FOR Medical-Surgical Nursing: Concepts for Clinical Judgment and
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Nursestar1 Stuvia ni
ni Collaborative Care (Evolve) 11th Edition by Donna D. Ignatavicius, Cherie R.
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ni Rebar& Nicole M. Heimgartner |ISBN: 9780323878265| Complete Guide
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,
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, Chapter 01: Overview of Professional Nursing Concepts forni ni ni ni ni ni ni
ni Medical- Surgical Nursing ni ni
MULTIPLE CHOICE ni
1. A nurse wishes to provide client-centered care in all interactions. Which
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ni action by the nurse best demonstrates this concept?
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a. Assesses for cultural influences affecting health careni ni ni ni ni ni
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 ni ni ni ni ni ni ni ni
CORRECT ANSWER: A ni ni
Competency in client-focused care is demonstrated when the nurse focuses on
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ni communication, culture, respect compassion, client education, and empowerment. By
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assessing the effect of the clients culture on health care, this nurse is practicing client-
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focused care. Providing for basic needs does not demonstrate this competence.
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ni Simply telling the client about all upcoming tests is not providing empowering education.
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Orienting the client and family to the room is an important safety measure, but not
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ni directly related to demonstrating client-centered care.
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DIF: Understanding/Comprehension REF: 3
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KEY: Patient-centered care| culture MSC: Integrated
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ni Process: Caring NOT: Client Needs Category:
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ni Psychosocial Integrity ni
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood
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ni pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action
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ni 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. ni ni ni ni
c. Notify the primary care provider.
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d. Repeat blood pressure measurement in 15 minutes.
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CORRECT ANSWER: A ni ni
The purpose of the Rapid Response Team (RRT) is to intervene when clients are
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ni deteriorating before they suffer either respiratory or cardiac arrest. Since the client
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ni has manifested a significant change, the nurse should call the RRT. Changes in blood
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ni pressure, mental status, heart rate, and pain are particularly significant.
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Documentation is vital, but the nurse must do more than document. The primary ni ni ni ni ni ni ni ni ni ni ni ni
care provider should be notified, but this is not the priority over calling the RRT.
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ni The clients blood pressure should be reassessed frequently, but the priority is
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ni getting the rapid care to the client.
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