l O M oA R c P S D | 6672187
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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 2
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing
MULTIPLE CHOICE
TEST BANK FOR MEDICAL SURGICAL
1. A nurse wishes to provide client-centered care in all interactions. Which
NURSING:CONCEPTS FOR CLINICAL JUDGEMENT
action by the nurse bestdemonstrates this concept?
AND COLLABORATIVE CARE 11TH EDITION a. Assesses for cultural influences affecting health care
b. Ensures that all the clients basic needs are met
IGNATAVICIUS
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
TEST BANK
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.
, l O M oA R c P S D | 6672187 l O M oA R c P S D | 6672187
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 3 Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 4
Documentation is vital, but the nurse must do more than document. The primary MSC: Integrated Process: Teaching/Learning
care provider should be notified, but this is not the priority over calling the RRT. The NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
clients blood pressure should be reassessed frequently, but the priority is getting Control
the rapid care to the client.
4. A client is going to be admitted for a scheduled surgical procedure. Which action
DIF: Applying/Application REF: 3 does the nurse explain is the most important thing the client can do to protect against
KEY: Rapid Response Team (RRT)| medical errors?
emergencies MSC: Integrated Process: a. Bring a list of all medications and what they are for.
Communication and Documentation b. Keep the doctors phone number by the telephone.
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation c. Make sure all providers wash hands before entering the room.
d. Write down the name of each caregiver who comes in the room.
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? ANS: A
a. Encourage the client and family to be active partners. Medication errors are the most common type of health care mistake. The Joint
b. Have the client monitor hand hygiene in caregivers. Commissions Speak Up campaign encourages clients to help ensure their safety. One
c. Offer the family the opportunity to stay with the client. recommendation is for clients to know all their medications and why they take them.
d. Tell the client to always wear his or her armband.
This will help prevent medication errors.
ANS: A
Each action could be important for the client or family to perform. However, DIF: Applying/Application REF: 4
encouraging the client to be active in his or her health care as a partner is the most
KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/Learning
critical. The other actions are very limited in scope and do not provide the broad
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
protection that being active and involved does.
Control
DIF: 5. A new nurse is working with a preceptor on an inpatient medical-surgical unit. The
Understanding/Comprehension preceptor advises the student that which is the priority when working as a
REF: 3KEY: Patient safety professional nurse?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care
ANS: B
All actions are appropriate for the professional nurse. However, ensuring client safety is
the priority. Up to98,000 deaths result each year from errors in hospital care, according
to the 2000 Institute of Medicine report. Many more clients have suffered injuries and
less serious outcomes. Every nurse has the responsibility to guard the clients safety.
, l O M oA R c P S D | 6672187 l O M oA R c P S D | 6672187
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 5 Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 6
DIF:
d. No differences exist in communicating with this population.
Understanding/Comprehension
REF: 2KEY: Patient safety
ANS: B
MSC: Integrated Process: Nursing Process: Intervention
Many members of the LGBTQ community have faced discrimination from health care
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
providers and may bereluctant to seek health care. The nurse should never make
Control
assumptions about the needs of members of this population. Rather, respectful questions
are appropriate. If approached with sensitivity, the client with any health care need is
more likely to answer honestly.
6. Which action by the nurse working with a client best demonstrates respect for
autonomy? DIF:
a. Asks if the client has questions before signing a consent Understanding/Comprehension
b. Gives the client accurate information when questioned REF: 4KEY: LGBTQ| diversity
c. Keeps the promises made to the client and family MSC: Integrated Process: Teaching/Learning
d. Treats the client fairly compared to other clients NOT: Client Needs Category: Psychosocial Integrity
ANS: A 8. A nurse is calling the on-call physician about a client who had a hysterectomy 2 days
Autonomy is self-determination. The client should make decisions regarding care. When ago and has pain that is unrelieved by the prescribed narcotic pain medication.
the nurse obtains a signature on the consent form, assessing if the client still has Which statement is part of the SBAR format for communication?
questions is vital, because without full information the client cannot practice autonomy. a. A: I would like you to order a different pain medication.
