,Chapter 1: Introduction to Medical-Surgical Nursing
Chapter 1: Introduction to Medical-Surgical Nursing
Test Bank
MULTIPLE CHOICE
1. Which action demonstrates that the nurse understands the purpose of the Rapid Response Team?
a. Monitoring the client for changes in postoperative status such as wound
infection
b. Documenting all changes observed in the client and maintaining a
postoperative flow sheet
c. Notifying the physician of the client‘s change in blood pressure from
140 to 88 mm Hg systolic
d. Notifying the physician of the client‘s increase in restlessness after
medication change
ANS: C
The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to
clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code
Team, which responds to client arrests, it intervenes rapidly for those who are beginning to decline
clinically. It would be appropriate for the RRT to intervene when the client has experienced a 52-
point drop in blood pressure. Monitoring the client‘s postoperative status, maintaining a
postoperative flow sheet, and notifying the physician of a change in the client‘s status after a
medication change would not be considered activities of the Rapid Response Team.
DIF: Cognitive Level: Comprehension/Understanding REF: pp. 2-3
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team)
,MSC: Integrated Process: Nursing Process (Assessment)
, 2. The Joint Commission focuses on safety in health care. Which action by the nurse reflects The
Joint Commission‘s main objective?
a. Performing range-of-motion exercises on the client three times each day
b. Ensuring that the client is eating 100% of the meals served to him or
her
c. Assessing the client‘s respirations when administering opioids
d. Delegating to the nursing assistant to give the client a complete bath
daily
ANS: C
It is important for the nurse to assess respirations of the client when administering opioids because
of the possibility of respiratory depression. The other interventions may or may not be necessary in
the care of the client and do not focus on safety.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control)
MSC: Integrated Process: Nursing Process (Assessment)
3. Which action by the nurse shows an understanding of the principle of self-determination?
a. Allowing a postoperative client to decide to take medication with fruit
juice rather than water
b. Allowing a teenager to decide not to go to a clinic when there is
evidence that she is having profuse vaginal bleeding
c. Allowing a parent to decide not to proceed with a lifesaving operation
for a 12-year-old client
Chapter 1: Introduction to Medical-Surgical Nursing
Test Bank
MULTIPLE CHOICE
1. Which action demonstrates that the nurse understands the purpose of the Rapid Response Team?
a. Monitoring the client for changes in postoperative status such as wound
infection
b. Documenting all changes observed in the client and maintaining a
postoperative flow sheet
c. Notifying the physician of the client‘s change in blood pressure from
140 to 88 mm Hg systolic
d. Notifying the physician of the client‘s increase in restlessness after
medication change
ANS: C
The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to
clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code
Team, which responds to client arrests, it intervenes rapidly for those who are beginning to decline
clinically. It would be appropriate for the RRT to intervene when the client has experienced a 52-
point drop in blood pressure. Monitoring the client‘s postoperative status, maintaining a
postoperative flow sheet, and notifying the physician of a change in the client‘s status after a
medication change would not be considered activities of the Rapid Response Team.
DIF: Cognitive Level: Comprehension/Understanding REF: pp. 2-3
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team)
,MSC: Integrated Process: Nursing Process (Assessment)
, 2. The Joint Commission focuses on safety in health care. Which action by the nurse reflects The
Joint Commission‘s main objective?
a. Performing range-of-motion exercises on the client three times each day
b. Ensuring that the client is eating 100% of the meals served to him or
her
c. Assessing the client‘s respirations when administering opioids
d. Delegating to the nursing assistant to give the client a complete bath
daily
ANS: C
It is important for the nurse to assess respirations of the client when administering opioids because
of the possibility of respiratory depression. The other interventions may or may not be necessary in
the care of the client and do not focus on safety.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control)
MSC: Integrated Process: Nursing Process (Assessment)
3. Which action by the nurse shows an understanding of the principle of self-determination?
a. Allowing a postoperative client to decide to take medication with fruit
juice rather than water
b. Allowing a teenager to decide not to go to a clinic when there is
evidence that she is having profuse vaginal bleeding
c. Allowing a parent to decide not to proceed with a lifesaving operation
for a 12-year-old client
