Test Bank For Medical-Surgical
Nursing Concepts for Inter
professional Collaborative Care
10th Edition by Donna
Ignatavicius, 9780323612425,
Chapter 1-69 Complete Questions
and Answers A+
•
,1. 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?
a. Call the Rapid Response Team.
, b. Document and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes.
Choose matching definition
CORRECT 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 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
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
CORRECT ANSWER: 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
CORRECT 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 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
CORRECT ANSWER: 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
Nursing Concepts for Inter
professional Collaborative Care
10th Edition by Donna
Ignatavicius, 9780323612425,
Chapter 1-69 Complete Questions
and Answers A+
•
,1. 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?
a. Call the Rapid Response Team.
, b. Document and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes.
Choose matching definition
CORRECT 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 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
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
CORRECT ANSWER: 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
CORRECT 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 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
CORRECT ANSWER: 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