Giving accurate information is practicing with veracity. b. B: This client has allergies to morphine and codeine.
Keeping promises is upholding fidelity. Treating the client fairly is providing social justice. c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
d. S: This client had a vaginal hysterectomy 2 days ago.
DIF: Applying/Application REF: 4
KEY: Autonomy| ethical principles MSC: Integrated Process: Caring ANS: B
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care SBAR is a recommended form of communication, and the acronym stands for
Situation, Background, Assessment, and Recommendation. Appropriate background
7. A student nurse asks the faculty to explain best practices when communicating with information includes allergies to medications theon-call physician might order.
a person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) Situation describes what is happening right now that must be communicated; the clients
community. What answer by the faculty is most accurate? surgery 2 days ago would be considered background. Assessment would include an
a. Avoid embarrassing the client by asking questions. analysis of the clients problem; asking for a different pain medication is a
b. Dont make assumptions about their health needs. recommendation. Recommendation is a statementof what is needed or what outcome
c. Most LGBTQ people do not want to share information. is desired; this information about the surgeons preference might be betterplaced in
background.
DIF: Applying/Application
REF: 5KEY: SBAR|
communication
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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 7 Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 8
MSC: Integrated Process: Communication and Documentation a. Ask the hospitals there about standard nurse-client ratios.
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care b. Choose the hospital that has the newest technology.
c. Find a hospital that is accredited by The Joint Commission.
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced d. Use a facility affiliated with a medical or nursing school.
unlicensed assistive personnel (UAP). Four hours later, the nurse notes the clients
blood pressure is much higher than previous readings, and the clients mental status ANS: C
has changed. What action by the nurse would most likely have prevented this Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance
negative outcome? that the facility has a focus on safety. Nurse-client ratios differ by unit type and change
a. Determining if the UAP knew how to take blood pressure
over time. New technology doesnt necessarily mean the hospital is safe. Affiliation with a
b. Double-checking the UAP by taking another blood pressure health professions school has several advantages, but safety is most important.
c. Providing more appropriate supervision of the UAP
d. Taking the blood pressure instead of delegating the task DIF: Understanding/Comprehension
REF: 2 KEY: The Joint Commission
ANS: C (TJC)| accreditation
Supervision is one of the five rights of delegation and includes directing, evaluating, MSC: Integrated Process: Communication and Documentation
and following up on delegated tasks. The nurse should either have asked the UAP NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
about the vital signs or instructed the UAP to report them right away. An experienced Control
UAP should know how to take vital signs and the nurse should not have to assess this
at this point. Double-checking the work defeats the purpose of delegation. Vital signs 11. A newly graduated nurse in the hospital states that, since she is so new, she cannot
arewithin the scope of practice for a UAP and are permissible to delegate. The only participate in quality improvement (QI) projects. What response by the precepting
appropriate answer is that the nurse did not provide adequate instruction to the UAP. nurse is best?
a. All staff nurses are required to participate in quality improvement here.
DIF: Applying/Application REF: 6 b. Even being new, you can implement activities designed to improve care.
KEY: Supervision| delegation| unlicensed c. Its easy to identify what indicators should be used to measure quality.
assistive personnel MSC: Integrated Process: d. You should ask to be assigned to the research and quality committee.
Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care ANS: B
The preceptor should try to reassure the nurse that implementing QI measures is not
10. A nurse is talking with a client who is moving to a new state and needs to find a new
out of line for a newly licensed nurse. Simply stating that all nurses are required to
doctor and hospital there. What advice by the nurse is best? participate does not help the nurse understand how that is possible and is dismissive.
Identifying indicators of quality is not an easy, quick process and would not be the best
place to suggest a new nurse to start. Asking to be assigned to the QI committee does
not give the nurse information about how to implement QI in daily practice.
