lOMoAR c PSD| 60 78199
1
Test Bank -
Medical-Surgical
Nursing:
Concepts for
Interprofessional
Collaborative
Care 9e
,Chapter 01: Overview of Professional Nursing Concepts for
Medical-Surgical Nursing
MULTIPLE CHOICE
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
ANS: A
Competency in client-focused care is demonstrated when the nursefocuses 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 andfamily to theroom is
animportantsafetymeasure, butnotdirectlyrelatedtodemonstratingclient-centered care.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity
A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76
Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse isbest?
Call the Rapid Response Team.
Document and continue to monitor.
Notify the primary care provider.
Repeat blood pressure measurement in 15 minutes.
ANS: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before
they suffereitherrespiratoryorcardiacarrest. Sincetheclienthasmanifestedasignificantchange,
thenurseshould call the RRT. Changes in blood pressure, mental status, heart rate, and pain are
particularly significant. Documentation is vital, but the nursemust 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 theclient.
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
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.
ANS: 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 involveddoes.
DIF: Understanding/Comprehension REF: 3
KEY: Patient safety
, lOMoAR c PSD| 60 78199
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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 2
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A new nurse is working with a preceptor on an inpatientmedical-surgical unit. The preceptor
advises the student that which is the priority when working as a professionalnurse?
Attending to holistic client needs
Ensuring client safety
Not making medication errors
Providing client-focused care
ANS: 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 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 againsterrors?
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.
ANS: 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? a. Asks if the client has questions before signing a consent
b. Gives the client accurate information when questioned
c. Keeps the promises made to the client and family
d. Treats the client fairly compared to other clients
ANS: A
Autonomy is self-determination. The client should make decisions regarding care. When the
nurseobtainsa 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 client fairly is providing social justice.
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
A student nurse asks the faculty to explain best practices when communicating with a
person from the lesbian, gay, bisexual, transgender, andqueer/questioning (LGBTQ)
community. Whatanswerbythe 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.
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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 3
d. No differences exist in communicating with this population.
ANS: B
Manymembersofthe LGBTQcommunity have faceddiscrimination from health care
providersandmaybe reluctant to seek health care. The nurse should never make assumptions about
the needs of members of this population. Rather, respectful questionsareappropriate. If approached
with sensitivity, the clientwith 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
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.
ANS: B
SBAR is a recommended form of communication, and the acronym stands for Situation, Background,
Assessment, and Recommendation. Appropriatebackgroundinformationincludesallergies to
medicationsthe on-callphysicianmightorder. Situationdescribeswhat is happening rightnow
thatmustbecommunicated; 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/ApplicationREF: 5
KEY: SBAR| communication
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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
higherthan 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
ANS: 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
A nurse is talking with a client who is moving to a new state and needs to find a new
doctor and hospital there. What advice by the nurse is best?
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1
Test Bank -
Medical-Surgical
Nursing:
Concepts for
Interprofessional
Collaborative
Care 9e
,Chapter 01: Overview of Professional Nursing Concepts for
Medical-Surgical Nursing
MULTIPLE CHOICE
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
ANS: A
Competency in client-focused care is demonstrated when the nursefocuses 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 andfamily to theroom is
animportantsafetymeasure, butnotdirectlyrelatedtodemonstratingclient-centered care.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity
A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76
Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse isbest?
Call the Rapid Response Team.
Document and continue to monitor.
Notify the primary care provider.
Repeat blood pressure measurement in 15 minutes.
ANS: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before
they suffereitherrespiratoryorcardiacarrest. Sincetheclienthasmanifestedasignificantchange,
thenurseshould call the RRT. Changes in blood pressure, mental status, heart rate, and pain are
particularly significant. Documentation is vital, but the nursemust 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 theclient.
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
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.
ANS: 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 involveddoes.
DIF: Understanding/Comprehension REF: 3
KEY: Patient safety
, lOMoAR c PSD| 60 78199
Stuvia.com - The Marketplace to Buy and Sell your Study Material
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 2
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A new nurse is working with a preceptor on an inpatientmedical-surgical unit. The preceptor
advises the student that which is the priority when working as a professionalnurse?
Attending to holistic client needs
Ensuring client safety
Not making medication errors
Providing client-focused care
ANS: 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 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 againsterrors?
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.
ANS: 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? a. Asks if the client has questions before signing a consent
b. Gives the client accurate information when questioned
c. Keeps the promises made to the client and family
d. Treats the client fairly compared to other clients
ANS: A
Autonomy is self-determination. The client should make decisions regarding care. When the
nurseobtainsa 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 client fairly is providing social justice.
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
A student nurse asks the faculty to explain best practices when communicating with a
person from the lesbian, gay, bisexual, transgender, andqueer/questioning (LGBTQ)
community. Whatanswerbythe 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.
Downloaded by: rubricguru |
Distribution of this document is illegal
, lOMoAR c PSD| 60 78199
Stuvia.com - The Marketplace to Buy and Sell your Study Material
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 3
d. No differences exist in communicating with this population.
ANS: B
Manymembersofthe LGBTQcommunity have faceddiscrimination from health care
providersandmaybe reluctant to seek health care. The nurse should never make assumptions about
the needs of members of this population. Rather, respectful questionsareappropriate. If approached
with sensitivity, the clientwith 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
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.
ANS: B
SBAR is a recommended form of communication, and the acronym stands for Situation, Background,
Assessment, and Recommendation. Appropriatebackgroundinformationincludesallergies to
medicationsthe on-callphysicianmightorder. Situationdescribeswhat is happening rightnow
thatmustbecommunicated; 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/ApplicationREF: 5
KEY: SBAR| communication
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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
higherthan 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
ANS: 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
A nurse is talking with a client who is moving to a new state and needs to find a new
doctor and hospital there. What advice by the nurse is best?
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