TEST BANK
,
,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
Rationale: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
Rationale: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
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.
,
,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
Rationale: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
Rationale: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
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.
