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 - ANS a. Assesses for cultural influences
affecting health care
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.
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. - ANS a. Call the Rapid Response
Team.
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.
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.
d. Tell the client to always wear his or her armband. - ANS a. Encourage the client and family to
be active partners.
, 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.
4. 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?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care - ANS b. Ensuring client safety
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.
5. 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?
a. Bring a list of all medications and what they are for.
b. Keep the doctors phone number by the telephone.
c. Make sure all providers wash hands before entering the room.
d. Write down the name of each caregiver who comes in the room. - ANS a. Bring a list of all
medications and what they are for.
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.
6. 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. Asks if the client has questions
before signing a consent
Autonomy is self-determination. The client should make decisions regarding care. When the
nurse obtains a