,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
bestdemonstra tes 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
Competency in client-
focused care is demonstrated when the nurse focuses on communication, culture, respectco
mpassion, client education, and`empowerment` By`assessing the effect of`the clients
culture on health care, thisnurse 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` Or
ienting the client and family to the room is an important safety measure, but not `directly rel
ated to demonstrating client-centeredcare`
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 pre
ssure was 142/76 mmHg 30 minutes ago, and now is 88/50 mm Hg` What action by th
e 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
The purpose of`the Rapid Response Team (RRT) is to intervene when clients are deteriorat
ing before they`suffer either`respiratory`or cardiac arrest` Since the client`has manifested a
si gnificant change, the nurse shouldcall the RRT` Changes in blood
, pressure, mental status, heart`rate, and pain are particularly significant`
Documentat ion`is vital, but the nurse must do more than document` The primary
care provider sh ould`be notified, but this is not the priority over`calling`the RRT`
The clients blood` pr essure 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 emergen
cies MSC: Integrated Process:
Communication and` Documentation
NOT: Client` Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse isorienting anew`client andfamily`to the inpatient unit` What information
d oes the nurse provide tohelp 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
Each action could be important for the client or family to perform` However, encoura
ging 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 anddo not provide the broad`protection that b
eing active and involved does`
DIF: Understanding/Comprehension
REF: 3KEY: Patient safety
Surgical Nursing
MULTIPLE CHOICE
1. A`nurse wishes to provide client-
centered care in`all interactions` Which`action by`the nurse
bestdemonstra tes 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
Competency in client-
focused care is demonstrated when the nurse focuses on communication, culture, respectco
mpassion, client education, and`empowerment` By`assessing the effect of`the clients
culture on health care, thisnurse 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` Or
ienting the client and family to the room is an important safety measure, but not `directly rel
ated to demonstrating client-centeredcare`
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 pre
ssure was 142/76 mmHg 30 minutes ago, and now is 88/50 mm Hg` What action by th
e 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
The purpose of`the Rapid Response Team (RRT) is to intervene when clients are deteriorat
ing before they`suffer either`respiratory`or cardiac arrest` Since the client`has manifested a
si gnificant change, the nurse shouldcall the RRT` Changes in blood
, pressure, mental status, heart`rate, and pain are particularly significant`
Documentat ion`is vital, but the nurse must do more than document` The primary
care provider sh ould`be notified, but this is not the priority over`calling`the RRT`
The clients blood` pr essure 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 emergen
cies MSC: Integrated Process:
Communication and` Documentation
NOT: Client` Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse isorienting anew`client andfamily`to the inpatient unit` What information
d oes the nurse provide tohelp 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
Each action could be important for the client or family to perform` However, encoura
ging 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 anddo not provide the broad`protection that b
eing active and involved does`
DIF: Understanding/Comprehension
REF: 3KEY: Patient safety
