l OM oARc PSD|170 4709 3
TEST BANK Medical Surgical Nursing 10th Edition by Donna D.
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ty Ignatavicius , ISBN: 9780323612425 |COMPLETE TEST BANK| Guide
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ty A+
, l OM oARc PSD|170 4709 3
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing
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Ignatavicius: Medical-Surgical Nursing, 10th Edition
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MULTIPLE CHOICE ty
1. A nurse is caring for a postoperative client on the surgical unit. The client’s blood
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pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What
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action would the nurse take first?
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a. Call the Rapid Response Team. ty ty ty ty
b. Document and continue to monitor. ty ty ty ty
c. Notify the primary health care provider. ty ty ty ty ty
d. Repeat the blood pressure in 15 minutes. ty ty ty ty ty ty
ANS: t y A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are
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deteriorating before they suffer either respiratory or cardiac arrest. Since the client has
ty ty ty ty ty ty ty ty ty ty ty ty ty
manifested a significant change, the nurse would call the RRT. Changes in blood
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pressure, mental status, heart rate, temperature, oxygen saturation, and last 2 hours’
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urine output are particularly significant and are part of the Modified Early Warning
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System guide.
ty ty
Documentation is vital, but the nurse must do more than document. The primary health ty ty ty ty ty ty ty t y ty ty ty ty ty
care provider would be notified, but this is not more important than calling the RRT.
t y ty ty ty ty ty ty ty ty ty ty ty ty ty ty
The client’s blood pressure would be reassessed frequently, but the priority is getting
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the rapid care to the client.
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DIF: Applying TOP: Integrated Process: Communication and t y ty ty ty
Documentation KEY: Rapid Response Team (RRT), Clinical
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judgment
ty
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
t y ty ty ty ty ty ty
2. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor
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advises the new nurse that which is the priority when working as a professional
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nurse?
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a. Attending to holistic client needs ty ty ty ty
b. Ensuring client safety ty ty
c. Not making medication errors ty ty ty
d. Providing client-focused care ty ty
ANS: t y B
All actions are appropriate for the professional nurse. However, ensuring client safety is
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the priority. Health care errors have been widely reported for 25 years, many of which
ty ty ty ty ty ty ty ty ty ty ty ty ty ty ty
result in client injury, death, and increased health care costs. There are several national
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and international organizations that have either recommended or mandated safety
ty ty ty ty ty ty ty ty ty ty
initiatives.
ty
Every nurse has the responsibility to guard the client’s safety. The other
t y t y ty t y t y t y ty t y t y t y t y
actions are important for quality nursing, but they are not as vital as providing safety.
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Not making medication errors does provide safety, but is too narrow in scope to be
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the best answer.
ty ty t y
DIF: Understanding TOP: Integrated Process: Nursing t y ty ty
Process: Intervention KEY: Client safety
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MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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3. A nurse is orienting a new client and family to the medical-surgical unit. What
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information does the nurse provide to best help the client promote his or her
ty ty ty ty ty ty ty ty ty ty ty ty ty ty
own safety?
ty ty
a. Encourage the client and family to be active partners. ty ty ty ty ty ty ty ty
b. Have the client monitor hand hygiene in caregivers.
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c. Offer the family the opportunity to stay with the client.
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d. Tell the client to always wear his or her armband.
ty ty ty ty ty ty ty ty ty
, l OM oARc PSD|170 4709 3
ANS: t y A
Each action could be important for the client or family to perform. However, encouraging the
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client to be active in his or her health care as a safety partner is the most critical. The
ty ty ty ty ty t y ty ty t y ty ty ty ty ty ty ty ty ty ty
other actions are very limited in scope and do not provide the broad protection that being
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active and involved does.
ty ty ty ty
DIF: Understanding TOP: Integrated Process: Teaching/Learning ty ty ty
KEY: Client safety
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MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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4. A nurse wishes to provide client-centered care in all interactions. Which action by the
ty ty ty ty ty ty ty ty ty ty ty ty ty
ty nurse best demonstrates this concept?
ty ty ty ty
a. Assesses for cultural influences affecting health care.
ty ty ty ty ty ty
b. Ensures that all the client’s basic needs are met.
ty ty ty ty ty ty ty ty
c. Tells the client and family about all upcoming tests.
