Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e
bn bn bn bn bn bn bn bn bn bn 1
,Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e
bn bn bn bn bn bn bn bn bn bn 2
Table of Contents bn bn
Table of Contents bn bn Overview of Professional Nursing Concepts for Medical- bn bn bn bn bn bn
Surgical Nursing1 bn bn
Chapter 01: Overview of Professional Nursing Concepts for Medical-
bn bn 3 bn bn bn bn bn bn
Surgical Nursing Chapter 02: Overview of Health Concepts for Medical-
bn bn 8 bn bn bn bn bn bn bn
Surgical Nursing bn 13
Chapter 03: Common Health Problems of Older Adults Chapt
bn bn 20 bn bn bn bn bn bn
er 04: Assessment and Care of Patients with Pain Chapter 05
bn bn bn 32 bn bn bn bn bn bn bn
: Genetic Concepts for Medical-Surgical Nursing
bn bn bn 38 bn bn
Chapter 06: Rehabilitation Concepts for Chronic and Disabling Health Problems Chapt
bn bn 44 bn bn bn bn bn bn bn bn
er 07: End-of-Life Care
bn bn bn 50
Chapter 08: Concepts of Emergency and Trauma Nursing
bn bn 56 bn bn bn bn bn
Chapter 09: Care of Patients with Common Environmental Emergencies Chapt
bn bn bn 62bn bn bn bn bn bn
er 10: Concepts of Emergency and Disaster Preparedness
bn bn bn bn 68 bn bn bn
Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances C
bn bn 76 bn bn bn bn bn bn bn bn bn bn
hapter 12: Assessment and Care of Patients with Acid-Base Imbalances
bn bn 83 bn bn bn bn bn bn bn
Chapter 13: Infusion Therapy bn bn 94 bn
Chapter 14: Care of Preoperative Patients Chapt
bn bn bn 103 bn bn bn
er 15: Care of Intraoperative Patients Chapter 16:
bn bn bn bn 109 bn bn bn
Care of Postoperative Patients Chapter 17: Infla
bn bn bn 116 bn bn bn bn
mmation and Immunity bn bn 122
Chapter 18: Care of Patients with Arthritis and Other Connective Tissue Diseases Cha
bn bn bn 138 bn bn bn bn bn bn bn bn bn
pter 19: Care of Patients with HIV Disease
bn bn bn bn 147 bn bn bn
Chapter 20: Care of Patients with Hypersensitivity (Allergy) and Autoimmunity
bn bn bn 152 bn bn bn bn bn bn bn
Chapter 21: Cancer Development bn bn 157
bn
Chapter 22: Care of Patients with Cancer Chapt
bn bn bn 167 bn bn bn bn
er 23: Care of Patients with Infection
bn bn bn bn 174 bn bn
Chapter 24: Assessment of the Skin, Hair, and Nails Ch
bn bn 179 bn bn bn bn bn bn bn
apter 25: Care of Patients with Skin Problems Chapter
bn bn bn bn 196 bn bn bn bn bn
26: Care of Patients with Burns
bn bn bn 213 bn bn
Chapter 27: Assessment of the Respiratory System
bn bn 220 bn bn bn bn
Chapter 28: Care of Patients Requiring Oxygen Therapy or Tracheostomy Cha
bn bn bn 226 bn bn bn bn bn bn bn
pter 29: Care of Patients with Noninfectious Upper Respiratory Problems Chapt
bn bn bn bn 233 bn bn bn bn bn bn
er 30: Care of Patients with Noninfectious Lower Respiratory Problems Chapter
bn bn bn bn 245 bn bn bn bn bn bn
31: Care of Patients with Infectious Respiratory Problems
bn bn bn bn 256 bn bn bn bn
Chapter 32: Care of Critically Ill Patients with Respiratory Problems Chapt
bn bn bn 269 bn bn bn bn bn bn bn
er 33: Assessment of the Cardiovascular System
bn bn bn 278 bn bn bn
Chapter 34: Care of Patients with Dysrhythmias Chapt
bn bn bn 287 bn bn bn bn
er 35: Care of Patients with Cardiac Problems Chapter
bn bn bn bn 298 bn bn bn bn bn
36: Care of Patients with Vascular Problems Chapter 3
bn bn bn 310 bn bn bn bn bn
7: Care of Patients with Shock
bn bn bn bn 317 bn
Chapter 38: Care of Patients with Acute Coronary Syndromes Chapt
bn bn bn 327 bn bn bn bn bn bn
er 39: Assessment of the Hematologic System
bn bn bn 331 bn bn bn
Chapter 40: Care of Patients with Hematologic Problems Cha
