TEST BANK for Medical-Surgical
Nursing: Concepts for Clinical
Judgment and Collaborative Care
11th Edition by Donna D.
Ignatavicius,
All chapters 1 - 74
,
,
, 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 best demonstrates
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
CORRECT ANSWER: 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:
Caring NOT: 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.
CORRECT ANSWER: A
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.
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
M M M M
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
M M M M M M M
3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse
M M M M M M M M M M M M M M M M M
Mprovide to help the client promote his or her own safety?
M M M M M M M M M M
a. Encourage the client and family to be active partners.
M M M M M M M M
b. Have the client monitor hand hygiene in caregivers.
M M M M M M M
c. Offer the family the opportunity to stay with the client.
M M M M M M M M M
Nursing: Concepts for Clinical
Judgment and Collaborative Care
11th Edition by Donna D.
Ignatavicius,
All chapters 1 - 74
,
,
, 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 best demonstrates
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
CORRECT ANSWER: 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:
Caring NOT: 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.
CORRECT ANSWER: A
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.
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
M M M M
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
M M M M M M M
3. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse
M M M M M M M M M M M M M M M M M
Mprovide to help the client promote his or her own safety?
M M M M M M M M M M
a. Encourage the client and family to be active partners.
M M M M M M M M
b. Have the client monitor hand hygiene in caregivers.
M M M M M M M
c. Offer the family the opportunity to stay with the client.
M M M M M M M M M
