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