bn bn bn 343 bn bn bn bn bn
pter 41: Assessment of the Nervous System
bn bn 353 bn bn bn bn
Chapter 42: Care of Patients with Problems of the CNS: The Brain Chapt
bn bn bn 364 bn bn bn bn bn bn bn bn bn
er 43: Care of Patients with Problems of the CNS: The Spinal Cord
bn bn bn bn 374 bn bn bn bn bn bn bn bn
Chapter 44: Care of Patients with Problems of the Peripheral Nervous System
bn bn bn 380 bn bn bn bn bn bn bn bn bn
Chapter 45: Care of Critically Ill Patients with Neurologic Problems
bn bn bn 394 bn bn bn bn bn bn
Chapter 46: Assessment of the Eye and Vision
bn bn 397 bn bn bn bn bn
Chapter 47: Care of Patients with Eye and Vision Problems
bn bn bn 403 bn bn bn bn bn bn
Chapter 48: Assessment and Care of Patients with Ear and Hearing Problems
bn bn 410 bn bn bn bn bn bn bn bn bn bn
Chapter 49: Assessment of the Musculoskeletal System
bn bn 415 bn bn bn bn
Chapter 50: Care of Patients with Musculoskeletal Problems
bn bn bn bn bn bn bn
,Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e
bn bn bn bn bn bn bn bn bn bn 3
Chapter 51: Care of Patients with Musculoskeletal Trauma
bn bn bn bn bn bn bn bn 424
Chapter 52: Assessment of the Gastrointestinal System Ch
bn bn bn bn bn bn bn 435
apter 53: Care of Patients with Oral Cavity Problems Chapt
bn bn bn bn bn bn bn bn bn 441
er 54: Care of Patients with Esophageal Problems Chapter
bn bn bn bn bn bn bn bn bn 445
55: Care of Patients with Stomach Disorders
bn bn bn bn bn bn 454
Chapter 56: Care of Patients with Noninflammatory Intestinal Disorders Ch
bn bn bn bn bn bn bn bn bn 461
apter 57: Care of Patients with Inflammatory Intestinal Disorders Chapter
bn bn bn bn bn bn bn bn bn bn 471
58: Care of Patients with Liver Problems
bn bn bn bn bn bn 481
Chapter 59: Care of Patients with Problems of the Biliary System and Pancreas
bn bn bn bn bn bn bn bn bn bn bn bn bn 489
Chapter 60: Care of Patients with Malnutrition: Undernutrition and Obesity Chapt
bn bn bn bn bn bn bn bn bn bn 497
er 61: Assessment of the Endocrine System
bn bn bn bn bn bn 506
Chapter 62: Care of Patients with Pituitary and Adrenal Gland Problems
bn bn bn bn bn bn bn bn bn bn 512
Chapter 63: Care of Patients with Problems of the Thyroid and Parathyroid Glands
bn bn bn bn bn bn bn bn bn bn bn bn bn 520
Chapter 64: Care of Patients with Diabetes Mellitus
bn bn bn bn bn bn bn 527
Chapter 65: Assessment of the Renal/Urinary System Ch
bn bn bn bn bn bn bn 549
apter 66: Care of Patients with Urinary Problems Chapter
bn bn bn bn bn bn bn bn bn 557
67: Care of Patients with Kidney Disorders
bn bn bn bn bn bn 568
Chapter 68: Care of Patients with Acute Kidney Injury and Chronic Kidney Disease
bn bn bn bn bn bn bn bn bn bn bn bn bn 575
Chapter 69: Assessment of the Reproductive System
bn bn bn bn bn bn 587
Chapter 70: Care of Patients with Breast Disorders Chapt
bn bn bn bn bn bn bn bn 591
er 71: Care of Patients with Gynecologic Problems
bn bn bn bn bn bn bn 598
Chapter 72: Care of Patients with Male Reproductive Problems Chapt
bn bn bn bn bn bn bn bn bn 605
er 73: Care of Transgender Patients
bn bn bn bn bn 614
Chapter 74: Care of Patients with Sexually Transmitted Diseases
bn bn bn bn bn bn bn bn 618
, Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e
bn bn bn bn bn bn bn bn bn bn 4
Chapter 01: Overview of Professional Nursing Concepts for Medical- bn bn bn bn bn bn bn bn
Surgical Nursing
bn bn
MULTIPLE CHOICE bn
1. A nurse wishes to provide client-
bn bn bn bn bn
centered care in all interactions. Which action by the nurse best demonstrates this concept?