DIF: Applying/Application
REF: 6KEY: Quality
improvement
l O M oA R c P S D | 6672187
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 2
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing
MULTIPLE CHOICE
TEST BANK FOR MEDICAL SURGICAL
1. A nurse wishes to provide client-centered care in all interactions. Which
NURSING:CONCEPTS FOR CLINICAL JUDGEMENT
action by the nurse bestdemonstrates this concept?
AND COLLABORATIVE CARE 11TH EDITION a. Assesses for cultural influences affecting health care
b. Ensures that all the clients basic needs are met
IGNATAVICIUS
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
TEST BANK
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.
, l O M oA R c P S D | 6672187 l O M oA R c P S D | 6672187
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 3 Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 4
Documentation is vital, but the nurse must do more than document. The primary MSC: Integrated Process: Teaching/Learning
care provider should be notified, but this is not the priority over calling the RRT. The NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
clients blood pressure should be reassessed frequently, but the priority is getting Control
the rapid care to the client.
4. A client is going to be admitted for a scheduled surgical procedure. Which action
DIF: Applying/Application REF: 3 does the nurse explain is the most important thing the client can do to protect against
KEY: Rapid Response Team (RRT)| medical errors?
emergencies MSC: Integrated Process: a. Bring a list of all medications and what they are for.
Communication and Documentation b. Keep the doctors phone number by the telephone.
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation c. Make sure all providers wash hands before entering the room.
d. Write down the name of each caregiver who comes in the room.
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? ANS: A
a. Encourage the client and family to be active partners. Medication errors are the most common type of health care mistake. The Joint
b. Have the client monitor hand hygiene in caregivers. Commissions Speak Up campaign encourages clients to help ensure their safety. One
c. Offer the family the opportunity to stay with the client. recommendation is for clients to know all their medications and why they take them.
d. Tell the client to always wear his or her armband.
This will help prevent medication errors.
ANS: A
Each action could be important for the client or family to perform. However, DIF: Applying/Application REF: 4
encouraging the client to be active in his or her health care as a partner is the most
KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/Learning
critical. The other actions are very limited in scope and do not provide the broad
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
protection that being active and involved does.
Control
DIF: 5. A new nurse is working with a preceptor on an inpatient medical-surgical unit. The
Understanding/Comprehension preceptor advises the student that which is the priority when working as a
REF: 3KEY: Patient safety professional nurse?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care
ANS: B
All actions are appropriate for the professional nurse. However, ensuring client safety is
the priority. Up to98,000 deaths result each year from errors in hospital care, according
to the 2000 Institute of Medicine report. Many more clients have suffered injuries and
less serious outcomes. Every nurse has the responsibility to guard the clients safety.
, l O M oA R c P S D | 6672187 l O M oA R c P S D | 6672187
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 5 Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 6
DIF:
d. No differences exist in communicating with this population.
Understanding/Comprehension
REF: 2KEY: Patient safety
ANS: B
MSC: Integrated Process: Nursing Process: Intervention
Many members of the LGBTQ community have faced discrimination from health care
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
providers and may bereluctant to seek health care. The nurse should never make
Control
assumptions about the needs of members of this population. Rather, respectful questions
are appropriate. If approached with sensitivity, the client with any health care need is
more likely to answer honestly.
6. Which action by the nurse working with a client best demonstrates respect for
autonomy? DIF:
a. Asks if the client has questions before signing a consent Understanding/Comprehension
b. Gives the client accurate information when questioned REF: 4KEY: LGBTQ| diversity
c. Keeps the promises made to the client and family MSC: Integrated Process: Teaching/Learning
d. Treats the client fairly compared to other clients NOT: Client Needs Category: Psychosocial Integrity
ANS: A 8. A nurse is calling the on-call physician about a client who had a hysterectomy 2 days
Autonomy is self-determination. The client should make decisions regarding care. When ago and has pain that is unrelieved by the prescribed narcotic pain medication.
the nurse obtains a signature on the consent form, assessing if the client still has Which statement is part of the SBAR format for communication?
questions is vital, because without full information the client cannot practice autonomy. a. A: I would like you to order a different pain medication.
