◦ Timby'slIntroductory lMedical-SurgicallNursing l13thlEditionlMoreno lTestlBank
Chapterl 1 Conceptsl and l Trendsl in l Healthcare
◦ Alnewlnurselislworkinglwith lalpreceptorlon lan linpatientlmedical-
surgicallunit.lThelpreceptorladviseslthelstudentlthatlwhichlislthelpriority lwhen lwork
inglaslalprofessionallnurse?
◦ Attendingl to l holisticl clientl needs
◦ Ensuringl clientl safety
◦ Notl makingl medication l errors
◦ Providinglclient-
lfocused lcare lAN
S:lB
◦ Alllactionslarelappropriate lforlthelprofessionallnurse.lHowever,l ensuringl c
lientl safety l isl thel priority.l Up l to l 98,000 l deathsl resultl eachl yearl froml errorslinlhospitallcare
,laccordinglto lthel2000 lInstituteloflMedicinelreport.lMany lmorelclientslhavelsuffered linjurie
sland llesslseriousloutcomes.lEvery lnurse lhaslthelresponsibility lto lguard lthelclientslsafety.
◦ DIF:lUnderstanding/Comprehension lREF:l2 l
KEY:lPatientlsafety lMSC:lIntegrated lProcess:lNursinglProces
s:lIntervention
◦ NOT:lClientlNeedslCategory:lSafeland lEffective lCarelEn
vironment:lSafety land lInfection lControl
◦ Alnurselislorientinglalnewlclientland lfamily lto lthelinpatientlunit.lWhatlinformatio
n ldoeslthelnurselprovide lto lhelp lthelclientlpromote lhislorlherlown lsafety?
◦ Encourage l thel clientl and l family l to l bel activel partners.
◦ Havel thel clientl monitorl hand l hygiene l in l caregivers.
◦ Offerl thel family l thel opportunity l to l stay l with l thel client.
◦ Telllthelclientlto lalwayslwearlhislorlhe
rlarmband.lANS:lA
◦ Each laction lcould lbelimportantlforlthelclientlorlfamily lto lperform.lHowe
ver,lencouraginglthelclientlto lbelactivelin lhislorlherlhealth lcarelaslalpartnerlislthelmostlcriti
cal.lThelotherlactionslare
◦
◦ very llimited lin lscope land ldolnotlprovidelthelbroad lprotection lthatlbein
glactiveland linvolved ldoes.
◦ DIF:lUnderstanding/Comprehension lREF:l3 l
KEY:lPatientlsafety lMSC:lIntegrated lProcess:lTeaching/lLear
ning
◦ NOT:l Clientl Needsl Category:l Safel and l Effective l Care
,Environment:l Safety l and l Infection l Control
◦ Alnurselislcaringlforlalpostoperative lclientlon lthelsurgicallunit.lThelclientslblood lpress
urelwasl142/76 lmmlHgl30 lminuteslago,land lnowlisl88/50 lmmlHg.lWhatlaction lbyltheln
urselislbest?
◦ Calll thel Rapid l Response l Team.
◦ Documentl and l continue l to l monitor.
◦ Notify l thel primary l carel provider.
◦ Repeatlblood lpressure lmeasurementli
n l15 lminutes.lANS:lA
◦ Thelpurpose lof lthelRapid lResponse lTeaml(RRT)lislto lintervene lwhenlclientsl
areldeterioratinglbefore lthey lsufferleitherlrespiratory lorlcardiaclarrest.lSincelthelclientlhaslm
anifested lalsignificantlchange,lthelnurselshould lcalllthelRRT.lChangeslin lblood lpressure,lme
ntallstatus,lheartlrate,land lpain larelparticularly lsignificant.lDocumentation lislvital,lbutlthelnu
rselmustldo lmorelthan ldocument.lThelprimary lcarelproviderlshould lbelnotified,lbutlthislislnot
lthe lpriority loverlcallingl the lRRT. lThe l clients lblood lpressure lshould lbe lreassessedlfrequent
ly,lbutlthelpriority lislgetting
thelrapid lcarelto lthelclient.
◦ DIF:lApplying/Application l REF:l 3
◦ KEY:lRapid lResponse lTeaml(RRT)|l
medicallemergencieslMSC:lIntegrated lProcess:
Communication l and l Documentation
◦ NOT:l Clientl Needsl Category:l Physiologicall Integrity:l PhysiologicallAdaptation
◦
◦ Alnurselwisheslto lprovide lclient-
centered lcarelin lalllinteractions.lWhich laction lby lthelnurselbestldemonstrates
lthislconcept?