bn bn bn bn bn bn bn bn bn bn bn bn bn
a. Assesses for cultural influences affecting health care bn bn bn bn bn bn
b. Ensures that all the clients basic needs are met bn bn bn bn bn bn bn bn
c. Tells the client and family about all upcoming tests
bn bn bn bn bn bn bn bn
d. Thoroughly orients the client and family to the room bn bn bn bn bn bn bn bn
ANS: A bn
Competency in client- bn bn
focused care is demonstrated when the nurse focuses on communication, culture, respect compassion, client e
bn bn bn bn bn bn bn bn bn bn bn b n bn bn
ducation, and empowerment. By assessing the effect of the clients culture on health care, this nurse is pract
bn bn bn bn bn bn bn bn bn bn bn bn bn b n b n b n b n
icing client-focused care. Providing for basic needs does not demonstrate this competence.
b n b n b n b n b n b n b n b n b n b n b n
Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
b and family to the room is an important safety measure, but not directly related to demonstrating client-
n bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
centered care. bn
DIF: Understanding/Comprehension REF: 3
bn bn bn
KEY: Patient- bn
centered care| culture MSC: Integrated Process: Caring NOT: Client
bn bn bn bn bn bn bn bn bn
Needs Category: Psychosocial Integrity
bn bn bn
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76 mm
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn b
nHg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
a. Call the Rapid Response Team.
bn bn bn bn
b. Document and continue to monitor. bn bn bn bn
c. Notify the primary care provider. bn bn bn bn
d. Repeat blood pressure measurement in 15 minutes.
bn bn bn bn bn bn
ANS: A bn
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before
bn bn bn b n bn b n bn b n bn bn bn bn bn bn bn b
nthey suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
should call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significan
b n bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
t.
Documentation is vital, but the nurse must do more than document. The primary care provider should be
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
notified, but this is not the priority over calling the RRT. The clients blood pressure should be reassessed
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
frequently, but the priority is getting the rapid care to the client.
bn bn bn bn bn bn bn bn bn bn bn
DIF: Applying/Application REF: 3
bn bn bn
KEY: Rapid Response Team (RRT)| medical emergencies M
bn bn bn bn bn bn b n
SC: Integrated Process: Communication and Documentation
bn bn bn bn bn
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
bn bn bn bn bn bn bn
3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn b
nhelp the client promote his or her own safety?
bn bn bn bn bn bn bn bn
a. Encourage the client and family to be active partners. bn bn bn bn bn bn bn bn
b. Have the client monitor hand hygiene in caregivers.
bn bn bn bn bn bn bn
c. Offer the family the opportunity to stay with the client.
bn bn bn bn bn bn bn bn bn
d. Tell the client to always wear his or her armband.
bn bn bn bn bn bn bn bn bn
ANS: A bn
Each action could be important for the client or family to perform. However, encouraging the client t
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
o be active in his or her health care as a partner is the most critical. The other actions are very limited in sco
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
pe and do not provide the broad protection that being active and involved does.
