Test Bank
Medical-Surgical Nursing Concepts For Interprofessional Collaborative
Care 10th Edition Chapter 1-69 | Complete Guide
,Table Of Contents
Chapter 01: Overview Of Professional Nursing Concepts For Medical-Surgical Nursing ........... 5
Chapter 02: Clinical Judgment And Systems Thinking .............................................................. 15
Chapter 03: Overview Of Health Concepts For Medical-Surgical Nursing ................................ 23
Chapter 04: Common Health Problems Of Older Adults .......................................................... 31
Chapter 05: Assessment And Care Of Patients With Pain ........................................................ 45
Chapter 06: Concepts Of Genetics And Genomics ................................................................... 63
Chapter 07: Concepts Of Rehabilitation For Chronic And Disabling Health Problems ............. 73
Chapter 08: Concepts Of Care For Patients At End Of Life........................................................ 85
Chapter 09: Concepts Of Care For Perioperative Patients ........................................................ 96
Chapter 10: Concepts Of Emergency And Trauma Nursing .................................................... 115
Chapter 11: Concepts Of Care For Patients With Common Environmental Emergencies ...... 128
Chapter 12: Concepts Of Disaster Preparedness .................................................................... 144
Chapter 13: Concepts Of Fluid And Electrolyte Balance ......................................................... 156
Chapter 14: Concepts Of Acid–Base Balance .......................................................................... 171
Chapter 15: Concepts Of Infusion Therapy ............................................................................. 184
Chapter 16: Concepts Of Inflammation And Immunity .......................................................... 198
Chapter 17: Concepts Of Care For Patients With HIV Disease................................................ 211
Chapter 18: Concepts Of Care For Patients With Hypersensitivity (Allergy) And Autoimmunity
................................................................................................................................................. 227
Chapter 19: Concepts Of Cancer Development ...................................................................... 234
Chapter 20: Concepts Of Care For Patients With Cancer ....................................................... 241
Chapter 21: Concepts Of Care For Patients With Infection .................................................... 261
Chapter 22: Assessment Of The Skin, Hair, And Nails ............................................................. 273
Chapter 23: Concepts Of Care For Patients With Skin Problems ............................................ 282
Chapter 24: Assessment Of The Respiratory System .............................................................. 299
Chapter 25: Concepts Of Care For Patients Requiring Oxygen Therapy Or Tracheostomy .... 311
Chapter 26: Concepts Of Care For Patients With Noninfectious Upper Respiratory Problems
................................................................................................................................................. 322
,Chapter 27: Concepts Of Care For Patients With Noninfectious Lower Respiratory Problems
................................................................................................................................................. 335
Chapter 28: Concepts Of Care For Patients With Infectious Respiratory Problems ............... 356
Chapter 29: Critical Care Of Patients With Respiratory Emergencies ..................................... 372
Chapter 30: Assessment Of The Cardiovascular System ......................................................... 390
Chapter 31: Concepts Of Care For Patients With Dysrhythmias............................................. 405
Chapter 32: Concepts Of Care For Patients With Cardiac Problems ...................................... 422
Chapter 33: Concepts Of Care For Patients With Vascular Problems ..................................... 442
Chapter 34: Critical Care Of Patients With Shock ................................................................... 465
Chapter 35: Critical Care Of Patients With Acute Coronary Syndromes ................................. 477
Chapter 36: Assessment Of The Hematologic System ............................................................ 495
Chapter 37: Concepts Of Care For Patients With Hematologic Problems .............................. 503
Chapter 38: Assessment Of The Nervous System ................................................................... 523
Chapter 39: Concepts Of Care For Patients With Problems Of The Central Nervous System:
The Brain ................................................................................................................................. 538
Chapter 40: Concepts Of Care For Patients With Problems Of The Central Nervous System:
The Spinal Cord ....................................................................................................................... 556
Chapter 41: Critical Care Of Patients With Neurologic Emergencies ...................................... 572
