, ◦ Timby's Introductory Medical-Surgical Nursing 13th Edition Moreno Test Bank
ho ho ho ho ho ho ho ho
Chapter 1 ho Concepts and Trends in Healthcare ho ho ho ho
◦ A new nurse is working with a preceptor on an inpatient medical-
ho ho ho ho ho ho ho ho ho ho ho
surgical unit. The preceptor advises the student that which is the priority whe
ho ho ho ho ho ho ho ho ho ho ho ho
n working as a professional nurse?
ho ho ho ho ho
◦ Attending to holistic client needs ho ho ho ho
◦ Ensuring client safety ho ho
◦ Not making medication errors
ho ho ho
◦
Providing client- ho
focused care A ho ho ho
NS: B ho
◦ All actions are appropriate for the professional nurse. However, ensu
ho ho ho ho ho ho ho ho h o
ring client safety is the priority. Up to 98,000 deaths result each year from erro
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
rs in hospital care, according to the 2000 Institute of Medicine report. Many more cli
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
ents have suffered injuries and less serious outcomes. Every nurse has the responsibil
ho ho ho ho ho ho ho ho ho ho ho ho
ity to guard the clients safety.
ho ho ho ho ho
◦ DIF: Understanding/Comprehension REF: 2 ho ho ho
KEY: Patient safety MSC: Integrated Process: Nursing Pr
ho ho ho ho ho ho ho ho
ocess: Intervention ho
◦ NOT: Client Needs Category: Safe and Effective Car ho ho ho ho ho ho ho
e Environment: Safety and Infection Control
ho ho ho ho ho
◦ A nurse is orienting a new client and family to the inpatient unit. What inf
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
ormation does the nurse provide to help the client promote his or her own
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
safety?
◦ Encourage the client and family to be active partners.
ho ho ho ho ho ho ho ho
◦ Have the client monitor hand hygiene in caregivers.
ho ho ho ho ho ho ho
◦ Offer the family the opportunity to stay with the client.
ho ho ho ho ho ho ho ho ho
◦
Tell the client to always wear his ho ho ho ho ho ho ho
or her armband. ANS: A ho ho ho ho
◦ Each action could be important for the client or family to perform. ho ho ho ho ho ho ho ho ho ho ho h
oHowever, encouraging the client to be active in his or her health care as a partne
ho ho ho ho ho ho ho ho ho ho ho ho ho ho ho
r is the most critical. The other actions are
ho ho ho ho ho ho ho ho
◦
◦ very limited in scope and do not provide the broad protection th ho ho ho ho ho ho ho ho ho ho ho
at being active and involved does.
ho ho ho ho ho
◦ DIF: Understanding/Comprehension REF: 3 ho ho ho
KEY: Patient safety MSC: Integrated Process: Teaching/
ho ho ho ho ho ho ho ho
Learning
◦ NOT: Client Needs Category: Safe and Effective Care ho ho ho ho ho ho ho
,Environment: Safety and Infection Control ho ho ho ho
◦ A nurse is caring for a postoperative client on the surgical unit. The clients blo
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
od pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. W
ho ho ho ho ho ho ho ho ho ho ho ho ho ho ho
hat action by the nurse is best?
ho ho ho ho ho ho
◦ Call the Rapid Response Team.
ho ho ho ho
◦ Document and continue to monitor. ho ho ho ho
◦ Notify the primary care provider.
