TEST BANK - Timby's Introductory Medical-Surgical
Nursing, 13th Edition (Donnelly-Moreno),
Verified Chapters 1 - 72, Complete
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Chapter 1 Concepts and Trends in Healthcare
◦ A new nurse is working with a preceptor on an inpatient medical-surgical unit.
The preceptor advises the student that which is the priority when working as a
professional nurse?
◦ Attending to holistic client needs
◦ Ensuring client safety
◦ Not making medication errors
◦ Providing client-
focused care
ANSWER: B
◦ All actions are appropriate for the professional nurse. However,
ensuring client safety is the priority. Up to 98,000 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.
◦ DIF: Understanding/Comprehension REF: 2
KEY: Patient safety MSC: Integrated Process: Nursing
Process: Intervention
◦ NOT: Client Needs Category: Safe and Effective Care
Environment: Safety and Infection Control
◦ 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?
◦ Encourage the client and family to be active partners.
◦ Have the client monitor hand hygiene in caregivers.
◦ Offer the family the opportunity to stay with the client.
◦ Tell the client to always wear his or
her armband.
ANSWER: 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: 3
KEY: Patient safety MSC: Integrated Process: Teaching/
Learning
,◦ NOT: Client Needs Category: Safe and Effective Care
,Environment: Safety and Infection Control
◦ 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?
◦ Call the Rapid Response Team.
◦ Document and continue to monitor.
◦ Notify the primary care provider.
◦ Repeat blood pressure measurement
in 15 minutes.
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
◦ NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
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◦ A nurse wishes to provide client-centered care in all interactions. Which
action by the nurse best demonstrates this concept?
◦ Assesses for cultural influences affecting health care
◦ Ensures that all the clients basic needs are met
◦ Tells the client and family about all upcoming tests
◦ Thoroughly orients the client and
family to the room
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
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◦ 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
◦ A client is going to be admitted for a scheduled surgical procedure. Which
action does the nurse explain is the most important thing the client can do
to protect against errors?
◦ Bring a list of all medications and what they are for.
◦ Keep the doctors phone number by the telephone.
◦ Make sure all providers wash hands before entering the room.
◦ Write down the name of each caregiver who
comes in the room.
ANSWER: A
◦ Medication errors are the most common type of health care mistake.
The Joint Commissions Speak Up campaign encourages clients to help ensure their
safety. One recommendation is for clients to know all their medications and why they
take them. This will help prevent medication errors.
◦ DIF: Applying/Application REF: 4
◦ KEY: Speak Up campaign| patient safety MSC: Integrated
Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective
Care Environment: Safety and Infection Control
◦ Which action by the nurse working with a client best demonstrates respect for
autonomy?
◦ Asks if the client has questions before signing a consent
◦ Gives the client accurate information when questioned
◦ Keeps the promises made to the client and family
◦ Treats the client fairly
compared to other clients
ANSWER: A
◦ Autonomy is self-determination. The client should make decisions
regarding care. When the nurse obtains a signature on the consent form, assessing if
the client still has questions is vital, because without full information the client cannot
practice autonomy. Giving accurate information is practicing with veracity. Keeping
promises is upholding fidelity. Treating the
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◦ client fairly is providing social justice.
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◦ DIF: Applying/Application REF: 4
◦ KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
◦ NOT: Client Needs Category: Safe and Effective Care Environment: Management
of Care
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◦ A student nurse asks the faculty to explain best practices when communicating
with a person from the lesbian, gay, bisexual, transgender, and queer/
questioning (LGBTQ) community. What answer by the faculty is most
accurate?
◦ Avoid embarrassing the client by asking questions.
◦ Dont make assumptions about their health needs.
◦ Most LGBTQ people do not want to share information.
◦ No differences exist in communicating with
this population.
ANSWER: B
◦ Many members of the LGBTQ community have faced discrimination
from health care providers and may be reluctant to seek health care. The nurse should
never make 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.
◦ DIF: Understanding/Comprehension REF: 4
KEY: LGBTQ| diversity MSC: Integrated Process:
Teaching/Learning
◦ NOT: Client Needs Category: Psychosocial Integrity
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◦ A nurse is calling the on-call physician about a client who had a hysterectomy 2
days ago and has pain that is unrelieved by the prescribed narcotic pain
medication. Which statement is part of the SBAR format for communication?
◦ A: I would like you to order a different pain medication.
◦ B: This client has allergies to morphine and codeine.
◦ R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds.
◦ S: This client had a vaginal
hysterectomy 2 days ago.
ANSWER: B
◦ SBAR is a recommended form of communication, and the acronym
stands for Situation, Background, Assessment, and Recommendation. Appropriate
background information includes allergies to medications the on-call physician might
order. Situation describes what is happening right now that must be communicated;
the clients surgery 2 days ago would be considered background. Assessment would
include an analysis of the clients problem; asking for a different pain medication is a
recommendation. Recommendation is a statement of what is needed or what
◦
◦ outcome is desired; this information about the surgeons preference
might be better placed in background.
◦ DIF: Applying/
Application REF: 5 KEY:
SBAR| communication
, ◦ MSC: Integrated Process: Communication and Documentation
◦ NOT: Client Needs Category: Safe and Effective Care Environment: Management
of Care
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◦ A nurse working on a cardiac unit delegated taking vital signs to an
experienced 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 has changed. What action by the nurse would most
likely have prevented this negative outcome?
◦ Determining if the UAP knew how to take blood pressure
◦ Double-checking the UAP by taking another blood pressure
◦ Providing more appropriate supervision of the UAP
◦ Taking the blood pressure instead of
delegating the task
ANSWER: C
◦ Supervision is one of the five rights of delegation and includes
directing, evaluating, and following up on delegated tasks. The nurse should either
have asked the UAP about the vital signs or instructed the UAP to report them right
away. An experienced 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 are within the scope of practice for a UAP and are
permissible to delegate. The only appropriate answer is that the nurse did not provide
adequate instruction to the UAP.
◦ DIF: Applying/Application REF: 6
◦ KEY: Supervision| delegation|
unlicensed assistive personnel MSC: Integrated
Process: Communication and Documentation
◦ NOT: Client Needs Category: Safe and Effective Care Environment: Management
of Care
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◦ A newly graduated nurse in the hospital states that, since she is so new, she
cannot participate in quality improvement (QI) projects. What response by the
precepting nurse is best?
◦ All staff nurses are required to participate in quality improvement here.
◦ Even being new, you can implement activities designed to improve care.
◦ Its easy to identify what indicators should be used to measure quality.
◦ You should ask to be assigned to the research and
quality committee.
ANSWER: B
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◦ The preceptor should try to reassure the nurse that implementing QI
measures is not out of line for a newly licensed nurse. Simply stating that all nurses
are required to participate does not help the nurse understand how that is possible and