bn b n bn bn bn bn bn bn bn bn bn bn bn
DIF: Understanding/Comprehension REF: 3
bn bn bn b
KEY: Patient safety
n bn bn
bn bn bn bn bn bn bn bn bn bn 1
,Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e
bn bn bn bn bn bn bn bn bn bn 2
Table of Contents bn bn
Table of Contents bn bn Overview of Professional Nursing Concepts for Medical- bn bn bn bn bn bn
Surgical Nursing1 bn bn
Chapter 01: Overview of Professional Nursing Concepts for Medical-
bn bn 3 bn bn bn bn bn bn
Surgical Nursing Chapter 02: Overview of Health Concepts for Medical-
bn bn 8 bn bn bn bn bn bn bn
Surgical Nursing bn 13
Chapter 03: Common Health Problems of Older Adults Chapt
bn bn 20 bn bn bn bn bn bn
er 04: Assessment and Care of Patients with Pain Chapter 05
bn bn bn 32 bn bn bn bn bn bn bn
: Genetic Concepts for Medical-Surgical Nursing
bn bn bn 38 bn bn
Chapter 06: Rehabilitation Concepts for Chronic and Disabling Health Problems Chapt
bn bn 44 bn bn bn bn bn bn bn bn
er 07: End-of-Life Care
bn bn bn 50
Chapter 08: Concepts of Emergency and Trauma Nursing
bn bn 56 bn bn bn bn bn
Chapter 09: Care of Patients with Common Environmental Emergencies Chapt
bn bn bn 62bn bn bn bn bn bn
er 10: Concepts of Emergency and Disaster Preparedness
bn bn bn bn 68 bn bn bn
Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances C
bn bn 76 bn bn bn bn bn bn bn bn bn bn
hapter 12: Assessment and Care of Patients with Acid-Base Imbalances
bn bn 83 bn bn bn bn bn bn bn
Chapter 13: Infusion Therapy bn bn 94 bn
Chapter 14: Care of Preoperative Patients Chapt
bn bn bn 103 bn bn bn
er 15: Care of Intraoperative Patients Chapter 16:
bn bn bn bn 109 bn bn bn
Care of Postoperative Patients Chapter 17: Infla
bn bn bn 116 bn bn bn bn
mmation and Immunity bn bn 122
Chapter 18: Care of Patients with Arthritis and Other Connective Tissue Diseases Cha
bn bn bn 138 bn bn bn bn bn bn bn bn bn
pter 19: Care of Patients with HIV Disease
bn bn bn bn 147 bn bn bn
Chapter 20: Care of Patients with Hypersensitivity (Allergy) and Autoimmunity
bn bn bn 152 bn bn bn bn bn bn bn
Chapter 21: Cancer Development bn bn 157
bn
Chapter 22: Care of Patients with Cancer Chapt
bn bn bn 167 bn bn bn bn
er 23: Care of Patients with Infection
bn bn bn bn 174 bn bn
Chapter 24: Assessment of the Skin, Hair, and Nails Ch
bn bn 179 bn bn bn bn bn bn bn
apter 25: Care of Patients with Skin Problems Chapter
bn bn bn bn 196 bn bn bn bn bn
26: Care of Patients with Burns
bn bn bn 213 bn bn
Chapter 27: Assessment of the Respiratory System
bn bn 220 bn bn bn bn
Chapter 28: Care of Patients Requiring Oxygen Therapy or Tracheostomy Cha
bn bn bn 226 bn bn bn bn bn bn bn
pter 29: Care of Patients with Noninfectious Upper Respiratory Problems Chapt
bn bn bn bn 233 bn bn bn bn bn bn
er 30: Care of Patients with Noninfectious Lower Respiratory Problems Chapter
bn bn bn bn 245 bn bn bn bn bn bn
31: Care of Patients with Infectious Respiratory Problems
bn bn bn bn 256 bn bn bn bn
Chapter 32: Care of Critically Ill Patients with Respiratory Problems Chapt
bn bn bn 269 bn bn bn bn bn bn bn
er 33: Assessment of the Cardiovascular System
bn bn bn 278 bn bn bn
Chapter 34: Care of Patients with Dysrhythmias Chapt
bn bn bn 287 bn bn bn bn
er 35: Care of Patients with Cardiac Problems Chapter
bn bn bn bn 298 bn bn bn bn bn
36: Care of Patients with Vascular Problems Chapter 3
bn bn bn 310 bn bn bn bn bn
7: Care of Patients with Shock
bn bn bn bn 317 bn
Chapter 38: Care of Patients with Acute Coronary Syndromes Chapt
bn bn bn 327 bn bn bn bn bn bn
er 39: Assessment of the Hematologic System
bn bn bn 331 bn bn bn
