TEST BANK for Medical-Surgical Nursing: Concepts
for Clinical Judgment and Collaborative Care
11th Edition by Donna D. Ignatavicius,
All chapters 1 - 74
,
,
, Chapter 01: Overview of Professional Nursing Concepts for Medical-
Surgical Nursing
MULTIPLE CHOICE
1. A nurse2wishes2to provide client-
centered care in all interactions. Which action by the nurse2best demonstrates this concept?
a. Assesses for2 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 client2 and family to the2room
CORRECT2ANSWER: A
Competency in client-
focused care2is demonstrated when the nurse focuses on communication, culture, respect compassion, client educ
ation, and empowerment. By assessing the effect of the clients culture on health care, this nurse is practicing c
lient-
focused care. Providing for basic needs does not demonstrate this competence. Simply telling the2client about2
all upcoming tests is not providing empowering education. Orienting the client and family to the2room is an im
portant2safety measure, but2not directly related to demonstrating client-centered care.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-
centered care| culture MSC: Integrated Process: Caring2NOT: Client
Needs Category: Psychosocial Integrity
2. A nurse2is caring for2a postoperative2client on the surgical unit. The clients blood pressure was 142/762mm H
g 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team.
b. Document2and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood2 pressure2measurement2 in215 minutes.
CORRECT2ANSWER: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they su
ffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the2nurse should call t
he 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 provider2should be
notified, but this is not the2priority over2calling the RRT. The2clients blood pressure2should be reassessed fre
quently, but the priority is getting the rapid care to the client.
DIF: Applying/Application REF: 3
KEY: Rapid Response Team (RRT)| medical emergencies MS
for Clinical Judgment and Collaborative Care
11th Edition by Donna D. Ignatavicius,
All chapters 1 - 74
,
,
, Chapter 01: Overview of Professional Nursing Concepts for Medical-
Surgical Nursing
MULTIPLE CHOICE
1. A nurse2wishes2to provide client-
centered care in all interactions. Which action by the nurse2best demonstrates this concept?
a. Assesses for2 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 client2 and family to the2room
CORRECT2ANSWER: A
Competency in client-
focused care2is demonstrated when the nurse focuses on communication, culture, respect compassion, client educ
ation, and empowerment. By assessing the effect of the clients culture on health care, this nurse is practicing c
lient-
focused care. Providing for basic needs does not demonstrate this competence. Simply telling the2client about2
all upcoming tests is not providing empowering education. Orienting the client and family to the2room is an im
portant2safety measure, but2not directly related to demonstrating client-centered care.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-
centered care| culture MSC: Integrated Process: Caring2NOT: Client
Needs Category: Psychosocial Integrity
2. A nurse2is caring for2a postoperative2client on the surgical unit. The clients blood pressure was 142/762mm H
g 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team.
b. Document2and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood2 pressure2measurement2 in215 minutes.
CORRECT2ANSWER: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they su
ffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the2nurse should call t
he 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 provider2should be
notified, but this is not the2priority over2calling the RRT. The2clients blood pressure2should be reassessed fre
quently, but the priority is getting the rapid care to the client.
DIF: Applying/Application REF: 3
KEY: Rapid Response Team (RRT)| medical emergencies MS