Giving accurate information is practicing with veracity. b. B: This client has allergies to morphine and codeine.
Keeping promises is upholding fidelity. Treating the client fairly is providing social justice. c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
d. S: This client had a vaginal hysterectomy 2 days ago.
DIF: Applying/Application REF: 4
KEY: Autonomy| ethical principles MSC: Integrated Process: Caring ANS: B
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care SBAR is a recommended form of communication, and the acronym stands for
Situation, Background, Assessment, and Recommendation. Appropriate background
7. A student nurse asks the faculty to explain best practices when communicating with information includes allergies to medications theon-call physician might order.
a person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) Situation describes what is happening right now that must be communicated; the clients
community. What answer by the faculty is most accurate? surgery 2 days ago would be considered background. Assessment would include an
a. Avoid embarrassing the client by asking questions. analysis of the clients problem; asking for a different pain medication is a
b. Dont make assumptions about their health needs. recommendation. Recommendation is a statementof what is needed or what outcome
c. Most LGBTQ people do not want to share information. is desired; this information about the surgeons preference might be betterplaced in
background.
DIF: Applying/Application
REF: 5KEY: SBAR|
communication
, l O M oA R c P S D | 6672187 l O M oA R c P S D | 6672187
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 7 Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 11e 8
MSC: Integrated Process: Communication and Documentation a. Ask the hospitals there about standard nurse-client ratios.
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care b. Choose the hospital that has the newest technology.
c. Find a hospital that is accredited by The Joint Commission.
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced d. Use a facility affiliated with a medical or nursing school.
unlicensed assistive personnel (UAP). Four hours later, the nurse notes the clients
blood pressure is much higher than previous readings, and the clients mental status ANS: C
has changed. What action by the nurse would most likely have prevented this Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance
negative outcome? that the facility has a focus on safety. Nurse-client ratios differ by unit type and change
a. Determining if the UAP knew how to take blood pressure
over time. New technology doesnt necessarily mean the hospital is safe. Affiliation with a
b. Double-checking the UAP by taking another blood pressure health professions school has several advantages, but safety is most important.
c. Providing more appropriate supervision of the UAP
d. Taking the blood pressure instead of delegating the task DIF: Understanding/Comprehension
REF: 2 KEY: The Joint Commission
ANS: C (TJC)| accreditation
Supervision is one of the five rights of delegation and includes directing, evaluating, MSC: Integrated Process: Communication and Documentation
and following up on delegated tasks. The nurse should either have asked the UAP NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
about the vital signs or instructed the UAP to report them right away. An experienced Control
UAP should know how to take vital signs and the nurse should not have to assess this
at this point. Double-checking the work defeats the purpose of delegation. Vital signs 11. A newly graduated nurse in the hospital states that, since she is so new, she cannot
arewithin the scope of practice for a UAP and are permissible to delegate. The only participate in quality improvement (QI) projects. What response by the precepting
appropriate answer is that the nurse did not provide adequate instruction to the UAP. nurse is best?
a. All staff nurses are required to participate in quality improvement here.
DIF: Applying/Application REF: 6 b. Even being new, you can implement activities designed to improve care.
KEY: Supervision| delegation| unlicensed c. Its easy to identify what indicators should be used to measure quality.
assistive personnel MSC: Integrated Process: d. You should ask to be assigned to the research and quality committee.
Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care ANS: B
The preceptor should try to reassure the nurse that implementing QI measures is not
10. A nurse is talking with a client who is moving to a new state and needs to find a new
out of line for a newly licensed nurse. Simply stating that all nurses are required to
doctor and hospital there. What advice by the nurse is best? participate does not help the nurse understand how that is possible and is dismissive.
Identifying indicators of quality is not an easy, quick process and would not be the best
place to suggest a new nurse to start. Asking to be assigned to the QI committee does
not give the nurse information about how to implement QI in daily practice.
DIF: Applying/Application
REF: 6KEY: Quality
improvement