ho ho ho ho
◦
Repeat blood pressure measurement ho ho ho
in 15 minutes. ANS: A
ho ho ho ho ho
◦ The purpose of the Rapid Response Team (RRT) is to intervene when ho ho ho ho ho ho ho ho ho ho ho ho
clients are deteriorating before they suffer either respiratory or cardiac arrest. Since th
ho ho ho ho ho ho ho ho ho ho ho ho
e client has manifested a significant change, the nurse should call the RRT. Changes
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
in blood pressure, mental status, heart rate, and pain are particularly significant. Docu
ho ho ho ho ho ho ho ho ho ho ho ho
mentation is vital, but the nurse must do more than document. The primary care prov
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
ider should be notified, but this is not the priority over calling the RRT. The clien
ho ho ho ho ho ho ho ho ho ho ho h o ho ho h o
ts blood pressure should be reassessed frequently, but the priority is getting
ho ho ho ho ho ho ho ho ho ho ho
the rapid care to the client. ho ho ho ho ho
◦ DIF: Applying/Application REF: 3
ho ho ho
◦ KEY: Rapid Response Team (RRT) ho ho ho ho
| medical emergencies MSC: Integrated Process:
ho ho ho ho ho
Communication and Documentation ho ho
◦ NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
ho ho ho ho ho ho ho
◦
◦ A nurse wishes to provide client-
ho ho ho ho ho
centered care in all interactions. Which action by the nurse best demon
ho ho ho ho ho ho ho ho ho ho ho
strates this concept? ho ho
◦ Assesses for cultural influences affecting health care ho ho ho ho ho ho
◦ Ensures that all the clients basic needs are met
ho ho ho ho ho ho ho ho
◦ Tells the client and family about all upcoming tests
ho ho ho ho ho ho ho ho
◦
Thoroughly orients the client an ho ho ho ho
d family to the room ANS: A
ho ho ho ho ho ho
◦ Competency in client- ho ho
focused care is demonstrated when the nurse focuses on communication, culture,
ho ho ho ho ho ho ho ho ho ho
respect, compassion, client education, and empowerment. By assessing the effec
ho ho ho ho ho ho ho ho ho ho
t of the
ho ho
◦
◦ clients culture on health care, this nurse is practicing client- ho ho ho ho ho ho ho ho ho
focused care. Providing for basic needs does not demonstrate this competence. Sim
ho ho ho ho h o ho ho ho ho ho ho
ply telling the client about all upcoming tests is not providing empowering educatio
ho ho ho ho ho ho ho ho ho ho ho ho
n. Orienting the client and family to the room is an important safety measure, but n
ho ho ho ho ho ho ho ho ho ho ho ho ho ho ho
ot directly related to demonstrating client-centered care.
ho h o ho ho ho h o
◦ DIF: Understanding/Comprehension REF: 3
ho ho ho
, ◦ KEY: Patient- ho
centered care| culture MSC: Integrated Process: Caring
ho ho ho ho ho ho ho
NOT: Client Needs Category:
ho ho ho
Psychosocial Integrity ho
◦ A client is going to be admitted for a scheduled surgical procedure. Whi
ho ho ho ho ho ho ho ho ho ho ho ho
ch action does the nurse explain is the most important thing the client ca
ho ho ho ho ho ho ho ho ho ho ho ho ho
n do to protect against errors?
ho h o ho ho ho
◦ Bring a list of all medications and what they are for.
ho ho ho ho ho ho ho ho ho ho
◦ Keep the doctors phone number by the telephone.
ho ho ho ho ho ho ho
◦ Make sure all providers wash hands before entering the room.
ho ho ho ho ho ho ho ho h o
◦ Write down the name of each caregiver whho ho ho ho ho ho ho
o comes in the room. ANS: A
ho ho ho ho ho ho
◦ Medication errors are the most common type of health care mistake. ho ho ho ho ho ho ho ho ho ho ho
The Joint Commissions Speak Up campaign encourages clients to help ensure their
ho ho ho ho ho ho ho ho ho ho ho ho
safety. One recommendation is for clients to know all their medications and why th
ho ho ho ho ho ho ho ho ho ho ho ho ho
ey take them. This will help prevent medication errors.
ho ho ho ho ho ho ho ho
◦ DIF: Applying/Application REF: 4
ho ho ho
◦ KEY: Speak Up campaign| patient safety MSC: Integrated Pr ho ho ho ho ho ho ho ho
ocess: Teaching/Learning NOT: Client Needs Category: Safe and Effective
ho ho ho ho ho ho ho ho ho
Care Environment: Safety and Infection Control
ho ho ho ho ho
◦ Which action by the nurse working with a client best demonstrates respect fo
ho ho ho ho ho ho ho ho ho ho ho ho
r autonomy?
h o
◦ Asks if the client has questions before signing a consent
ho ho ho ho ho ho ho ho ho
◦ Gives the client accurate information when questioned
ho ho ho ho ho ho
◦ Keeps the promises made to the client and family
ho ho ho ho ho ho ho ho
◦
Treats the client fairly c ho ho ho ho
ompared to other clients ho ho ho ho
ANS: A ho
◦ Autonomy is self- ho ho
determination. The client should make decisions regarding care. When the nurse obta
ho ho ho ho ho ho ho ho ho ho ho
ins a signature on the consent form, assessing if the client still has questions is vit
ho ho ho ho ho ho ho ho h o ho ho ho ho ho ho
al, because without full information the client cannot practice autonomy. Giving acc
ho ho ho ho ho ho ho ho ho ho ho
urate information is practicing with veracity. Keeping promises is upholding fidelity.
ho ho ho ho ho ho ho ho ho ho h
oTreating the ho
◦
◦ client fairly is providing social justice.