Chapter 40: Care of Patients with Hematologic Problems Cha
bn bn bn 343 bn bn bn bn bn
pter 41: Assessment of the Nervous System
bn bn 353 bn bn bn bn
Chapter 42: Care of Patients with Problems of the CNS: The Brain Chapt
bn bn bn 364 bn bn bn bn bn bn bn bn bn
er 43: Care of Patients with Problems of the CNS: The Spinal Cord
bn bn bn bn 374 bn bn bn bn bn bn bn bn
Chapter 44: Care of Patients with Problems of the Peripheral Nervous System
bn bn bn 380 bn bn bn bn bn bn bn bn bn
Chapter 45: Care of Critically Ill Patients with Neurologic Problems
bn bn bn 394 bn bn bn bn bn bn
Chapter 46: Assessment of the Eye and Vision
bn bn 397 bn bn bn bn bn
Chapter 47: Care of Patients with Eye and Vision Problems
bn bn bn 403 bn bn bn bn bn bn
Chapter 48: Assessment and Care of Patients with Ear and Hearing Problems
bn bn 410 bn bn bn bn bn bn bn bn bn bn
Chapter 49: Assessment of the Musculoskeletal System
bn bn 415 bn bn bn bn
Chapter 50: Care of Patients with Musculoskeletal Problems
bn bn bn bn bn bn bn
,Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e
bn bn bn bn bn bn bn bn bn bn 3
Chapter 51: Care of Patients with Musculoskeletal Trauma
bn bn bn bn bn bn bn bn 424
Chapter 52: Assessment of the Gastrointestinal System Ch
bn bn bn bn bn bn bn 435
apter 53: Care of Patients with Oral Cavity Problems Chapt
bn bn bn bn bn bn bn bn bn 441
er 54: Care of Patients with Esophageal Problems Chapter
bn bn bn bn bn bn bn bn bn 445
55: Care of Patients with Stomach Disorders
bn bn bn bn bn bn 454
Chapter 56: Care of Patients with Noninflammatory Intestinal Disorders Ch
bn bn bn bn bn bn bn bn bn 461
apter 57: Care of Patients with Inflammatory Intestinal Disorders Chapter
bn bn bn bn bn bn bn bn bn bn 471
58: Care of Patients with Liver Problems
bn bn bn bn bn bn 481
Chapter 59: Care of Patients with Problems of the Biliary System and Pancreas
bn bn bn bn bn bn bn bn bn bn bn bn bn 489
Chapter 60: Care of Patients with Malnutrition: Undernutrition and Obesity Chapt
bn bn bn bn bn bn bn bn bn bn 497
er 61: Assessment of the Endocrine System
bn bn bn bn bn bn 506
Chapter 62: Care of Patients with Pituitary and Adrenal Gland Problems
bn bn bn bn bn bn bn bn bn bn 512
Chapter 63: Care of Patients with Problems of the Thyroid and Parathyroid Glands
bn bn bn bn bn bn bn bn bn bn bn bn bn 520
Chapter 64: Care of Patients with Diabetes Mellitus
bn bn bn bn bn bn bn 527
Chapter 65: Assessment of the Renal/Urinary System Ch
bn bn bn bn bn bn bn 549
apter 66: Care of Patients with Urinary Problems Chapter
bn bn bn bn bn bn bn bn bn 557
67: Care of Patients with Kidney Disorders
bn bn bn bn bn bn 568
Chapter 68: Care of Patients with Acute Kidney Injury and Chronic Kidney Disease
bn bn bn bn bn bn bn bn bn bn bn bn bn 575
Chapter 69: Assessment of the Reproductive System
bn bn bn bn bn bn 587
Chapter 70: Care of Patients with Breast Disorders Chapt
bn bn bn bn bn bn bn bn 591
er 71: Care of Patients with Gynecologic Problems
bn bn bn bn bn bn bn 598
Chapter 72: Care of Patients with Male Reproductive Problems Chapt
bn bn bn bn bn bn bn bn bn 605
er 73: Care of Transgender Patients
bn bn bn bn bn 614
Chapter 74: Care of Patients with Sexually Transmitted Diseases
bn bn bn bn bn bn bn bn 618
, Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e
bn bn bn bn bn bn bn bn bn bn 4
Chapter 01: Overview of Professional Nursing Concepts for Medical- bn bn bn bn bn bn bn bn
Surgical Nursing
bn bn
MULTIPLE CHOICE bn
1. A nurse wishes to provide client-
bn bn bn bn bn
centered care in all interactions. Which action by the nurse best demonstrates this concept?
