Introduction to Medical-Surgical Nursing Test Bank

Which action demonstrates that the nurse understands the purpose of the Rapid Response Team? a. Monitoring the client for changes in postoperative status such as wound infection b. Documenting all changes observed in the client and maintaining a postoperative flow sheet c. Notifying the physician of the client’s change in blood pressure from 140 to 88 mm Hg systolic d. Notifying the physician of the client’s increase in restlessness after medication change ANS: C The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team, which responds to client arrests, it intervenes rapidly for those who are beginning to decline clinically. It would be appropriate for the RRT to intervene when the client has experienced a 52- point drop in blood pressure. Monitoring the client’s postoperative status, maintaining a postoperative flow sheet, and notifying the physician of a change in the client’s status after a medication change would not be considered activities of the Rapid Response Team. DIF: Cognitive Level: Comprehension/Understanding REF: pp. 2-3 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team) MSC: Integrated Process: Nursing Process (Assessment) 2. The Joint Commission focuses on safety in health care. Which action by the nurse reflects The Joint Commission’s main objective? a. Performing range-of-motion exercises on the client three times each day b. Ensuring that the client is eating 100% of the meals served to him or her c. Assessing the client’s respirations when administering opioids d. Delegating to the nursing assistant to give the client a complete bath daily ANS: C It is important for the nurse to assess respirations of the client when administering opioids because of the possibility of respiratory depression. The other interventions may or may not be necessary in the care of the client and do not focus on safety. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control) MSC: Integrated Process: Nursing Process (Assessment) 3. Which action by the nurse shows an understanding of the principle of self-determination? a. Allowing a postoperative client to decide to take medication with fruit juice rather than water b. Allowing a teenager to decide not to go to a clinic when there is evidence that she is having profuse vaginal bleeding c. Allowing a parent to decide not to proceed with a lifesaving operation for a 12-year-old client d. Allowing an older client with dementia to decide not to take cardiac medication throughout the shift ANS: A Respect for people is one of three basic ethical principles that nurses and other health care professionals should use as a basis for clinical decision making. Respect implies that clients are treated as autonomous individuals capable of making informed decisions about their care. This client autonomy is referred to as self-determination, or self-management, and is best illustrated by allowing a client to decide to take medication with fruit juice rather than water. The other answer choices would not illustrate self-determination appropriately and might possibly endanger the client’s life. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice) MSC: Integrated Process: Nursing Process (Assessment) 4. The nurse is initiating a series of teaching sessions with an older client. What is the nurse’s highest-priority, client-centered action before beginning the session? a. Ensure that the client’s family is present and will participate. b. Make certain that the client is wearing his glasses. c. Have printed handouts ready to use during the session. d. Schedule the session for early evening after the client’s meal. ANS: B The most important client-centered action is to ensure that the client is wearing his or her glasses. The ability to see adequately will outweigh the need for family presence, use of printed handouts, and hunger (or lack thereof). DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning 5. Which action best demonstrates the nurse using client-centered care when planning a menu for a Vietnamese client who is newly diagnosed with diabetes? a. Asking the client what food he or she would eat on a standard diabetic menu b. Asking family members to make selections for the client from a diabetic menu c. Ordering a typical diabetic meal for the client and planning diet teaching d. Researching the Vietnamese culture before discussing diabetic meal planning ANS: D Client-centered care is best illustrated by the nurse researching Vietnamese culture and native cooking before discussing meal planning. This shows that the nurse is interested and is involved in the client’s care. The nurse can then suggest foods from the standard diabetic menu to the client and his or her family. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Teaching/Learning 6. The Institute for Healthcare Improvement (IHI) identified interventions to save client lives. Which actions are within the scope of nursing practice to improve quality of care? a. Insert a central line to give intravenous fluid to a dehydrated client. b. Use sterile technique when changing dressings on a new surgical site. c. Intubate a client whose oxygen saturation is 92%. d. Prescribe aspirin for a client who presents with an acute myocardial infarction ANS: B The only intervention identified within the scope of nursing practice is to use sterile technique. Central line insertion, intubation, and prescription are functions of the physician. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Legal Rights and Responsibilities) MSC: Integrated Process: Nursing Process (Implementation) 7. Which action by the nurse demonstrates the best practice for nursing documentation on a computerized record? a. Deleting all documentation errors on the computerized record b. Using red font to denote all significant events that have occurred c. Waiting until the end of the shift to record a summary of information d. Documenting assessment data at the point of care ANS: D The best practice for nursing documentation is to document as soon as the assessment is completed. The other practices listed are ineffective and are not recommended. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Legal Rights and Responsibilities) MSC: Integrated Process: Communication and Documentation 8. A client is scheduled for a mastectomy. As she is about to receive the preoperative medication, she tells the nurse that she does not want to have her breast removed but wants a lumpectomy. Which response indicates that the nurse is acting as a client advocate? a. Telling the client her surgeon is excellent and knows what is best for her condition b. Calling the surgeon to come and explain all treatment options to the client c. Holding the client’s hand and offering to pray with her for a good outcome d. Arranging for a postoperative visit from a cancer survivor ANS: B Clients have the right to be fully informed about their treatment plans and to change their minds. A client who expresses doubt, uncertainty, or a change of feeling about a treatment plan should be supported by the nurse and heard by the health care provider, and should serve as an active participant in treatment planning. The nurse would be functioning best as a client advocate by notifying the surgeon that the client wants a different treatment option. The nurse would not be acting as a client advocate by providing vague reassurance, arranging for a cancer survivor to come meet with the client, or offering to pray with the client because none of these options would address the client’s desire for a different treatment option. Calling the surgeon to come and explain all treatment options also promotes communication and client advocacy.