ho ho ho ho ho
◦
◦ DIF: Applying/Application REF: 4
ho ho ho
◦ KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
ho ho ho ho ho ho ho
◦ NOT: Client Needs Category: Safe and Effective Care Environment: Manageme
ho ho ho ho ho ho ho ho ho
nt
of Care
ho
ho ho ho ho ho ho ho ho
Chapter 1 ho Concepts and Trends in Healthcare ho ho ho ho
◦ A new nurse is working with a preceptor on an inpatient medical-
ho ho ho ho ho ho ho ho ho ho ho
surgical unit. The preceptor advises the student that which is the priority whe
ho ho ho ho ho ho ho ho ho ho ho ho
n working as a professional nurse?
ho ho ho ho ho
◦ Attending to holistic client needs ho ho ho ho
◦ Ensuring client safety ho ho
◦ Not making medication errors
ho ho ho
◦
Providing client- ho
focused care A ho ho ho
NS: B ho
◦ All actions are appropriate for the professional nurse. However, ensu
ho ho ho ho ho ho ho ho h o
ring client safety is the priority. Up to 98,000 deaths result each year from erro
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
rs in hospital care, according to the 2000 Institute of Medicine report. Many more cli
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
ents have suffered injuries and less serious outcomes. Every nurse has the responsibil
ho ho ho ho ho ho ho ho ho ho ho ho
ity to guard the clients safety.
ho ho ho ho ho
◦ DIF: Understanding/Comprehension REF: 2 ho ho ho
KEY: Patient safety MSC: Integrated Process: Nursing Pr
ho ho ho ho ho ho ho ho
ocess: Intervention ho
◦ NOT: Client Needs Category: Safe and Effective Car ho ho ho ho ho ho ho
e Environment: Safety and Infection Control
ho ho ho ho ho
◦ A nurse is orienting a new client and family to the inpatient unit. What inf
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
ormation does the nurse provide to help the client promote his or her own
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
safety?
◦ Encourage the client and family to be active partners.
ho ho ho ho ho ho ho ho
◦ Have the client monitor hand hygiene in caregivers.
ho ho ho ho ho ho ho
◦ Offer the family the opportunity to stay with the client.
ho ho ho ho ho ho ho ho ho
◦
Tell the client to always wear his ho ho ho ho ho ho ho
or her armband. ANS: A ho ho ho ho
◦ Each action could be important for the client or family to perform. ho ho ho ho ho ho ho ho ho ho ho h
oHowever, encouraging the client to be active in his or her health care as a partne
ho ho ho ho ho ho ho ho ho ho ho ho ho ho ho
r is the most critical. The other actions are
ho ho ho ho ho ho ho ho
◦
◦ very limited in scope and do not provide the broad protection th ho ho ho ho ho ho ho ho ho ho ho
at being active and involved does.
ho ho ho ho ho
◦ DIF: Understanding/Comprehension REF: 3 ho ho ho
KEY: Patient safety MSC: Integrated Process: Teaching/
ho ho ho ho ho ho ho ho
Learning
◦ NOT: Client Needs Category: Safe and Effective Care ho ho ho ho ho ho ho
,Environment: Safety and Infection Control ho ho ho ho
◦ A nurse is caring for a postoperative client on the surgical unit. The clients blo
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
od pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. W
ho ho ho ho ho ho ho ho ho ho ho ho ho ho ho
hat action by the nurse is best?
ho ho ho ho ho ho
◦ Call the Rapid Response Team.
ho ho ho ho
◦ Document and continue to monitor. ho ho ho ho
◦ Notify the primary care provider.
ho ho ho ho
◦
Repeat blood pressure measurement ho ho ho
in 15 minutes. ANS: A
ho ho ho ho ho
◦ The purpose of the Rapid Response Team (RRT) is to intervene when ho ho ho ho ho ho ho ho ho ho ho ho
clients are deteriorating before they suffer either respiratory or cardiac arrest. Since th
ho ho ho ho ho ho ho ho ho ho ho ho
e client has manifested a significant change, the nurse should call the RRT. Changes
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
in blood pressure, mental status, heart rate, and pain are particularly significant. Docu
ho ho ho ho ho ho ho ho ho ho ho ho
mentation is vital, but the nurse must do more than document. The primary care prov
ho ho ho ho ho ho ho ho ho ho ho ho ho ho
ider should be notified, but this is not the priority over calling the RRT. The clien
ho ho ho ho ho ho ho ho ho ho ho h o ho ho h o
ts blood pressure should be reassessed frequently, but the priority is getting
ho ho ho ho ho ho ho ho ho ho ho
the rapid care to the client. ho ho ho ho ho
◦ DIF: Applying/Application REF: 3
ho ho ho
◦ KEY: Rapid Response Team (RRT) ho ho ho ho
| medical emergencies MSC: Integrated Process:
ho ho ho ho ho
Communication and Documentation ho ho
◦ NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
ho ho ho ho ho ho ho
◦
◦ A nurse wishes to provide client-
ho ho ho ho ho
centered care in all interactions. Which action by the nurse best demon
ho ho ho ho ho ho ho ho ho ho ho
strates this concept? ho ho
◦ Assesses for cultural influences affecting health care ho ho ho ho ho ho
◦ Ensures that all the clients basic needs are met
ho ho ho ho ho ho ho ho
◦ Tells the client and family about all upcoming tests
ho ho ho ho ho ho ho ho
◦
Thoroughly orients the client an ho ho ho ho
d family to the room ANS: A
ho ho ho ho ho ho
◦ Competency in client- ho ho
focused care is demonstrated when the nurse focuses on communication, culture,
ho ho ho ho ho ho ho ho ho ho
respect, compassion, client education, and empowerment. By assessing the effec
ho ho ho ho ho ho ho ho ho ho
t of the
ho ho
◦
◦ clients culture on health care, this nurse is practicing client- ho ho ho ho ho ho ho ho ho
focused care. Providing for basic needs does not demonstrate this competence. Sim
ho ho ho ho h o ho ho ho ho ho ho
ply telling the client about all upcoming tests is not providing empowering educatio
ho ho ho ho ho ho ho ho ho ho ho ho
n. Orienting the client and family to the room is an important safety measure, but n
ho ho ho ho ho ho ho ho ho ho ho ho ho ho ho
ot directly related to demonstrating client-centered care.