bn bn bn bn bn bn bn bn bn bn bn bn bn
a. Assesses for cultural influences affecting health care bn bn bn bn bn bn
b. Ensures that all the clients basic needs are met bn bn bn bn bn bn bn bn
c. Tells the client and family about all upcoming tests
bn bn bn bn bn bn bn bn
d. Thoroughly orients the client and family to the room bn bn bn bn bn bn bn bn
ANS: A bn
Competency in client- bn bn
focused care is demonstrated when the nurse focuses on communication, culture, respect compassion, client e
bn bn bn bn bn bn bn bn bn bn bn b n bn bn
ducation, and empowerment. By assessing the effect of the clients culture on health care, this nurse is pract
bn bn bn bn bn bn bn bn bn bn bn bn bn b n b n b n b n
icing client-focused care. Providing for basic needs does not demonstrate this competence.
b n b n b n b n b n b n b n b n b n b n b n
Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
b and family to the room is an important safety measure, but not directly related to demonstrating client-
n bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
centered care. bn
DIF: Understanding/Comprehension REF: 3
bn bn bn
KEY: Patient- bn
centered care| culture MSC: Integrated Process: Caring NOT: Client
bn bn bn bn bn bn bn bn bn
Needs Category: Psychosocial Integrity
bn bn bn
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76 mm
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn b
nHg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
a. Call the Rapid Response Team.
bn bn bn bn
b. Document and continue to monitor. bn bn bn bn
c. Notify the primary care provider. bn bn bn bn
d. Repeat blood pressure measurement in 15 minutes.
bn bn bn bn bn bn
ANS: A bn
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before
bn bn bn b n bn b n bn b n bn bn bn bn bn bn bn b
nthey suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
should call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significan
b n bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
t.
Documentation is vital, but the nurse must do more than document. The primary care provider should be
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
notified, but this is not the priority over calling the RRT. The clients blood pressure should be reassessed
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
frequently, but the priority is getting the rapid care to the client.
bn bn bn bn bn bn bn bn bn bn bn
DIF: Applying/Application REF: 3
bn bn bn
KEY: Rapid Response Team (RRT)| medical emergencies M
bn bn bn bn bn bn b n
SC: Integrated Process: Communication and Documentation
bn bn bn bn bn
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
bn bn bn bn bn bn bn
3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn b
nhelp the client promote his or her own safety?
bn bn bn bn bn bn bn bn
a. Encourage the client and family to be active partners. bn bn bn bn bn bn bn bn
b. Have the client monitor hand hygiene in caregivers.
bn bn bn bn bn bn bn
c. Offer the family the opportunity to stay with the client.
bn bn bn bn bn bn bn bn bn
d. Tell the client to always wear his or her armband.
bn bn bn bn bn bn bn bn bn
ANS: A bn
Each action could be important for the client or family to perform. However, encouraging the client t
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
o be active in his or her health care as a partner is the most critical. The other actions are very limited in sco
bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn bn
pe and do not provide the broad protection that being active and involved does.
bn b n bn bn bn bn bn bn bn bn bn bn bn
DIF: Understanding/Comprehension REF: 3
bn bn bn b
KEY: Patient safety
n bn bn