ty ty ty ty ty ty ty ty
d. Thoroughly orients the client and family to the room. ty ty ty ty ty ty ty ty
ANS: t y A
Showing respect for the client and family’s preferences and needs is essential to ensure a
ty ty ty ty ty ty ty ty ty ty ty ty ty ty
holistic or “whole-person” approach to care. By assessing the effect of the client’s
ty ty ty ty ty ty ty ty ty ty ty ty ty
culture on health care, this nurse is practicing client-focused care. Providing for basic
ty ty ty ty ty ty ty ty ty ty ty ty ty
needs does not demonstrate this competence. Simply telling the client about all
ty ty ty ty ty ty ty ty ty ty ty ty
upcoming tests is not providing empowering education. Orienting the client and family
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to the room is an important safety measure, but not directly related to demonstrating
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client-centered care.
ty ty
DIF: Understanding TOP: Integrated Process: Culture and ty ty ty ty ty
Spirituality KEY: Client-centered care, Culture
ty MSC: Client Needs Category:
ty t y ty ty t y ty ty
Psychosocial Integrity
ty ty
5. A client is going to be admitted for a scheduled surgical procedure. Which action
ty ty ty ty ty ty ty ty ty ty ty ty ty
does the nurse explain is the most important thing the client can do to protect
ty ty ty ty ty ty ty ty ty ty ty ty ty ty ty
against errors?
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a. Bring a list of all medications and what they are for.
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b. Keep the provider’s phone number by the telephone.
ty ty ty ty ty ty ty
c. Make sure that all providers wash hands before entering the room.
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d. Write down the name of each caregiver who comes in the room.
ty ty ty ty ty ty ty ty ty ty ty
ANS: t y A
Medication reconciliation is a formal process in which the client’s actual current
ty ty ty ty ty ty ty ty ty ty ty
medications are compared to the prescribed medications at the time of admission,
ty ty ty ty ty ty ty ty ty ty ty ty
transfer, or discharge. This National client Safety Goal is important to reduce medication
ty ty ty ty ty ty ty ty ty ty ty ty ty
errors. The client would not have to be responsible for providers washing their
ty ty ty ty ty ty ty ty ty t y ty ty t y
hands, and even if the client does so, this is too narrow to be the most important
ty ty ty ty ty ty t y ty ty ty ty ty ty ty ty ty ty
action to prevent errors. Keeping the provider’s phone number nearby and
ty ty ty ty ty ty ty ty t y t y ty
documenting everyone who enters the room also do not guarantee safety.
t y ty t y t y ty t y ty t y ty ty ty
DIF: Applying TOP: Integrated Process: ty ty
Teaching/Learning KEY: Client safety, Informatics ty ty ty ty
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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, l OM oARc PSD|170 4709 3
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
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a. Asks if the client has questions before signing a consent.
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b. Gives the client accurate information when questioned.
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c. Keeps the promises made to the client and family. ty ty ty ty ty ty ty ty
d. Treats the client fairly compared to other clients.ty ty ty ty ty ty ty
ANS: t y A
Autonomy is self-determination. The client would make decisions regarding care. When the
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nurse obtains a signature on the consent form, assessing if the client still has questions is
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vital, because without full information the client cannot practice autonomy. Giving accurate
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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 TOP: Integrated Process: Caring KEY: Ethics, Autonomy ty ty ty ty
MSC: Client Needs Category: Safe and Effective Care Environment: Management
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of Care
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7. A nurse asks a more seasoned colleague to explain best practicesqwhenq communicating
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with a person from the lesbian, gay, bisexual, transgender, and questioning/queer
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(LGBTQ) community. What answer by the faculty is most accurate?
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a. Avoid embarrassing the client by asking questions. ty ty ty ty ty ty
b. Don’t make assumptions about his or her health needs.
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c. Most LGBTQ people do not want to share information.
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d. No differences exist in communicating with this population.
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ANS: t y B
Many members of the LGBTQ community haveqfaced discrimination from health care
ty ty ty ty ty ty ty ty ty ty
providers and may be reluctant to seek health care. The nurse would never make
ty ty ty ty ty ty ty ty ty ty ty ty ty ty
assumptions about the needs of members of this population. Rather, respectful questions
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are appropriate. If approached withqsensitivity, qthe client with any health care need is
ty ty ty ty ty ty ty ty ty ty ty ty ty
more likely to answer honestly.