Chapter 42: Assessment And Care Of Patients With Eye And Vision Problems ..................... 591
Chapter 43: Assessment And Care Of Patients With Ear And Hearing Problems ................... 604
Chapter 44: Assessment Of The Musculoskeletal System ...................................................... 615
Chapter 45: Concepts Of Care For Patients With Musculoskeletal Problems ........................ 623
Chapter 46: Concepts Of Care For Patients With Arthritis And Total Joint Arthroplasty........ 634
Chapter 47: Concepts Of Care For Patients With Musculoskeletal Trauma ........................... 651
Chapter 48: Assessment Of The Gastrointestinal System ....................................................... 669
Chapter 49: Concepts Of Care For Patients With Oral Cavity And Esophageal Problems ...... 678
Chapter 50: Concepts Of Care For Of Patients With Stomach Disorders ............................... 686
Chapter 51: Concepts Of Care For Patients With Noninflammatory Intestinal Disorders ...... 696
Chapter 52: Concepts Of Care For Patients With Inflammatory Intestinal Disorders ............ 712
Chapter 53: Concepts Of Care For Patients With Liver Problems ........................................... 727
,Chapter 54: Concepts Of Care For Patients With Problems Of The Biliary System And Pancreas
................................................................................................................................................. 740
Chapter 55: Concepts Of Care For Patients With Malnutrition: Undernutrition And Obesity 751
Chapter 56: Assessment Of The Endocrine System ................................................................ 762
Chapter 57: Concepts Of Care For Patients With Pituitary And Adrenal Gland Problems ..... 770
Chapter 58: Concepts Of Care For Patients With Problems Of The Thyroid And Parathyroid
Glands ..................................................................................................................................... 780
Chapter 59: Concepts Of Care For Patients With Diabetes Mellitus ...................................... 789
Chapter 60: Assessment Of The Renal/Urinary ...................................................................... 814
Chapter 61: Concepts Of Care For Patients With Urinary Problems ...................................... 824
Chapter 62: Concepts Of Care For Patients With Kidney Disorders ....................................... 839
Chapter 63: Concepts Of Care For Patients With Acute Kidney Injury And Chronic Kidney
Disease .................................................................................................................................... 849
Chapter 64: Assessment Of The Reproductive System ........................................................... 866
Chapter 65: Concepts Of Care For Patients With Breast Disorders ........................................ 872
Chapter 66: Concepts Of Care For Patients With Gynecologic Problems ............................... 882
Chapter 67: Concepts Of Care For Clients With Male Reproductive Problems ...................... 893
Chapter 68: Concepts Of Care For Transgender Patients ....................................................... 903
Chapter 69: Concepts Of Care For Patients With Sexually Transmitted Infections................. 910
,Chapter 01: Overview Of Professional Nursing Concepts For Medical-
Surgical Nursing
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A New Nurse Is Working With A Preceptor On A Medical-Surgical Unit. The Preceptor
Advises The New Nurse That Which Is The Priority When Working As A Professional Nurse?
A. Attending To Holistic Client Needs
B. Ensuring Client Safety
C. Not Making Medication Errors
D. Providing Client-Focused Care
ANSWER: B
All Actions Are Appropriate For The Professional Nurse. However, Ensuring Client Safety Is The
Priority. Health Care Errors Have Been Widely Reported For 25 Years, Many Of Which Result In
Client Injury, Death, And Increased Health Care Costs. There Are Several National And
International Organizations That Have Either Recommended Or Mandated Safety Initiatives.
Every Nurse Has The Responsibility To Guard The Client’s Safety. The Other Actions Are
Important For Quality Nursing, But They Are Not As Vital As Providing Safety. Not Making
Medication Errors Does Provide Safety, But Is Too Narrow In Scope To Be The Best Answer.
DIF: UnderstandingTOP: Integrated Process: Nursing Process: Intervention KEY: Client Safety
MSC: Client Needs Category: Safe And Effective Care Environment: Safety And Infection Control
2. A Nurse Is Orienting A New Client And Family To The Medical-Surgical Unit. What
Information Does The Nurse Provide To Best 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.
ANSWER: 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 Safety 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: UnderstandingTOP: Integrated Process: Teaching/Learning KEY: Client Safety
MSC: Client Needs Category: Safe And Effective Care Environment: Safety And Infection Control
3. A Nurse Is Caring For A Postoperative Client On The Surgical Unit. The Client’s Blood
Pressure Was 142/76 Mm Hg 30 Minutes Ago, And Now Is 88/50 Mm Hg. What Action Would
The Nurse Take First?