◦ Assessesl forl culturall influencesl affectingl health l care
◦ Ensureslthatlalll thelclientsl basiclneedsl arel met
◦ Tellslthel clientl and l family l aboutl alll upcomingl tests
◦ Thoroughly lorientslthelclientland lf
amily lto lthelroomlANS:lA
◦ Competency lin lclient-
focused lcarelisldemonstrated lwhen lthelnurselfocuseslonlcommunication, lculture,lrespe
ct,lcompassion, lclientleducation,land lempowerment. lBy lassessingltheleffectlof lthe
◦
◦ clientslculturelon lhealth lcare,lthislnurselislpracticinglclient-
focused lcare.lProvidinglforlbasicl needsldoeslnotldemonstrate lthislcompetence.lSimply ltelli
nglthelclientlaboutlalllupcomingltestslislnotlprovidinglempoweringleducation.lOrientinglth
elclientland lfamily lto lthelroomlislan limportantlsafety lmeasure,lbutlnotldirectly l related lto lde
monstratinglclient-centered l care.
◦ DIF:l Understanding/Comprehension l REF:l 3
, ◦ KEY:lPatient-
centered lcare|lculturelMSC:lIntegrated lProcess:lCaringlNO
T:lClientlNeedslCategory:
Psychosociall Integrity
◦ Alclientlislgoinglto lbeladmitted lforlalscheduled lsurgicallprocedure.lWhich lactio
n ldoeslthelnurselexplain lislthelmostlimportantlthinglthelclientlcan ldo l to lprotectla
gainstlerrors?
◦ Bringlal listlof l alllmedicationsl and l whatlthey l arel for.
◦ Keep l thel doctorsl phonel numberl by l thel telephone.
◦ Makel surel alll providersl wash l handsl beforel enteringl thel room.
◦ Writeldown lthelnamelof leach lcaregiverlwholco
meslin lthelroom.lANS:lA
◦ Medication lerrorslarelthelmostlcommon ltypeloflhealth lcarelmistake.lThelJo
intlCommissionslSpeak lUp lcampaign lencourageslclientslto lhelp lensureltheirlsafety.lOnelre
commendation lislforlclientslto lknowlallltheirlmedicationsland lwhy ltheyltakelthem.lThislwil
llhelp lpreventlmedication lerrors.
◦ DIF:lApplying/Application l REF:l 4
◦ KEY:lSpeak lUp lcampaign|lpatientlsafety lMSC:lIntegrated lProces
s:lTeaching/LearninglNOT:lClientlNeedslCategory:lSafeland lEffective lCarelEnvi
ronment:lSafety land lInfection lControl
◦ Which laction lby lthelnurselworkinglwith lalclientlbestldemonstrateslrespectlforl auton
omy?
◦ Asksl if l thel clientl hasl questionsl before l signingl al consent
◦ Givesl thel clientl accurate l information l when l questioned
◦ Keepsl thel promisesl madel to l thel clientl and l family
◦ Treatslthelclientlfairly lcom
pared lto lotherlclientslANS
:lA
◦ Autonomy lislself-
determination. lThelclientlshould lmakeldecisionslregardinglcare.lWhen lthelnurselobtainslals
ignaturelon lthelconsentlform,lassessinglifl thelclientlstilllhaslquestionslislvital,lbecause lwith
outlfulllinformation lthelclientlcannotlpractice lautonomy.lGivinglaccurate linformationlislpra
cticinglwith lveracity.lKeepinglpromiseslislupholdinglfidelity.lTreatinglthe
◦
◦ clientl fairly l isl providingl sociall justice.
◦
◦ DIF:lApplying/Application l REF:l 4
◦ KEY:lAutonomy|l ethicall principlesl MSC:l Integrated l Process:l Caring
◦ NOT:l Clientl Needsl Category:l Safel and l Effective l Carel Environment:l Management
of lCare
, ◦
◦ Alstudentlnurselaskslthelfaculty lto lexplain lbestlpracticeslwhen lcommunicatinglwith l
alperson lfromlthellesbian,lgay,lbisexual,ltransgender,land lqueer/lquestioningl(LGB
TQ)lcommunity. lWhatlanswerlby lthelfaculty lislmostl accurate?
◦ Avoid l embarrassingl thel clientl by l askingl questions.
◦ Dontl makel assumptionsl aboutl theirl health l needs.
◦ Mostl LGBTQl peoplel do l notl wantl to l sharel information.