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DIF: Understanding TOP: Integrated Process: Teaching/Learning t y ty ty
KEY: Health care disparities, LGBTQ MSC: Client Needs Category: Psychosocial Integrity
t y ty ty ty t y ty ty ty ty
8. A nurse is callingq theqon-callq health care provider about a client who had a
ty ty ty ty ty ty ty ty ty ty ty
hysterectomy 2 days ago andqhas painqthat is unrelieved by the prescribed opioid
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pain medication. Whichqstatement qcomprises the background portion of the SBAR
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format for communication?
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a. “Iqwould qlike you to order a different pain medication.” ty ty ty ty ty ty ty ty
b. “This clientq has allergies to morphine and codeine.”
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c. “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.”
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d. “Thisqclient had a vaginal hysterectomy 2 days ago.” ty ty ty ty ty ty ty
ANS: t y B
TEST BANK Medical Surgical Nursing 10th Edition by Donna D.
ty ty ty ty ty ty ty ty ty ty
ty Ignatavicius , ISBN: 9780323612425 |COMPLETE TEST BANK| Guide
ty ty ty ty ty ty ty
ty A+
, l OM oARc PSD|170 4709 3
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing
ty ty ty ty ty ty ty ty ty
Ignatavicius: Medical-Surgical Nursing, 10th Edition
ty ty ty ty ty
MULTIPLE CHOICE ty
1. A nurse is caring for a postoperative client on the surgical unit. The client’s blood
ty ty ty ty ty ty ty ty ty ty ty ty ty ty
pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What
ty ty ty ty ty ty ty ty ty ty ty ty ty ty ty
action would the nurse take first?
ty ty ty ty ty ty
a. Call the Rapid Response Team. ty ty ty ty
b. Document and continue to monitor. ty ty ty ty
c. Notify the primary health care provider. ty ty ty ty ty
d. Repeat the blood pressure in 15 minutes. ty ty ty ty ty ty
ANS: t y A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are
ty ty ty ty ty ty ty ty ty ty ty ty ty
deteriorating before they suffer either respiratory or cardiac arrest. Since the client has
ty ty ty ty ty ty ty ty ty ty ty ty ty
manifested a significant change, the nurse would call the RRT. Changes in blood
ty ty ty ty ty ty ty ty ty ty ty ty ty
pressure, mental status, heart rate, temperature, oxygen saturation, and last 2 hours’
ty ty ty ty ty ty ty ty ty ty ty ty
urine output are particularly significant and are part of the Modified Early Warning
ty ty ty ty ty ty ty ty ty ty ty ty ty
System guide.
ty ty
Documentation is vital, but the nurse must do more than document. The primary health ty ty ty ty ty ty ty t y ty ty ty ty ty
care provider would be notified, but this is not more important than calling the RRT.
t y ty ty ty ty ty ty ty ty ty ty ty ty ty ty
The client’s blood pressure would be reassessed frequently, but the priority is getting
ty ty ty ty ty ty ty ty ty ty ty ty ty
the rapid care to the client.
ty ty ty ty ty ty
DIF: Applying TOP: Integrated Process: Communication and t y ty ty ty
Documentation KEY: Rapid Response Team (RRT), Clinical
ty ty ty ty ty ty ty
judgment
ty
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
t y ty ty ty ty ty ty
2. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor
ty ty ty ty ty ty ty ty ty ty ty ty ty
advises the new nurse that which is the priority when working as a professional
ty ty ty t y ty ty ty ty ty ty ty ty ty ty
nurse?
ty
a. Attending to holistic client needs ty ty ty ty
b. Ensuring client safety ty ty
c. Not making medication errors ty ty ty
d. Providing client-focused care ty ty
ANS: t y B
All actions are appropriate for the professional nurse. However, ensuring client safety is
ty ty ty ty ty ty ty ty ty ty ty ty
the priority. Health care errors have been widely reported for 25 years, many of which
ty ty ty ty ty ty ty ty ty ty ty ty ty ty ty
result in client injury, death, and increased health care costs. There are several national
ty ty ty ty ty ty ty ty ty ty ty ty ty ty
and international organizations that have either recommended or mandated safety
ty ty ty ty ty ty ty ty ty ty
initiatives.
ty
Every nurse has the responsibility to guard the client’s safety. The other
t y t y ty t y t y t y ty t y t y t y t y
actions are important for quality nursing, but they are not as vital as providing safety.