A. Call The Rapid Response Team.
B. Document And Continue To Monitor.
C. Notify The Primary Health Care Provider.
D. Repeat The Blood Pressure In 15 Minutes.
ANSWER: 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 Would Call The RRT. Changes In Blood Pressure, Mental Status,
Heart Rate, Temperature, Oxygen Saturation, And Last 2 Hours’ Urine Output Are Particularly
Significant And Are Part Of The Modified Early Warning System Guide. Documentation Is Vital,
But The Nurse Must Do More Than Document. The Primary Health Care Provider Would Be
Notified, But This Is Not More Important Than Calling The RRT. The Client’s Blood Pressure
Would Be Reassessed Frequently, But The Priority Is Getting The Rapid Care To The Client.
DIF: Applying TOP: Integrated Process: Communication And Documentation KEY: Rapid
Response Team (RRT), Clinical Judgment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
,4. A Nurse Wishes To Provide Client-Centered Care In All Interactions. Which Action By The
Nurse
Best Demonstrates This Concept?
A. Assesses For Cultural Influences Affecting Health Care.
B. Ensures That All The Client’s Basic Needs Are Met.
C. Tells The Client And Family About All Upcoming Tests.
D. Thoroughly Orients The Client And Family To The Room.
ANSWER: A
Showing Respect For The Client And Family’s Preferences And Needs Is Essential To Ensure A
Holistic Or “Whole-Person” Approach To Care. By Assessing The Effect Of The Client’s 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: UnderstandingTOP: Integrated Process: Culture And Spirituality KEY: Client-Centered
Care, Culture MSC: Client Needs Category: Psychosocial Integrity
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 Against Errors?
A. Bring A List Of All Medications And What They Are For.
B. Keep The Provider’s Phone Number By The Telephone.
C. Make Sure That All Providers Wash Hands Before Entering The Room.
D. Write Down The Name Of Each Caregiver Who Comes In The Room.
ANSWER: A
Medication Reconciliation Is A Formal Process In Which The Client’s Actual Current Medications
Are Compared To The Prescribed Medications At The Time Of Admission, Transfer, Or Discharge.
This National Client Safety Goal Is Important To Reduce Medication Errors. The Client Would Not
Have To Be Responsible For Providers Washing Their Hands, And Even If The Client Does So, This
Is Too Narrow To Be The Most Important Action To Prevent Errors. Keeping The Provider’s Phone
Number Nearby And Documenting Everyone Who Enters The Room Also Do Not Guarantee
Safety.
,DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Client Safety, Informatics
MSC: 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.
B. Gives The Client Accurate Information When Questioned.
C. Keeps The Promises Made To The Client And Family.
D. Treats The Client Fairly Compared To Other Clients.
ANSWER: A
Autonomy Is Self-Determination. The Client Would 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
Client Fairly Is Providing Social Justice.
DIF: Applying TOP: Integrated Process: Caring KEY: Ethics, Autonomy MSC: Client
Needs Category: Safe And Effective Care Environment: Management Of Care
7. A Nurse Asks A More Seasoned Colleague To Explain Best Practices When
Communicating With A Person From The Lesbian, Gay, Bisexual, Transgender, And
Questioning/Queer (LGBTQ) Community. What Answer By The Faculty Is Most Accurate?
A. Avoid Embarrassing The Client By Asking Questions.
B. Don’t Make Assumptions About His Or Her Health Needs.
C. Most LGBTQ People Do Not Want To Share Information.
D. No Differences Exist In Communicating With This Population.
,ANSWER: B
Many Members Of The LGBTQ Community Have Faced Discrimination From Health Care
Providers And May Be Reluctant To Seek Health Care. The Nurse Would 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: UnderstandingTOP: Integrated Process: Teaching/Learning
KEY: Health Care Disparities, LGBTQ MSC: Client Needs Category: Psychosocial Integrity
8. A Nurse Is Calling The On-Call Health Care Provider About A Client Who Had A
Hysterectomy 2 Days Ago And Has Pain That Is Unrelieved By The Prescribed Opioid Pain
Medication. Which Statement Comprises The Background Portion 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.”
C. “Dr. Smith Doesn’t Like Nonsteroidal Anti-Inflammatory Meds.”
D. “This Client Had A Vaginal Hysterectomy 2 Days Ago.”
ANSWER: 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 Health Care Provider Might Order. Situation Describes
What Is Happening Right Now That Must Be Communicated; The Client’s Surgery 2 Days Ago
Would Be Considered Background. Assessment Would Include An Analysis Of The Client’s
Problem; None Of The Options Has Assessment Information. Asking For A Different Pain
, Medication Is A Recommendation. Recommendation Is A Statement Of What Is Needed Or
What Outcome Is Desired.
