TEST BANK for Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care 11th Edition by Donna D. Ignatavicius, All chapters 1 - 74

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Overview ofProfessionalNursingConceptsforMedical- z0 0z 0z 0z 0z 0z




Surgical Nursing
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MULTIPLE CHOICE z0




1. A nurse wishes to provide client-
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centered care in all interactions. Which action by the nurse best demonstrates this concept?
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a. Assesses for cultural influences affecting health care
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b. Ensures that all the clients basic needs are met
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c. Tells the client and family about all upcoming tests
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d. Thoroughly orients the client and family to the room z0 z0 z0 z0 z0 z0 z0 z0




ANS: A z0


Competency in client- z0 z0


focused care is demonstrated when the nurse focuses on communication, culture, respect compassion, client
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ed ucation, and empowerment. By assessing the effect of the clients culture on health care, this nurse i
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s practici ng client-
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focused care. Providing for basic needs does not demonstrate this competence.
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Simply telling the client about all upcoming tests is not providing empowering education. Orienting the cli
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ent and family to the room is an important safety measure, but not directly related to demonstrating client
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- centered care.
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DIF: Understanding/Comprehension REF: 3
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KEY: Patient- z0


centered care| culture MSC: Integrated Process: Caring NOT: Client N
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eeds Category: Psychosocial Integrity
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2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76
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mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
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a. Call the Rapid Response Team.
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b. Document and continue to monitor. z0 z0 z0 z0


c. Notify the primary care provider. z0 z0 z0 z0


d. Repeat blood pressure measurement in 15 minutes.
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ANS: A z0


The purpose of the Rapid Response Team (RRT) is to intervene when clients are deterioratin
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g before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant chan
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ge, the nurse s hould call the RRT. Changes in blood pressure, mental status, heart rate, and pain are par
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ticularly significant. Documentation is vital, but the nurse must do more than document. The primary care
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0provider should be no tified, but this is not the priority over calling the RRT. The clients blood pressure s
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hould be reassessed freq uently, but the priority is getting the rapid care to the client.
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DIF: Applying/Application REF: 3
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KEY: Rapid Response Team (RRT)| medical emergencies M
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S C: Integrated Process: Communication and Documentation
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NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
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3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide t
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o h elp the client promote his or her own safety?
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a. Encourage the client and family to be active partners. z0 z0 z0 z0 z0 z0 z0 z0


b. Have the client monitor hand hygiene in caregivers.
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c. Offer the family the opportunity to stay with the client.
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d. Tell the client to always wear his or her armband.
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ANS: A z0


Each action could be important for the client or family to perform. However, encouraging the
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client to be active in his or her health care as a partner is the most critical. The other actions are very l
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imited in scope a nd do not provide the broad protection that being active and involved does.
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DIF: Understanding/Comprehension REF: 3 KE
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