:
Teaching/ Learning
◦ 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
bloodpressure 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
measurementin 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 theclient 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.
Whichaction 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
andfamily to the room ANS: A
◦ Competency in client-focused care is demonstrated when the
nursefocuses 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
tellingthe 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 doto 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
whocomes 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 theytake 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
EffectiveCare Environment: Safety and Infection Control
◦ Which action by the nurse working with a client best demonstrates
respect forautonomy?
◦ 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
clientsANS: 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 questions is vital, because without full information the client
cannotpractice autonomy. Giving accurate information is practicing with veracity.
Keeping promises is upholding fidelity. Treating the
◦
◦ client fairly is providing social justice.
◦
◦ DIF: Applying/Application REF: 4
◦ KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
◦ NOT: Client Needs Category: Safe and Effective Care Environment:
Management
of Care
, ◦
◦ A student nurse asks the faculty to explain best practices when
communicatingwith a person from the lesbian, gay, bisexual, transgender,
and queer/ questioning (LGBTQ) community. What answer by the faculty is
most accurate?
◦ Avoid embarrassing the client by asking questions.
◦ Dont make assumptions about their health needs.
◦ Most LGBTQ people do not want to share information.
◦ No differences exist in communicating
withthis population. ANS: B
◦ Many members of the LGBTQ community have faced
discrimination from health care providers and may be reluctant to seek health
care. The nurse should never make assumptions about the needs of members of
this population. Rather, respectful questions are appropriate. If approached with
sensitivity, the client with anyhealth care need is more likely to answer honestly.
◦ DIF: Understanding/Comprehension
REF: 4KEY: LGBTQ| diversity MSC: Integrated Process:
Teaching/Learning
◦ NOT: Client Needs Category: Psychosocial Integrity
◦
◦ A nurse is calling the on-call physician about a client who had a
hysterectomy 2days ago and has pain that is unrelieved by the prescribed
narcotic pain medication. Which statement is part of the SBAR format for
communication?
◦ A: I would like you to order a different pain medication.
◦ B: This client has allergies to morphine and codeine.
◦ R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
◦ S: This client had a vaginal
hysterectomy 2 days ago. ANS:
B
◦ SBAR is a recommended form of communication, and the acronym
stands for Situation, Background, Assessment, and Recommendation.
Appropriate background information includes allergies to medications the on-call
physician mightorder. Situation describes what is happening right now that must
be communicated; the clients surgery 2 days ago would be considered
background. Assessment would include an analysis of the clients problem; asking
for a different pain medication is a recommendation. Recommendation is a
statement of what is needed or what
◦
◦ outcome is desired; this information about the surgeons
preferencemight be better placed in background.
◦ DIF:
Applying/Application REF: 5
KEY: SBAR| communication