◦ No ldifferenceslexistlin lcommunicatinglwith lth
islpopulation. lANS:lB
◦ Many lmemberslof lthelLGBTQlcommunity lhavelfaced ldiscrimination lfroml
health lcarelprovidersland lmay lbelreluctantlto lseek lhealth lcare.lThelnurselshould lneverlmakel
assumptionslaboutlthelneedsloflmemberslof lthislpopulation.lRather,lrespectfullquestionslar
elappropriate. lIf lapproached lwith lsensitivity,lthelclientlwith lany lhealth lcarelneed lislmorellik
ely lto lanswerlhonestly.
◦ DIF:lUnderstanding/Comprehension lREF:l4 l
KEY:lLGBTQ|ldiversity lMSC:lIntegrated lProcess:lTeaching/
Learning
◦ NOT:l Clientl Needsl Category:l Psychosociall Integrity
◦
◦ Alnurselislcallinglthelon-
calllphysician laboutlalclientlwho lhad lalhysterectomy l2 ldayslago land lhaslpain lthatlislu
nrelieved lby lthelprescribed lnarcoticlpain lmedication.lWhich lstatementlislpartloflthelS
BARlformatlforlcommunication?
◦ A:lIlwould llikel you lto lorderl aldifferentlpain l medication.
◦ B:lThisl clientl hasl allergiesl to l morphine l and l codeine.
◦ R:l Dr.l Smith l doesntl likel nonsteroidall anti-inflammatory l meds.
◦ S:lThislclientlhad lalvaginallhysterec
tomy l2 ldayslago.lANS:lB
◦ SBARlislalrecommended lformloflcommunication,land lthelacronymlstandsl
forlSituation,lBackground, lAssessment, land lRecommendation. lAppropriate lbackground li
nformation lincludeslallergieslto lmedicationslthelon-
calllphysician lmightlorder.lSituation ldescribeslwhatlislhappeninglrightlnowlthatlmustlbelco
mmunicated;l thelclientslsurgery l2 ldayslago lwouldlbelconsidered lbackground.lAssessmen
tlwould lincludelan lanalysisloflthelclientslproblem;laskinglforlaldifferentlpain lmedication lisl
alrecommendation. lRecommendation lislalstatementlof lwhatlislneeded lorlwhat
◦
◦ outcome lisldesired;lthislinformation laboutlthelsurgeonslpreference lmi
ghtlbelbetterlplaced lin lbackground.
◦ DIF:lApplying/l
Application lREF:l5 lKEY:lSBA
R|lcommunication
Chapterl 1 Conceptsl and l Trendsl in l Healthcare
◦ Alnewlnurselislworkinglwith lalpreceptorlon lan linpatientlmedical-
surgicallunit.lThelpreceptorladviseslthelstudentlthatlwhichlislthelpriority lwhen lwork
inglaslalprofessionallnurse?
◦ Attendingl to l holisticl clientl needs
◦ Ensuringl clientl safety
◦ Notl makingl medication l errors
◦ Providinglclient-
lfocused lcare lAN
S:lB
◦ Alllactionslarelappropriate lforlthelprofessionallnurse.lHowever,l ensuringl c
lientl safety l isl thel priority.l Up l to l 98,000 l deathsl resultl eachl yearl froml errorslinlhospitallcare
,laccordinglto lthel2000 lInstituteloflMedicinelreport.lMany lmorelclientslhavelsuffered linjurie
sland llesslseriousloutcomes.lEvery lnurse lhaslthelresponsibility lto lguard lthelclientslsafety.
◦ DIF:lUnderstanding/Comprehension lREF:l2 l
KEY:lPatientlsafety lMSC:lIntegrated lProcess:lNursinglProces
s:lIntervention
◦ NOT:lClientlNeedslCategory:lSafeland lEffective lCarelEn
vironment:lSafety land lInfection lControl
◦ Alnurselislorientinglalnewlclientland lfamily lto lthelinpatientlunit.lWhatlinformatio
n ldoeslthelnurselprovide lto lhelp lthelclientlpromote lhislorlherlown lsafety?
◦ Encourage l thel clientl and l family l to l bel activel partners.
◦ Havel thel clientl monitorl hand l hygiene l in l caregivers.
◦ Offerl thel family l thel opportunity l to l stay l with l thel client.
◦ Telllthelclientlto lalwayslwearlhislorlhe
rlarmband.lANS:lA
◦ Each laction lcould lbelimportantlforlthelclientlorlfamily lto lperform.lHowe
ver,lencouraginglthelclientlto lbelactivelin lhislorlherlhealth lcarelaslalpartnerlislthelmostlcriti
cal.lThelotherlactionslare
◦
◦ very llimited lin lscope land ldolnotlprovidelthelbroad lprotection lthatlbein
glactiveland linvolved ldoes.