DIF: Applying TOP: Integrated Process: Communication And Documentation KEY:
Teamwork And Collaboration, SBAR
MSC: Client Needs Category: Safe And Effective Care Environment: Management Of Care
9. A Nurse Working On A Cardiac Unit Delegated Taking Vital Signs To An Experienced
Assistive Personnel (AP). Four Hours Later, The Nurse Notes That The Client’s Blood Pressure
Taken By The AP Was Much Higher Than Previous Readings, And The Client’s Mental Status Has
Changed. What Action By The Nurse Would Most Likely Have Prevented This Negative
Outcome?
A. Determining If The AP Knew How To Take Blood Pressure
B. Double-Checking The AP By Taking Another Blood Pressure
C. Providing More Appropriate Supervision Of The AP
D. Taking The Blood Pressure Instead Of Delegating The Task
ANSWER: C
Supervision Is One Of The Five Rights Of Delegation And Includes Directing, Evaluating, And
Following Up On Delegated Tasks. The Nurse Would Either Have Asked The AP About The Vital
Signs Or Instructed The AP To Report Them Right Away. An Experienced AP Would Know How To
Take Vital Signs And The Nurse Would 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
AP And Are Permissible To Delegate. The Only Appropriate Answer Is That The Nurse Did Not
Provide Adequate Instruction To The AP.
DIF: Analyzing TOP: Integrated Process: Communication And Documentation KEY:
Teamwork And Collaboration, Delegation
MSC: Client Needs Category: Safe And Effective Care Environment: Management Of Care
10. A Newly Graduated Nurse In The Hospital States That Because Of Being So New,
Participation In Quality Improvement (QI) Projects Is Not Wise. What Response By The
Precepting Nurse Is Best?
A. “All Staff Nurses Are Required To Participate In Quality Improvement Here.”
B. “Even Being New, You Can Implement Activities Designed To Improve Care.”
C. “It’s Easy To Identify What Indicators Would Be Used To Measure Quality.”
Medical-Surgical Nursing Concepts For Interprofessional Collaborative
Care 10th Edition Chapter 1-69 | Complete Guide
,Table Of Contents
Chapter 01: Overview Of Professional Nursing Concepts For Medical-Surgical Nursing ........... 5
Chapter 02: Clinical Judgment And Systems Thinking .............................................................. 15
Chapter 03: Overview Of Health Concepts For Medical-Surgical Nursing ................................ 23
Chapter 04: Common Health Problems Of Older Adults .......................................................... 31
Chapter 05: Assessment And Care Of Patients With Pain ........................................................ 45
Chapter 06: Concepts Of Genetics And Genomics ................................................................... 63
Chapter 07: Concepts Of Rehabilitation For Chronic And Disabling Health Problems ............. 73
Chapter 08: Concepts Of Care For Patients At End Of Life........................................................ 85
Chapter 09: Concepts Of Care For Perioperative Patients ........................................................ 96
Chapter 10: Concepts Of Emergency And Trauma Nursing .................................................... 115
Chapter 11: Concepts Of Care For Patients With Common Environmental Emergencies ...... 128
Chapter 12: Concepts Of Disaster Preparedness .................................................................... 144
Chapter 13: Concepts Of Fluid And Electrolyte Balance ......................................................... 156
Chapter 14: Concepts Of Acid–Base Balance .......................................................................... 171
Chapter 15: Concepts Of Infusion Therapy ............................................................................. 184
Chapter 16: Concepts Of Inflammation And Immunity .......................................................... 198
Chapter 17: Concepts Of Care For Patients With HIV Disease................................................ 211
Chapter 18: Concepts Of Care For Patients With Hypersensitivity (Allergy) And Autoimmunity
................................................................................................................................................. 227
Chapter 19: Concepts Of Cancer Development ...................................................................... 234
Chapter 20: Concepts Of Care For Patients With Cancer ....................................................... 241
Chapter 21: Concepts Of Care For Patients With Infection .................................................... 261
Chapter 22: Assessment Of The Skin, Hair, And Nails ............................................................. 273
Chapter 23: Concepts Of Care For Patients With Skin Problems ............................................ 282
Chapter 24: Assessment Of The Respiratory System .............................................................. 299
Chapter 25: Concepts Of Care For Patients Requiring Oxygen Therapy Or Tracheostomy .... 311
Chapter 26: Concepts Of Care For Patients With Noninfectious Upper Respiratory Problems
................................................................................................................................................. 322
,Chapter 27: Concepts Of Care For Patients With Noninfectious Lower Respiratory Problems
................................................................................................................................................. 335