t y t y ty ty ty ty ty ty ty ty ty ty ty ty ty
Not making medication errors does provide safety, but is too narrow in scope to be
ty ty ty ty ty ty ty t y t y ty t y ty ty ty ty
the best answer.
ty ty t y
DIF: Understanding TOP: Integrated Process: Nursing t y ty ty
Process: Intervention KEY: Client safety
ty ty ty ty ty
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
t y ty ty ty ty ty ty ty ty ty ty ty
3. A nurse is orienting a new client and family to the medical-surgical unit. What
ty ty ty ty ty ty ty ty ty ty ty ty ty
information does the nurse provide to best help the client promote his or her
ty ty ty ty ty ty ty ty ty ty ty ty ty ty
own safety?
ty ty
a. Encourage the client and family to be active partners. ty ty ty ty ty ty ty ty
b. Have the client monitor hand hygiene in caregivers.
ty ty ty ty ty ty ty
c. Offer the family the opportunity to stay with the client.
ty ty ty ty ty ty ty ty ty
d. Tell the client to always wear his or her armband.
ty ty ty ty ty ty ty ty ty
, l OM oARc PSD|170 4709 3
ANS: t y A
Each action could be important for the client or family to perform. However, encouraging the
ty ty ty ty ty ty ty ty ty ty ty ty ty ty
client to be active in his or her health care as a safety partner is the most critical. The
ty ty ty ty ty t y ty ty t y ty ty ty ty ty ty ty ty ty ty
other actions are very limited in scope and do not provide the broad protection that being
ty ty ty ty ty ty ty ty ty ty ty ty ty ty ty ty
active and involved does.
ty ty ty ty
DIF: Understanding TOP: Integrated Process: Teaching/Learning ty ty ty
KEY: Client safety
ty ty ty
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
t y ty ty ty ty ty ty ty ty ty ty ty
4. A nurse wishes to provide client-centered care in all interactions. Which action by the
ty ty ty ty ty ty ty ty ty ty ty ty ty
ty nurse best demonstrates this concept?
ty ty ty ty
a. Assesses for cultural influences affecting health care.
ty ty ty ty ty ty
b. Ensures that all the client’s basic needs are met.
ty ty ty ty ty ty ty ty
c. Tells the client and family about all upcoming tests.
ty ty ty ty ty ty ty ty
d. Thoroughly orients the client and family to the room. ty ty ty ty ty ty ty ty
ANS: t y A
Showing respect for the client and family’s preferences and needs is essential to ensure a
ty ty ty ty ty ty ty ty ty ty ty ty ty ty
holistic or “whole-person” approach to care. By assessing the effect of the client’s
ty ty ty ty ty ty ty ty ty ty ty ty ty
culture on health care, this nurse is practicing client-focused care. Providing for basic
ty ty ty ty ty ty ty ty ty ty ty ty ty
needs does not demonstrate this competence. Simply telling the client about all
ty ty ty ty ty ty ty ty ty ty ty ty
upcoming tests is not providing empowering education. Orienting the client and family
ty ty ty ty ty ty ty ty ty ty ty ty
to the room is an important safety measure, but not directly related to demonstrating
ty ty ty ty ty ty ty ty ty ty ty ty ty ty
client-centered care.
ty ty
DIF: Understanding TOP: Integrated Process: Culture and ty ty ty ty ty
Spirituality KEY: Client-centered care, Culture
ty MSC: Client Needs Category:
ty t y ty ty t y ty ty
Psychosocial Integrity
ty ty
5. A client is going to be admitted for a scheduled surgical procedure. Which action
ty ty ty ty ty ty ty ty ty ty ty ty ty
does the nurse explain is the most important thing the client can do to protect
ty ty ty ty ty ty ty ty ty ty ty ty ty ty ty
against errors?
ty t y
a. Bring a list of all medications and what they are for.
ty ty ty ty ty ty ty ty ty ty
b. Keep the provider’s phone number by the telephone.
ty ty ty ty ty ty ty
c. Make sure that all providers wash hands before entering the room.
ty ty ty ty ty ty ty ty ty ty
d. Write down the name of each caregiver who comes in the room.