◦ DIF:lUnderstanding/Comprehension lREF:l3 l
KEY:lPatientlsafety lMSC:lIntegrated lProcess:lTeaching/lLear
ning
◦ NOT:l Clientl Needsl Category:l Safel and l Effective l Care
,Environment:l Safety l and l Infection l Control
◦ Alnurselislcaringlforlalpostoperative lclientlon lthelsurgicallunit.lThelclientslblood lpress
urelwasl142/76 lmmlHgl30 lminuteslago,land lnowlisl88/50 lmmlHg.lWhatlaction lbyltheln
urselislbest?
◦ Calll thel Rapid l Response l Team.
◦ Documentl and l continue l to l monitor.
◦ Notify l thel primary l carel provider.
◦ Repeatlblood lpressure lmeasurementli
n l15 lminutes.lANS:lA
◦ Thelpurpose lof lthelRapid lResponse lTeaml(RRT)lislto lintervene lwhenlclientsl
areldeterioratinglbefore lthey lsufferleitherlrespiratory lorlcardiaclarrest.lSincelthelclientlhaslm
anifested lalsignificantlchange,lthelnurselshould lcalllthelRRT.lChangeslin lblood lpressure,lme
ntallstatus,lheartlrate,land lpain larelparticularly lsignificant.lDocumentation lislvital,lbutlthelnu
rselmustldo lmorelthan ldocument.lThelprimary lcarelproviderlshould lbelnotified,lbutlthislislnot
lthe lpriority loverlcallingl the lRRT. lThe l clients lblood lpressure lshould lbe lreassessedlfrequent
ly,lbutlthelpriority lislgetting
thelrapid lcarelto lthelclient.
◦ DIF:lApplying/Application l REF:l 3
◦ KEY:lRapid lResponse lTeaml(RRT)|l
medicallemergencieslMSC:lIntegrated lProcess:
Communication l and l Documentation
◦ NOT:l Clientl Needsl Category:l Physiologicall Integrity:l PhysiologicallAdaptation
◦
◦ Alnurselwisheslto lprovide lclient-
centered lcarelin lalllinteractions.lWhich laction lby lthelnurselbestldemonstrates
lthislconcept?
◦ Assessesl forl culturall influencesl affectingl health l care
◦ Ensureslthatlalll thelclientsl basiclneedsl arel met
◦ Tellslthel clientl and l family l aboutl alll upcomingl tests
◦ Thoroughly lorientslthelclientland lf
amily lto lthelroomlANS:lA
◦ Competency lin lclient-
focused lcarelisldemonstrated lwhen lthelnurselfocuseslonlcommunication, lculture,lrespe
ct,lcompassion, lclientleducation,land lempowerment. lBy lassessingltheleffectlof lthe
◦
◦ clientslculturelon lhealth lcare,lthislnurselislpracticinglclient-
focused lcare.lProvidinglforlbasicl needsldoeslnotldemonstrate lthislcompetence.lSimply ltelli
nglthelclientlaboutlalllupcomingltestslislnotlprovidinglempoweringleducation.lOrientinglth
elclientland lfamily lto lthelroomlislan limportantlsafety lmeasure,lbutlnotldirectly l related lto lde
monstratinglclient-centered l care.
◦ DIF:l Understanding/Comprehension l REF:l 3
, ◦ KEY:lPatient-
centered lcare|lculturelMSC:lIntegrated lProcess:lCaringlNO
T:lClientlNeedslCategory:
Psychosociall Integrity
◦ Alclientlislgoinglto lbeladmitted lforlalscheduled lsurgicallprocedure.lWhich lactio
n ldoeslthelnurselexplain lislthelmostlimportantlthinglthelclientlcan ldo l to lprotectla
gainstlerrors?
◦ Bringlal listlof l alllmedicationsl and l whatlthey l arel for.
◦ Keep l thel doctorsl phonel numberl by l thel telephone.
◦ Makel surel alll providersl wash l handsl beforel enteringl thel room.
◦ Writeldown lthelnamelof leach lcaregiverlwholco
meslin lthelroom.lANS:lA
◦ Medication lerrorslarelthelmostlcommon ltypeloflhealth lcarelmistake.lThelJo
intlCommissionslSpeak lUp lcampaign lencourageslclientslto lhelp lensureltheirlsafety.lOnelre
commendation lislforlclientslto lknowlallltheirlmedicationsland lwhy ltheyltakelthem.lThislwil
llhelp lpreventlmedication lerrors.