Chapter 28: Concepts Of Care For Patients With Infectious Respiratory Problems ............... 356
Chapter 29: Critical Care Of Patients With Respiratory Emergencies ..................................... 372
Chapter 30: Assessment Of The Cardiovascular System ......................................................... 390
Chapter 31: Concepts Of Care For Patients With Dysrhythmias............................................. 405
Chapter 32: Concepts Of Care For Patients With Cardiac Problems ...................................... 422
Chapter 33: Concepts Of Care For Patients With Vascular Problems ..................................... 442
Chapter 34: Critical Care Of Patients With Shock ................................................................... 465
Chapter 35: Critical Care Of Patients With Acute Coronary Syndromes ................................. 477
Chapter 36: Assessment Of The Hematologic System ............................................................ 495
Chapter 37: Concepts Of Care For Patients With Hematologic Problems .............................. 503
Chapter 38: Assessment Of The Nervous System ................................................................... 523
Chapter 39: Concepts Of Care For Patients With Problems Of The Central Nervous System:
The Brain ................................................................................................................................. 538
Chapter 40: Concepts Of Care For Patients With Problems Of The Central Nervous System:
The Spinal Cord ....................................................................................................................... 556
Chapter 41: Critical Care Of Patients With Neurologic Emergencies ...................................... 572
Chapter 42: Assessment And Care Of Patients With Eye And Vision Problems ..................... 591
Chapter 43: Assessment And Care Of Patients With Ear And Hearing Problems ................... 604
Chapter 44: Assessment Of The Musculoskeletal System ...................................................... 615
Chapter 45: Concepts Of Care For Patients With Musculoskeletal Problems ........................ 623
Chapter 46: Concepts Of Care For Patients With Arthritis And Total Joint Arthroplasty........ 634
Chapter 47: Concepts Of Care For Patients With Musculoskeletal Trauma ........................... 651
Chapter 48: Assessment Of The Gastrointestinal System ....................................................... 669
Chapter 49: Concepts Of Care For Patients With Oral Cavity And Esophageal Problems ...... 678
Chapter 50: Concepts Of Care For Of Patients With Stomach Disorders ............................... 686
Chapter 51: Concepts Of Care For Patients With Noninflammatory Intestinal Disorders ...... 696
Chapter 52: Concepts Of Care For Patients With Inflammatory Intestinal Disorders ............ 712
Chapter 53: Concepts Of Care For Patients With Liver Problems ........................................... 727
,Chapter 54: Concepts Of Care For Patients With Problems Of The Biliary System And Pancreas
................................................................................................................................................. 740
Chapter 55: Concepts Of Care For Patients With Malnutrition: Undernutrition And Obesity 751
Chapter 56: Assessment Of The Endocrine System ................................................................ 762
Chapter 57: Concepts Of Care For Patients With Pituitary And Adrenal Gland Problems ..... 770
Chapter 58: Concepts Of Care For Patients With Problems Of The Thyroid And Parathyroid
Glands ..................................................................................................................................... 780
Chapter 59: Concepts Of Care For Patients With Diabetes Mellitus ...................................... 789
Chapter 60: Assessment Of The Renal/Urinary ...................................................................... 814
Chapter 61: Concepts Of Care For Patients With Urinary Problems ...................................... 824
Chapter 62: Concepts Of Care For Patients With Kidney Disorders ....................................... 839
Chapter 63: Concepts Of Care For Patients With Acute Kidney Injury And Chronic Kidney
Disease .................................................................................................................................... 849
Chapter 64: Assessment Of The Reproductive System ........................................................... 866
Chapter 65: Concepts Of Care For Patients With Breast Disorders ........................................ 872
Chapter 66: Concepts Of Care For Patients With Gynecologic Problems ............................... 882
Chapter 67: Concepts Of Care For Clients With Male Reproductive Problems ...................... 893
Chapter 68: Concepts Of Care For Transgender Patients ....................................................... 903
Chapter 69: Concepts Of Care For Patients With Sexually Transmitted Infections................. 910
,Chapter 01: Overview Of Professional Nursing Concepts For Medical-
Surgical Nursing
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A New Nurse Is Working With A Preceptor On A Medical-Surgical Unit. The Preceptor
Advises The New Nurse That Which Is The Priority When Working As A Professional Nurse?
