,Chapter 01: Overview of Professional Nursing Concepts for Medical- Surgical Nursing
y# y# y# y# y# y# y# y# y# y#
MULTIPLE CHOICE y#
1. A nurse wishes to provide client-
y# y# y# y# y#
centered care in all interactions. Which action by thenurse best demonstrates this concept?
y# y# y# y# y# y# y# y# #
y y# y# y# y#
a. Assesses for cultural influences affecting health care
y# y# y# y# y# y#
b. Ensures that all the clients basic needs are met
y# y# y# y# y# y# y# y#
c. Tells the client and family about all upcoming tests
y# y# y# y# y# y# y# y#
d. Thoroughly orients the client and family to the room y# y# y# y# y# y# y# y#
ANS: A y#
Competency in client- y# y#
focused care is demonstrated when the nursefocuses on communication, culture, respect comp
y# y# y# y# y# y# y# y# y# y# y#
assion, client education, and empowerment. By assessing the effect of the clients culture on h
y# y# y# y# y# y# y# y# y# y# y# y# y# y#
ealth care, this nurse is practicing client-
y# y# y# y# y# y#
focused care. Providing for basic needs does not demonstrate this competence. Simply telling t
y# y# y# y# y# y# y# y# y# y# y# y# y#
he client about all upcoming tests isnot providing empowering education.
y# y# y# y# y# y# y# y# y# y#
Orienting the client andfamily to theroom is animportantsafetymeasur
y# y# y# y# y# y# y#
e,butnotdirectlyrelatedtodemonstratingclient-centered care.
#
y y#
DIF: Understanding/Comprehension REF: 3
y# y# y#
KEY: Patient- y#
centered care| culture MSC: Integrated Process: Caring NOT: Client NeedsCategory: Psychoso
y# y# y# y# y# y# y# y# y# #
y y#
cial Integrity y#
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood press
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
urewas 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is
#
y y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
best?
a. Call the Rapid Response Team.
y# y# y# y#
b. Document and continue to monitor. y# y# y# y#
c. Notify the primary care provider. y# y# y# y#
d. Repeat blood pressure measurement in 15 minutes.
y# y# y# y# y# y#
,ANS: A y#
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating
y# y# y# y# y# y# y# y# y# y# y# y# y# y# #
y
before they suffereitherrespiratoryorcardiacarrest.
y# y#
Sincetheclienthasmanifestedasignificantchange, thenurseshould call the RRT. Changes in bloo y# y# y# y# y# y# y#
d pressure, mental status, heart rate, and pain are particularly significant. Documentation is vit
y# y# y# y# y# y# y# y# y# y# y# y# y#
al, but the nursemust do more than document. The primary care provider should be notified, b
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
ut thisis not the priority over calling the RRT. The clients blood pressure should
y# #
y y# y# y# y# y# y# y# y# y# y# y# y#
be reassessed frequently, but the priority is getting the rapid care to theclient.
y# y# y# y# y# y# y# y# y# y# y# y#
DIF: Applying/Application REF: 3
y# y# y#
KEY: Rapid Response Team (RRT)| medical emergencies MSC: Integrated Process:Co
y# y# y# y# y# y# y# y# y# #
y
mmunication and Documentation y# y#
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
y# y# y# y# y# y# y#
3. A nurse is orienting a new client and family to the inpatient unit. What information d
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
oesthe nurse provide to help the client promote his or her own safety?
#
y y# y# y# y# y# y# y# y# y# y# y# y#
a. Encourage the client and family to be active partners.
y# y# y# y# y# y# y# y#
b. Have the client monitor hand hygiene in caregivers.
y# y# y# y# y# y# y#
c. Offer the family the opportunity to stay with the client.
y# y# y# y# y# y# y# y# y#
d. Tell the client to always wear his or her armband.
y# y# y# y# y# y# y# y# y#
ANS: A y#
Each action could be important for the client or family to perform. However, encouraging the c
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
lient to be active in his or her health care as a partner is the most critical. The other actions are
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
y# very limited in scope and do not provide the broad protection that being active and involveddo
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
es.