ty ty ty ty ty ty ty ty ty ty ty
ANS: t y A
Medication reconciliation is a formal process in which the client’s actual current
ty ty ty ty ty ty ty ty ty ty ty
medications are compared to the prescribed medications at the time of admission,
ty ty ty ty ty ty ty ty ty ty ty ty
transfer, or discharge. This National client Safety Goal is important to reduce medication
ty ty ty ty ty ty ty ty ty ty ty ty ty
errors. The client would not have to be responsible for providers washing their
ty ty ty ty ty ty ty ty ty t y ty ty t y
hands, and even if the client does so, this is too narrow to be the most important
ty ty ty ty ty ty t y ty ty ty ty ty ty ty ty ty ty
action to prevent errors. Keeping the provider’s phone number nearby and
ty ty ty ty ty ty ty ty t y t y ty
documenting everyone who enters the room also do not guarantee safety.
t y ty t y t y ty t y ty t y ty ty ty
DIF: Applying TOP: Integrated Process: ty ty
Teaching/Learning KEY: Client safety, Informatics ty ty ty ty
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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, l OM oARc PSD|170 4709 3
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
ty ty ty ty ty ty ty ty ty ty ty ty ty
a. Asks if the client has questions before signing a consent.
ty ty ty ty ty ty ty ty ty
b. Gives the client accurate information when questioned.
ty ty ty ty ty ty
c. Keeps the promises made to the client and family. ty ty ty ty ty ty ty ty
d. Treats the client fairly compared to other clients.ty ty ty ty ty ty ty
ANS: t y A
Autonomy is self-determination. The client would make decisions regarding care. When the
ty ty ty ty ty ty ty ty ty ty ty
nurse obtains a signature on the consent form, assessing if the client still has questions is
ty ty ty ty ty ty ty ty ty ty ty ty ty ty ty ty
vital, because without full information the client cannot practice autonomy. Giving accurate
ty ty ty ty ty ty ty ty ty ty ty ty
information is practicing with veracity. Keeping promises is upholding fidelity. Treating the
ty ty ty ty ty ty ty ty ty ty ty ty
client fairly is providing social justice.
ty ty ty ty ty ty
DIF: Applying TOP: Integrated Process: Caring KEY: Ethics, Autonomy ty ty ty ty
MSC: Client Needs Category: Safe and Effective Care Environment: Management
ty t y ty ty ty ty ty ty ty ty
of Care
ty ty
7. A nurse asks a more seasoned colleague to explain best practicesqwhenq communicating
ty ty ty ty ty ty ty ty ty ty
with a person from the lesbian, gay, bisexual, transgender, and questioning/queer
ty t y ty ty ty ty ty ty ty ty ty
(LGBTQ) community. What answer by the faculty is most accurate?
ty ty ty ty ty ty ty ty ty ty
a. Avoid embarrassing the client by asking questions. ty ty ty ty ty ty
b. Don’t make assumptions about his or her health needs.
ty ty ty ty ty ty ty ty
c. Most LGBTQ people do not want to share information.
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d. No differences exist in communicating with this population.
ty ty ty ty ty ty ty
ANS: t y B
Many members of the LGBTQ community haveqfaced discrimination from health care
ty ty ty ty ty ty ty ty ty ty
providers and may be reluctant to seek health care. The nurse would never make
ty ty ty ty ty ty ty ty ty ty ty ty ty ty
assumptions about the needs of members of this population. Rather, respectful questions
t y ty ty ty ty ty ty ty ty ty ty ty
are appropriate. If approached withqsensitivity, qthe client with any health care need is
ty ty ty ty ty ty ty ty ty ty ty ty ty
more likely to answer honestly.
ty ty ty ty ty
DIF: Understanding TOP: Integrated Process: Teaching/Learning t y ty ty
KEY: Health care disparities, LGBTQ MSC: Client Needs Category: Psychosocial Integrity
t y ty ty ty t y ty ty ty ty
8. A nurse is callingq theqon-callq health care provider about a client who had a
ty ty ty ty ty ty ty ty ty ty ty
hysterectomy 2 days ago andqhas painqthat is unrelieved by the prescribed opioid
ty t y ty ty ty ty ty ty ty ty ty ty
pain medication. Whichqstatement qcomprises the background portion of the SBAR
ty ty ty ty ty ty ty ty ty ty
format for communication?
ty ty ty
a. “Iqwould qlike you to order a different pain medication.” ty ty ty ty ty ty ty ty
b. “This clientq has allergies to morphine and codeine.”
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c. “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.”
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d. “Thisqclient had a vaginal hysterectomy 2 days ago.” ty ty ty ty ty ty ty
ANS: t y B