A. Attending To Holistic Client Needs
B. Ensuring Client Safety
C. Not Making Medication Errors
D. Providing Client-Focused Care
ANSWER: B
All Actions Are Appropriate For The Professional Nurse. However, Ensuring Client Safety Is The
Priority. Health Care Errors Have Been Widely Reported For 25 Years, Many Of Which Result In
Client Injury, Death, And Increased Health Care Costs. There Are Several National And
International Organizations That Have Either Recommended Or Mandated Safety Initiatives.
Every Nurse Has The Responsibility To Guard The Client’s Safety. The Other Actions Are
Important For Quality Nursing, But They Are Not As Vital As Providing Safety. Not Making
Medication Errors Does Provide Safety, But Is Too Narrow In Scope To Be The Best Answer.
DIF: UnderstandingTOP: Integrated Process: Nursing Process: Intervention KEY: Client Safety
MSC: Client Needs Category: Safe And Effective Care Environment: Safety And Infection Control
2. A Nurse Is Orienting A New Client And Family To The Medical-Surgical Unit. What
Information Does The Nurse Provide To Best 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.
ANSWER: 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 Safety 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: UnderstandingTOP: Integrated Process: Teaching/Learning KEY: Client Safety
MSC: Client Needs Category: Safe And Effective Care Environment: Safety And Infection Control
3. A Nurse Is Caring For A Postoperative Client On The Surgical Unit. The Client’s Blood
Pressure Was 142/76 Mm Hg 30 Minutes Ago, And Now Is 88/50 Mm Hg. What Action Would
The Nurse Take First?
A. Call The Rapid Response Team.
B. Document And Continue To Monitor.
C. Notify The Primary Health Care Provider.
D. Repeat The Blood Pressure In 15 Minutes.
ANSWER: 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 Would Call The RRT. Changes In Blood Pressure, Mental Status,
Heart Rate, Temperature, Oxygen Saturation, And Last 2 Hours’ Urine Output Are Particularly
Significant And Are Part Of The Modified Early Warning System Guide. Documentation Is Vital,
But The Nurse Must Do More Than Document. The Primary Health Care Provider Would Be
Notified, But This Is Not More Important Than Calling The RRT. The Client’s Blood Pressure
Would Be Reassessed Frequently, But The Priority Is Getting The Rapid Care To The Client.
DIF: Applying TOP: Integrated Process: Communication And Documentation KEY: Rapid
Response Team (RRT), Clinical Judgment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
,4. A Nurse Wishes To Provide Client-Centered Care In All Interactions. Which Action By The
Nurse
Best Demonstrates This Concept?
A. Assesses For Cultural Influences Affecting Health Care.
B. Ensures That All The Client’s Basic Needs Are Met.
C. Tells The Client And Family About All Upcoming Tests.
D. Thoroughly Orients The Client And Family To The Room.
ANSWER: A
Showing Respect For The Client And Family’s Preferences And Needs Is Essential To Ensure A
Holistic Or “Whole-Person” Approach To Care. By Assessing The Effect Of The Client’s 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: UnderstandingTOP: Integrated Process: Culture And Spirituality KEY: Client-Centered
Care, Culture MSC: Client Needs Category: Psychosocial Integrity
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 Against Errors?
A. Bring A List Of All Medications And What They Are For.
B. Keep The Provider’s Phone Number By The Telephone.
C. Make Sure That All Providers Wash Hands Before Entering The Room.
D. Write Down The Name Of Each Caregiver Who Comes In The Room.
ANSWER: A
Medication Reconciliation Is A Formal Process In Which The Client’s Actual Current Medications
Are Compared To The Prescribed Medications At The Time Of Admission, Transfer, Or Discharge.
This National Client Safety Goal Is Important To Reduce Medication Errors. The Client Would Not
Have To Be Responsible For Providers Washing Their Hands, And Even If The Client Does So, This
Is Too Narrow To Be The Most Important Action To Prevent Errors. Keeping The Provider’s Phone
Number Nearby And Documenting Everyone Who Enters The Room Also Do Not Guarantee
Safety.
,DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Client Safety, Informatics
MSC: 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.
B. Gives The Client Accurate Information When Questioned.
C. Keeps The Promises Made To The Client And Family.
D. Treats The Client Fairly Compared To Other Clients.
ANSWER: A
Autonomy Is Self-Determination. The Client Would 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
Client Fairly Is Providing Social Justice.
DIF: Applying TOP: Integrated Process: Caring KEY: Ethics, Autonomy MSC: Client
Needs Category: Safe And Effective Care Environment: Management Of Care
7. A Nurse Asks A More Seasoned Colleague To Explain Best Practices When
Communicating With A Person From The Lesbian, Gay, Bisexual, Transgender, And
Questioning/Queer (LGBTQ) Community. What Answer By The Faculty Is Most Accurate?
A. Avoid Embarrassing The Client By Asking Questions.
B. Don’t Make Assumptions About His Or Her Health Needs.
C. Most LGBTQ People Do Not Want To Share Information.
D. No Differences Exist In Communicating With This Population.
,ANSWER: B
Many Members Of The LGBTQ Community Have Faced Discrimination From Health Care
Providers And May Be Reluctant To Seek Health Care. The Nurse Would 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: UnderstandingTOP: Integrated Process: Teaching/Learning
KEY: Health Care Disparities, LGBTQ MSC: Client Needs Category: Psychosocial Integrity
8. A Nurse Is Calling The On-Call Health Care Provider About A Client Who Had A
Hysterectomy 2 Days Ago And Has Pain That Is Unrelieved By The Prescribed Opioid Pain
Medication. Which Statement Comprises The Background Portion 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.”
C. “Dr. Smith Doesn’t Like Nonsteroidal Anti-Inflammatory Meds.”
D. “This Client Had A Vaginal Hysterectomy 2 Days Ago.”
ANSWER: 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 Health Care Provider Might Order. Situation Describes
What Is Happening Right Now That Must Be Communicated; The Client’s Surgery 2 Days Ago
Would Be Considered Background. Assessment Would Include An Analysis Of The Client’s
Problem; None Of The Options Has Assessment Information. Asking For A Different Pain
, Medication Is A Recommendation. Recommendation Is A Statement Of What Is Needed Or
What Outcome Is Desired.
DIF: Applying TOP: Integrated Process: Communication And Documentation KEY:
Teamwork And Collaboration, SBAR
MSC: Client Needs Category: Safe And Effective Care Environment: Management Of Care
9. A Nurse Working On A Cardiac Unit Delegated Taking Vital Signs To An Experienced
Assistive Personnel (AP). Four Hours Later, The Nurse Notes That The Client’s Blood Pressure
Taken By The AP Was Much Higher Than Previous Readings, And The Client’s Mental Status Has
Changed. What Action By The Nurse Would Most Likely Have Prevented This Negative
Outcome?
A. Determining If The AP Knew How To Take Blood Pressure
B. Double-Checking The AP By Taking Another Blood Pressure
C. Providing More Appropriate Supervision Of The AP
D. Taking The Blood Pressure Instead Of Delegating The Task
ANSWER: C
Supervision Is One Of The Five Rights Of Delegation And Includes Directing, Evaluating, And
Following Up On Delegated Tasks. The Nurse Would Either Have Asked The AP About The Vital
Signs Or Instructed The AP To Report Them Right Away. An Experienced AP Would Know How To
Take Vital Signs And The Nurse Would 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
AP And Are Permissible To Delegate. The Only Appropriate Answer Is That The Nurse Did Not
Provide Adequate Instruction To The AP.
DIF: Analyzing TOP: Integrated Process: Communication And Documentation KEY:
Teamwork And Collaboration, Delegation
MSC: Client Needs Category: Safe And Effective Care Environment: Management Of Care
10. A Newly Graduated Nurse In The Hospital States That Because Of Being So New,
Participation In Quality Improvement (QI) Projects Is Not Wise. What Response By The
Precepting Nurse Is Best?
A. “All Staff Nurses Are Required To Participate In Quality Improvement Here.”
B. “Even Being New, You Can Implement Activities Designed To Improve Care.”
C. “It’s Easy To Identify What Indicators Would Be Used To Measure Quality.”