◦ DIF:lApplying/Application l REF:l 4
◦ KEY:lSpeak lUp lcampaign|lpatientlsafety lMSC:lIntegrated lProces
s:lTeaching/LearninglNOT:lClientlNeedslCategory:lSafeland lEffective lCarelEnvi
ronment:lSafety land lInfection lControl
◦ Which laction lby lthelnurselworkinglwith lalclientlbestldemonstrateslrespectlforl auton
omy?
◦ Asksl if l thel clientl hasl questionsl before l signingl al consent
◦ Givesl thel clientl accurate l information l when l questioned
◦ Keepsl thel promisesl madel to l thel clientl and l family
◦ Treatslthelclientlfairly lcom
pared lto lotherlclientslANS
:lA
◦ Autonomy lislself-
determination. lThelclientlshould lmakeldecisionslregardinglcare.lWhen lthelnurselobtainslals
ignaturelon lthelconsentlform,lassessinglifl thelclientlstilllhaslquestionslislvital,lbecause lwith
outlfulllinformation lthelclientlcannotlpractice lautonomy.lGivinglaccurate linformationlislpra
cticinglwith lveracity.lKeepinglpromiseslislupholdinglfidelity.lTreatinglthe
◦
◦ clientl fairly l isl providingl sociall justice.
◦
◦ DIF:lApplying/Application l REF:l 4
◦ KEY:lAutonomy|l ethicall principlesl MSC:l Integrated l Process:l Caring
◦ NOT:l Clientl Needsl Category:l Safel and l Effective l Carel Environment:l Management
of lCare
, ◦
◦ Alstudentlnurselaskslthelfaculty lto lexplain lbestlpracticeslwhen lcommunicatinglwith l
alperson lfromlthellesbian,lgay,lbisexual,ltransgender,land lqueer/lquestioningl(LGB
TQ)lcommunity. lWhatlanswerlby lthelfaculty lislmostl accurate?
◦ Avoid l embarrassingl thel clientl by l askingl questions.
◦ Dontl makel assumptionsl aboutl theirl health l needs.
◦ Mostl LGBTQl peoplel do l notl wantl to l sharel information.
◦ No ldifferenceslexistlin lcommunicatinglwith lth
islpopulation. lANS:lB
◦ Many lmemberslof lthelLGBTQlcommunity lhavelfaced ldiscrimination lfroml
health lcarelprovidersland lmay lbelreluctantlto lseek lhealth lcare.lThelnurselshould lneverlmakel
assumptionslaboutlthelneedsloflmemberslof lthislpopulation.lRather,lrespectfullquestionslar
elappropriate. lIf lapproached lwith lsensitivity,lthelclientlwith lany lhealth lcarelneed lislmorellik
ely lto lanswerlhonestly.
◦ DIF:lUnderstanding/Comprehension lREF:l4 l
KEY:lLGBTQ|ldiversity lMSC:lIntegrated lProcess:lTeaching/
Learning
◦ NOT:l Clientl Needsl Category:l Psychosociall Integrity
◦
◦ Alnurselislcallinglthelon-
calllphysician laboutlalclientlwho lhad lalhysterectomy l2 ldayslago land lhaslpain lthatlislu
nrelieved lby lthelprescribed lnarcoticlpain lmedication.lWhich lstatementlislpartloflthelS
BARlformatlforlcommunication?
◦ A:lIlwould llikel you lto lorderl aldifferentlpain l medication.
◦ B:lThisl clientl hasl allergiesl to l morphine l and l codeine.
◦ R:l Dr.l Smith l doesntl likel nonsteroidall anti-inflammatory l meds.
◦ S:lThislclientlhad lalvaginallhysterec
tomy l2 ldayslago.lANS:lB
◦ SBARlislalrecommended lformloflcommunication,land lthelacronymlstandsl
forlSituation,lBackground, lAssessment, land lRecommendation. lAppropriate lbackground li
nformation lincludeslallergieslto lmedicationslthelon-
calllphysician lmightlorder.lSituation ldescribeslwhatlislhappeninglrightlnowlthatlmustlbelco
mmunicated;l thelclientslsurgery l2 ldayslago lwouldlbelconsidered lbackground.lAssessmen
tlwould lincludelan lanalysisloflthelclientslproblem;laskinglforlaldifferentlpain lmedication lisl
alrecommendation. lRecommendation lislalstatementlof lwhatlislneeded lorlwhat
◦
◦ outcome lisldesired;lthislinformation laboutlthelsurgeonslpreference lmi
ghtlbelbetterlplaced lin lbackground.
◦ DIF:lApplying/l
Application lREF:l5 lKEY:lSBA
R|lcommunication
