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SurgicalNursing,10th 2k 2k
Edition, DonnaD.
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Ignatavicius, Linda
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Workman,CherieR.
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Rebar, NicoleM.
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Heimgartner 2k
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Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing
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MULTIPLE CHOICE 2k
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1. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new
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nurse that which is the priority when working as a professional nurse?
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a. Attending to holistic client needs 2k 2k 2k 2k
b. Ensuring client safety 2k 2k
c. Not making medication errors 2k 2k 2k
d. Providing client-focused care 2k 2k
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ANS: B 2 k
All actions are appropriate for the professional nurse. However, ensuring client safety is the
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priority. Health care errors have been widely reported for 25 years, many of which result in
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client injury, death, and increased health care costs. There are several national and
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international organizations that have either recommended or mandated safety initiatives. Every 2k 2k 2k 2k 2k 2k 2k 2k 2k 2k
nurse has the responsibility to guard the client’s safety. The other actions are important for quality
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nursing, but they are not as vital as providing safety. Not making medication errors does provide
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safety, but is too narrow in scope to be the best answer.
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DIF: Understanding
KEY: Client safety
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T O P : In teg rated Process: Nursing Process: Intervention
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MSC: Client Needs Category:SafeandEffective Care Environment: Safety andInfection Control
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2. Anurseisorientinganewclient and family to t h e m e d i c a l - surgicalunit.Whatinformationdoes
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the nurse provide to best help the client promote his or her own safety?
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a. Encourage the client and family to be active partners. 2k 2k 2k 2k 2k 2k 2k 2k
b. Have the client monitor hand hygiene in caregivers.
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. 2k 2k 2k 2k 2k 2k 2k 2k 2k
ANS: abirb.com/test
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Each action could be important for the client or family to perform. However, encouraging the client
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to be active in his or her health care as a safety partner is the most critical. The other
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actions are very limited in scope and do not provide the broad protection that being active and
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involved does. 2k
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DIF: Understanding TOP: Integrated Process: Teaching/Learning 2 k 2k 2k
KEY: Client 2 k
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safety
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MSC: Client Needs Category:SafeandEffective Care Environment: Safety andInfection Control
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3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressure was
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142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nurse
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take first? 2k
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a. Call the Rapid Response Team. 2k 2k 2k 2k
b. Document and continue to monitor. 2k 2k 2k 2k
c. Notify the primary health care provider. 2k 2k 2k 2k abirb.com/test 2k
d. Repeat the blood pressure in 15 minutes. 2k 2k 2k 2k 2k 2k
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ANS:
2A purposeoftheRapidResponse Team (RRT) is t o intervene whenclientsaredeteriorating
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2k before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant
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2k change, the nurse would call the RRT. Changes in blood pressure, mental status, heart rate,
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2k temperature, oxygen saturation, and last 2 hours’ urine output are particularly significant and are 2k 2k
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2k part of the Modified Early Warning System guide. Documentation is vital, but the nurse must do
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2k more than document. The primary health care provider would be notified, but this is not more
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important than calling the RRT. The client’s blood pressure would be reassessed frequently, but
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2k the priority is getting the rapid care to the client.
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DIF: Applying TOP: Integrated Process: Communication and Documentation 2 k 2k 2k 2k 2k
KEY: Rapid Response Team (RRT), Clinical judgment
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MSC: ClientNeedsCategory:PhysiologicalIntegrity: Physiological Adaptation
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4. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse
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best demonstrates this concep t? 2k
a. Assesses for cultural influences affecting health care. 2k 2k
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b. Ensures that all the client’s basic needs are met. 2k 2k 2k 2k 2k 2k 2k 2k
c. Tells the client and family about all upcoming tests.
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d. Thoroughly orients the client and family to the room. 2k 2k 2k 2k 2k 2k 2k 2k
ANS: 2 k A
Showing respect for the client and family’s preferences and needs is essential to ensure a holistic or
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“whole-person” approach to care. By assessing the effect of the client’s culture on health care, this
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nurse is practicing client-focused care. Providing for basic needs does not demonstrate this
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competence. Simply telling the client about all upcoming tests is not
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providingempoweringeducation. Orienting the client andfamilytotheroomisanimportant safety 2k 2k
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measure, but not directly related to demonstrating client-centered care.
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DIF: Understanding T OP : In teg rated Process: Culture and Spirituality
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KEY: Client-centered care, Culture 2 k 2k 2k MSC: Client 2 k 2k 2k 2k 2k
5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse
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explain is the most important thing the client can do to protect against errors?
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a. Bring a list of all medications and what they are for.
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b. Keep the provider’s phone number by the telephone. 2k 2k 2k 2k 2k 2k 2k
c. Make sure that all providers wash hands before entering the room. 2k 2k 2k 2k 2k 2k 2k 2k 2k 2k
d. Write down the name of each caregiver who comes in the room. 2k 2k 2k 2k 2k abirb.com/test 2k 2k 2k 2k 2k 2k
ANS: 2 k A
Medication reconciliation is a formal process in which the client’s actual current medications are
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compared to the prescribed medications at the time of admission, transfer, or discharge. This
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National client Safety Goal is important to reduce medication errors. The client would not have to
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be responsible for providers washing their hands, and even if the client does so, this is too narrow to
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be the most important action to prevent errors. Keeping the provider’s phone number nearby and
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documenting everyone who enters the room also do not guarantee safety.
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DIF: Applying TOP:
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Int eg rat e d Pro ce ss: Te a c h in g/ L earning KEY: Client safety, 2k 2 k 2k
Informatics
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MSC: Client Needs Category:SafeandEffective Care Environment: Safety and Infection Control
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