ho h o ho ho ho h o
◦ DIF: Understanding/Comprehension REF: 3
ho ho ho
, ◦ KEY: Patient- ho
centered care| culture MSC: Integrated Process: Caring
ho ho ho ho ho ho ho
NOT: Client Needs Category:
ho ho ho
Psychosocial Integrity ho
◦ A client is going to be admitted for a scheduled surgical procedure. Whi
ho ho ho ho ho ho ho ho ho ho ho ho
ch action does the nurse explain is the most important thing the client ca
ho ho ho ho ho ho ho ho ho ho ho ho ho
n do to protect against errors?
ho h o ho ho ho
◦ Bring a list of all medications and what they are for.
ho ho ho ho ho ho ho ho ho ho
◦ Keep the doctors phone number by the telephone.
ho ho ho ho ho ho ho
◦ Make sure all providers wash hands before entering the room.
ho ho ho ho ho ho ho ho h o
◦ Write down the name of each caregiver whho ho ho ho ho ho ho
o comes in the room. ANS: A
ho ho ho ho ho ho
◦ Medication errors are the most common type of health care mistake. ho ho ho ho ho ho ho ho ho ho ho
The Joint Commissions Speak Up campaign encourages clients to help ensure their
ho ho ho ho ho ho ho ho ho ho ho ho
safety. One recommendation is for clients to know all their medications and why th
ho ho ho ho ho ho ho ho ho ho ho ho ho
ey take them. This will help prevent medication errors.
ho ho ho ho ho ho ho ho
◦ DIF: Applying/Application REF: 4
ho ho ho
◦ KEY: Speak Up campaign| patient safety MSC: Integrated Pr ho ho ho ho ho ho ho ho
ocess: Teaching/Learning NOT: Client Needs Category: Safe and Effective
ho ho ho ho ho ho ho ho ho
Care Environment: Safety and Infection Control
ho ho ho ho ho
◦ Which action by the nurse working with a client best demonstrates respect fo
ho ho ho ho ho ho ho ho ho ho ho ho
r autonomy?
h o
◦ Asks if the client has questions before signing a consent
ho ho ho ho ho ho ho ho ho
◦ Gives the client accurate information when questioned
ho ho ho ho ho ho
◦ Keeps the promises made to the client and family
ho ho ho ho ho ho ho ho
◦
Treats the client fairly c ho ho ho ho
ompared to other clients ho ho ho ho
ANS: A ho
◦ Autonomy is self- ho ho
determination. The client should make decisions regarding care. When the nurse obta
ho ho ho ho ho ho ho ho ho ho ho
ins a signature on the consent form, assessing if the client still has questions is vit
ho ho ho ho ho ho ho ho h o ho ho ho ho ho ho
al, because without full information the client cannot practice autonomy. Giving acc
ho ho ho ho ho ho ho ho ho ho ho
urate information is practicing with veracity. Keeping promises is upholding fidelity.
ho ho ho ho ho ho ho ho ho ho h
oTreating the ho
◦
◦ client fairly is providing social justice.
ho ho ho ho ho
◦
◦ DIF: Applying/Application REF: 4
ho ho ho
◦ KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
ho ho ho ho ho ho ho
◦ NOT: Client Needs Category: Safe and Effective Care Environment: Manageme
ho ho ho ho ho ho ho ho ho
nt
of Care
ho