DIF: Understanding/Comprehension REF: 3 KEY: Patient safety
y# y# y# y# y# y#
, MSC: Integrated Process: Teaching/Learning
y# y# y#
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infecti
y# y# y# y# y# y# y# y# y# y# y#
onControl#
y
4. A new nurse is working with a preceptor on an inpatientmedical-
y# y# y# y# y# y# y# y# y# y#
surgical unit. The preceptor advises the student that which is the priority when working as
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y
a professionalnurse?
# y#
a. Attending to holistic client needs y# y# y# y#
b. Ensuring client safety y# y#
c. Not making medication errors
y# y# y#
d. Providing client-focused care y# y#
ANS: B y#
All actions are appropriate for the professional nurse. However, ensuring client safety is the pri
y# y# y# y# y# y# y# y# y# y# y# y# y# y#
ority. Up to 98,000 deaths result each year from errors in hospital care, according to the 2000 I
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
nstitute of Medicine report. Many more clients have suffered injuries and less serious outcomes.
y# y# y# y# y# y# y# y# y# y# y# y# y# #
y
Every nurse has the responsibility to guard the clients safety.
y# y# y# y# y# y# y# y# y#
DIF: Understanding/Comprehension REF: 2 KEY: Patient safety
y# y# y# y# y# y# #
y
MSC: Integrated Process: Nursing Process: Intervention
y# y# y# y# y#
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infecti
y# y# y# y# y# y# y# y# y# y# y#
onControl#
y
5. A client is going to be admitted for a scheduled surgical procedure. Which action d
y# y# y# y# y# y# y# y# y# y# y# y# y# y#
oesthe nurse explain is the most important thing the client can do to protect againsterrors?
#
y y# y# y# y# y# y# y# y# y# y# y# y# y# y#
a. Bring a list of all medications and what they are for.
y# y# y# y# y# y# y# y# y# y#
b. Keep the doctors phone number by the telephone.
y# y# y# y# y# y# y#
c. Make sure all providers wash hands before entering the room.
y# y# y# y# y# y# y# y# y#
d. Write down the name of each caregiver who comes in the room.
y# y# y# y# y# y# y# y# y# y# y#
ANS: A y#
y# y# y# y# y# y# y# y# y# y#
MULTIPLE CHOICE y#
1. A nurse wishes to provide client-
y# y# y# y# y#
centered care in all interactions. Which action by thenurse best demonstrates this concept?
y# y# y# y# y# y# y# y# #
y y# y# y# y#
a. Assesses for cultural influences affecting health care
y# y# y# y# y# y#
b. Ensures that all the clients basic needs are met
y# y# y# y# y# y# y# y#
c. Tells the client and family about all upcoming tests
y# y# y# y# y# y# y# y#
d. Thoroughly orients the client and family to the room y# y# y# y# y# y# y# y#
ANS: A y#
Competency in client- y# y#
focused care is demonstrated when the nursefocuses on communication, culture, respect comp
y# y# y# y# y# y# y# y# y# y# y#
assion, client education, and empowerment. By assessing the effect of the clients culture on h
y# y# y# y# y# y# y# y# y# y# y# y# y# y#
ealth care, this nurse is practicing client-
y# y# y# y# y# y#
focused care. Providing for basic needs does not demonstrate this competence. Simply telling t
y# y# y# y# y# y# y# y# y# y# y# y# y#
he client about all upcoming tests isnot providing empowering education.
y# y# y# y# y# y# y# y# y# y#
Orienting the client andfamily to theroom is animportantsafetymeasur
y# y# y# y# y# y# y#
e,butnotdirectlyrelatedtodemonstratingclient-centered care.
