2
TEST BANK for Medical-Surgical Nursing:
Concepts for Clinical Judgment and
Collaborative Care 11th Edition by Donna D.
Ignatavicius, All chapters 1 - 74||Complete A+
Guide
, 3
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing
MULTIPLE CHOICE
1. A nurse wishes to provide client-centered care in all interactions. Which
action by the nurse bestdemonstrates this concept?
a. Assesses for cultural influences affecting health care
b. Ensures that all the clients basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room
ANS: A
Competency in client-focused care is demonstrated when the nurse focuses on
communication, culture, respect compassion, client education, and empowerment. By
assessing the effect of the clients culture on health care, this nurse is practicing client-
focused care. Providing for basic needs does not demonstrate this competence. Simply
telling the client about all upcoming tests is not providing empowering education.
Orienting the client and family to the room is an important safety measure, but not
directly related to demonstrating client-centered care.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated
Process: CaringNOT: Client Needs Category:
Psychosocial Integrity
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood
pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action
by the nurse is best?
a. Call the Rapid Response Team.
b. Document and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes.
ANS: A
, 4
The purpose of the Rapid Response Team (RRT) is to intervene when clients are
deteriorating before they suffer either respiratory or cardiac arrest. Since the client has
manifested a significant change, the nurse should call the RRT. Changes in blood
pressure, mental status, heart rate, and pain are particularly significant.
, 5
Documentation is vital, but the nurse must do more than document. The primary
care provider should be notified, but this is not the priority over calling the RRT. The
clients blood pressure should be reassessed frequently, but the priority is getting
the rapid care to the client.
DIF: Applying/Application REF: 3
KEY: Rapid Response Team (RRT)| medical
emergencies MSC: Integrated Process:
Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is orienting a new client and family to the inpatient unit. What information
does the nurse provide to help the client promote his or her own safety?
a. Encourage the client and family to be active partners.
b. Have the client monitor hand hygiene in caregivers.
c. Offer the family the opportunity to stay with the client.
d. Tell the client to always wear his or her armband.
ANS: A
Each action could be important for the client or family to perform. However,
encouraging the client to be active in his or her health care as a partner is the most
critical. The other actions are very limited in scope and do not provide the broad
protection that being active and involved does.
DIF:
Understanding/Comprehension
REF: 3KEY: Patient safety
TEST BANK for Medical-Surgical Nursing:
Concepts for Clinical Judgment and
Collaborative Care 11th Edition by Donna D.
Ignatavicius, All chapters 1 - 74||Complete A+
Guide
, 3
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing
MULTIPLE CHOICE
1. A nurse wishes to provide client-centered care in all interactions. Which
action by the nurse bestdemonstrates this concept?
a. Assesses for cultural influences affecting health care
b. Ensures that all the clients basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room
ANS: A
Competency in client-focused care is demonstrated when the nurse focuses on
communication, culture, respect compassion, client education, and empowerment. By
assessing the effect of the clients culture on health care, this nurse is practicing client-
focused care. Providing for basic needs does not demonstrate this competence. Simply
telling the client about all upcoming tests is not providing empowering education.
Orienting the client and family to the room is an important safety measure, but not
directly related to demonstrating client-centered care.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated
Process: CaringNOT: Client Needs Category:
Psychosocial Integrity
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood
pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action
by the nurse is best?
a. Call the Rapid Response Team.
b. Document and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes.
ANS: A
, 4
The purpose of the Rapid Response Team (RRT) is to intervene when clients are
deteriorating before they suffer either respiratory or cardiac arrest. Since the client has
manifested a significant change, the nurse should call the RRT. Changes in blood
pressure, mental status, heart rate, and pain are particularly significant.
, 5
Documentation is vital, but the nurse must do more than document. The primary
care provider should be notified, but this is not the priority over calling the RRT. The
clients blood pressure should be reassessed frequently, but the priority is getting
the rapid care to the client.
DIF: Applying/Application REF: 3
KEY: Rapid Response Team (RRT)| medical
emergencies MSC: Integrated Process:
Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is orienting a new client and family to the inpatient unit. What information
does the nurse provide to help the client promote his or her own safety?
a. Encourage the client and family to be active partners.
b. Have the client monitor hand hygiene in caregivers.
c. Offer the family the opportunity to stay with the client.
d. Tell the client to always wear his or her armband.
ANS: A
Each action could be important for the client or family to perform. However,
encouraging the client to be active in his or her health care as a partner is the most
critical. The other actions are very limited in scope and do not provide the broad
protection that being active and involved does.
DIF:
Understanding/Comprehension
REF: 3KEY: Patient safety
