,
,
, Chapter 01:Overview of Professional Nursing Concepts for Medical-
NK NK NK NK NK NK NK
Surgical Nursing.
NK NK
MULTIPLE CHOICE NK
1. A nurse wishes to provide client-
NK NK NK NK NK
centered care in all interactions. Which action by the nurse best demonstrates this concept?
NK NK NK NK NK NK NK NK NK NK NK NK NK
a. Assesses for cultural influences affecting health care
NK NK NK NK NK NK
b. Ensures that all the clients basic needs are met
NK NK NK NK NK NK NK NK
c. Tells the client and family about all upcoming tests
NK NK NK NK NK NK NK NK
d. Thoroughly orients the client and family to the room NK NK NK NK NK NK NK NK
ANS: A NK
Rationale:Competency in client- NK NK
focused care is demonstrated when the nurse focuses on communication, culture, respect compassion, cli
NK NK NK NK NK NK NK NK NK NK NK N K NK
ent education, and empowerment. By assessing the effect of the clients culture on health care, this nur
NK NK NK NK NK NK NK NK NK NK NK NK NK NK N K NK
se is practicing client-
NK NK NK
focused care. Providing for basic needs does not demonstrate this competence.
NK NK NK NK NK NK NK NK NK NK
Simply telling the client about all upcoming tests is not providing empowering education. Orienting the
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
client and family to the room is an important safety measure, but not directly related to demonstrating cli
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
ent-centered care. NK
DIF: Understanding/Comprehension REF: 3
NK NK NK
KEY: Patient- NK
centered care| culture MSC: Integrated Process: Caring NOT: Client N
NK NK NK NK NK NK NK NK NK
eeds Category: Psychosocial Integrity
NK NK NK
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/7
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
6 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
a. Call the Rapid Response Team.
NK NK NK NK
b. Document and continue to monitor. NK NK NK NK
c. Notify the primary care provider.
NK NK NK NK
d. Repeat blood pressure measurement in 15 minutes.
NK NK NK NK NK NK
ANS: A NK
Rationale:The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriora
NK N K NK NK NK NK NK N K NK NK NK NK NK N K
ting before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant ch
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
ange, the nurse should call the RRT. Changes in blood pressure, mental status, heart rate, and pain are
NK NK NK N K NK NK NK NK NK NK NK NK NK NK NK NK NK NK
particularly significant. NK
Documentation is vital, but the nurse must do more than document. The primary care provider should
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
be notified, but this is not the priority over calling the RRT. The clients blood pressure should be re
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
assessed frequently, but the priority is getting the rapid care to the client.
NK NK NK NK NK NK NK NK NK NK NK NK
DIF: Applying/Application REF: 3
NK NK NK
KEY: Rapid Response Team (RRT)| medical emergencies M
NK NK NK NK NK NK NK
SC: Integrated Process: Communication and Documentation
NK NK NK NK NK
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
NK NK NK NK NK NK NK
3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse pro
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
vide to help the client promote his or her own safety?
NK NK NK NK NK NK NK NK NK NK
a. Encourage the client and family to be active partners.
NK NK NK NK NK NK NK NK
b. Have the client monitor hand hygiene in caregivers.
NK NK NK NK NK NK NK
c. Offer the family the opportunity to stay with the client.
NK NK NK NK NK NK NK NK NK
d. Tell the client to always wear his or her armband.
NK NK NK NK NK NK NK NK NK
ANS: A NK
Rationale:Each action could be important for the client or family to perform. However, encouraging the
NK NK NK NK NK NK NK NK NK NK NK NK NK NK
N client to be active in his or her health care as a partner is the most critical. The other actions are ver
K NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
y limited in scope and do not provide the broad protection that being active and involved does.
NK NK NK NK N K NK NK NK NK NK NK NK NK NK NK NK
DIF: Understanding/Comprehension REF: 3 KE
NK NK NK NK
,
, Chapter 01:Overview of Professional Nursing Concepts for Medical-
NK NK NK NK NK NK NK
Surgical Nursing.