#
y y#
DIF: Understanding/Comprehension REF: 3
y# y# y#
KEY: Patient- y#
centered care| culture MSC: Integrated Process: Caring NOT: Client NeedsCategory: Psychoso
y# y# y# y# y# y# y# y# y# #
y y#
cial Integrity y#
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood press
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
urewas 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is
#
y y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
best?
a. Call the Rapid Response Team.
y# y# y# y#
b. Document and continue to monitor. y# y# y# y#
c. Notify the primary care provider. y# y# y# y#
d. Repeat blood pressure measurement in 15 minutes.
y# y# y# y# y# y#
,ANS: A y#
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating
y# y# y# y# y# y# y# y# y# y# y# y# y# y# #
y
before they suffereitherrespiratoryorcardiacarrest.
y# y#
Sincetheclienthasmanifestedasignificantchange, thenurseshould call the RRT. Changes in bloo y# y# y# y# y# y# y#
d pressure, mental status, heart rate, and pain are particularly significant. Documentation is vit
y# y# y# y# y# y# y# y# y# y# y# y# y#
al, but the nursemust do more than document. The primary care provider should be notified, b
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
ut thisis not the priority over calling the RRT. The clients blood pressure should
y# #
y y# y# y# y# y# y# y# y# y# y# y# y#
be reassessed frequently, but the priority is getting the rapid care to theclient.
y# y# y# y# y# y# y# y# y# y# y# y#
DIF: Applying/Application REF: 3
y# y# y#
KEY: Rapid Response Team (RRT)| medical emergencies MSC: Integrated Process:Co
y# y# y# y# y# y# y# y# y# #
y
mmunication and Documentation y# y#
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
y# y# y# y# y# y# y#
3. A nurse is orienting a new client and family to the inpatient unit. What information d
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
oesthe nurse provide to help the client promote his or her own safety?
#
y y# y# y# y# y# y# y# y# y# y# y# y#
a. Encourage the client and family to be active partners.
y# y# y# y# y# y# y# y#
b. Have the client monitor hand hygiene in caregivers.
y# y# y# y# y# y# y#
c. Offer the family the opportunity to stay with the client.
y# y# y# y# y# y# y# y# y#
d. Tell the client to always wear his or her armband.
y# y# y# y# y# y# y# y# y#
ANS: A y#
Each action could be important for the client or family to perform. However, encouraging the c
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
lient to be active in his or her health care as a partner is the most critical. The other actions are
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
y# very limited in scope and do not provide the broad protection that being active and involveddo
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
es.
DIF: Understanding/Comprehension REF: 3 KEY: Patient safety
y# y# y# y# y# y#
, MSC: Integrated Process: Teaching/Learning
y# y# y#
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infecti
y# y# y# y# y# y# y# y# y# y# y#
onControl#
y
4. A new nurse is working with a preceptor on an inpatientmedical-
y# y# y# y# y# y# y# y# y# y#
surgical unit. The preceptor advises the student that which is the priority when working as
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y
a professionalnurse?
# y#
a. Attending to holistic client needs y# y# y# y#
b. Ensuring client safety y# y#
c. Not making medication errors
y# y# y#
d. Providing client-focused care y# y#
ANS: B y#
All actions are appropriate for the professional nurse. However, ensuring client safety is the pri
y# y# y# y# y# y# y# y# y# y# y# y# y# y#
ority. Up to 98,000 deaths result each year from errors in hospital care, according to the 2000 I
y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y# y#
nstitute of Medicine report. Many more clients have suffered injuries and less serious outcomes.
y# y# y# y# y# y# y# y# y# y# y# y# y# #
y
Every nurse has the responsibility to guard the clients safety.
y# y# y# y# y# y# y# y# y#
DIF: Understanding/Comprehension REF: 2 KEY: Patient safety
y# y# y# y# y# y# #
y
MSC: Integrated Process: Nursing Process: Intervention
y# y# y# y# y#
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infecti
y# y# y# y# y# y# y# y# y# y# y#
onControl#
y
5. A client is going to be admitted for a scheduled surgical procedure. Which action d
y# y# y# y# y# y# y# y# y# y# y# y# y# y#
oesthe nurse explain is the most important thing the client can do to protect againsterrors?
#
y y# y# y# y# y# y# y# y# y# y# y# y# y# y#
a. Bring a list of all medications and what they are for.
y# y# y# y# y# y# y# y# y# y#
b. Keep the doctors phone number by the telephone.
y# y# y# y# y# y# y#
c. Make sure all providers wash hands before entering the room.
y# y# y# y# y# y# y# y# y#
d. Write down the name of each caregiver who comes in the room.
y# y# y# y# y# y# y# y# y# y# y#
ANS: A y#