NK NK
MULTIPLE CHOICE NK
1. A nurse wishes to provide client-
NK NK NK NK NK
centered care in all interactions. Which action by the nurse best demonstrates this concept?
NK NK NK NK NK NK NK NK NK NK NK NK NK
a. Assesses for cultural influences affecting health care
NK NK NK NK NK NK
b. Ensures that all the clients basic needs are met
NK NK NK NK NK NK NK NK
c. Tells the client and family about all upcoming tests
NK NK NK NK NK NK NK NK
d. Thoroughly orients the client and family to the room NK NK NK NK NK NK NK NK
ANS: A NK
Rationale:Competency in client- NK NK
focused care is demonstrated when the nurse focuses on communication, culture, respect compassion, cli
NK NK NK NK NK NK NK NK NK NK NK N K NK
ent education, and empowerment. By assessing the effect of the clients culture on health care, this nur
NK NK NK NK NK NK NK NK NK NK NK NK NK NK N K NK
se is practicing client-
NK NK NK
focused care. Providing for basic needs does not demonstrate this competence.
NK NK NK NK NK NK NK NK NK NK
Simply telling the client about all upcoming tests is not providing empowering education. Orienting the
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
client and family to the room is an important safety measure, but not directly related to demonstrating cli
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
ent-centered care. NK
DIF: Understanding/Comprehension REF: 3
NK NK NK
KEY: Patient- NK
centered care| culture MSC: Integrated Process: Caring NOT: Client N
NK NK NK NK NK NK NK NK NK
eeds Category: Psychosocial Integrity
NK NK NK
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/7
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
6 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
a. Call the Rapid Response Team.
NK NK NK NK
b. Document and continue to monitor. NK NK NK NK
c. Notify the primary care provider.
NK NK NK NK
d. Repeat blood pressure measurement in 15 minutes.
NK NK NK NK NK NK
ANS: A NK
Rationale:The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriora
NK N K NK NK NK NK NK N K NK NK NK NK NK N K
ting before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant ch
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
ange, the nurse should call the RRT. Changes in blood pressure, mental status, heart rate, and pain are
NK NK NK N K NK NK NK NK NK NK NK NK NK NK NK NK NK NK
particularly significant. NK
Documentation is vital, but the nurse must do more than document. The primary care provider should
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
be notified, but this is not the priority over calling the RRT. The clients blood pressure should be re
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
assessed frequently, but the priority is getting the rapid care to the client.
NK NK NK NK NK NK NK NK NK NK NK NK
DIF: Applying/Application REF: 3
NK NK NK
KEY: Rapid Response Team (RRT)| medical emergencies M
NK NK NK NK NK NK NK
SC: Integrated Process: Communication and Documentation
NK NK NK NK NK
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
NK NK NK NK NK NK NK
3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse pro
NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
vide to help the client promote his or her own safety?
NK NK NK NK NK NK NK NK NK NK
a. Encourage the client and family to be active partners.
NK NK NK NK NK NK NK NK
b. Have the client monitor hand hygiene in caregivers.
NK NK NK NK NK NK NK
c. Offer the family the opportunity to stay with the client.
NK NK NK NK NK NK NK NK NK
d. Tell the client to always wear his or her armband.
NK NK NK NK NK NK NK NK NK
ANS: A NK
Rationale:Each action could be important for the client or family to perform. However, encouraging the
NK NK NK NK NK NK NK NK NK NK NK NK NK NK
N client to be active in his or her health care as a partner is the most critical. The other actions are ver
K NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK NK
y limited in scope and do not provide the broad protection that being active and involved does.
NK NK NK NK N K NK NK NK NK NK NK NK NK NK NK NK
DIF: Understanding/Comprehension REF: 3 KE
NK NK NK NK