test bank for medical surgical nursing 7th edition by donna d ignatavicius and m linda workman

Test bank for Medical Surgica
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l Nursing 7th Editionby Donna
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D.Ignatavicius andM.Linda
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Workman

,Test bank for Medical Surgical Nursing 7th edition
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by Donna D.Ignatavicius and M.Linda Workman
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Chapter 1: Introduction to Medical-Surgical Nursing
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MULTIPLEPCHOICE

1. WhichPactionPdemonstratesPthatPthePnursePunderstandsPthePpurposePofPthePRapidPResponsePTeam?


a. MonitoringPthePclientPforPchangesPinPpostoperativePstatusPsuchPasPwoundPi
nfection


b. DocumentingPallPchangesPobservedPinPthePclientPandPmaintainingPaP
postoperative flow sheet P P




c. NotifyingPthePphysicianPofPthePclient’sPchangePinPbloodPpressurePfromP1
40 to 88 mm Hg systolic
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d. NotifyingPthePphysicianPofPthePclient’sPincreasePinPrestlessnessPafterP
medication change P




ANS:PC

The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to cli
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ents before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team,
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which responds to client arrests, it intervenes rapidly for those who are beginning to declineclinicall
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y. It would be appropriate for the RRT to intervene when the client has experienced a 52-
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point drop in blood pressure. Monitoring the client’s postoperative status, maintaining a postoperativ
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e flow sheet, and notifying the physician of a change in the client’s status after a medication change
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would not be considered activities of the Rapid Response Team.
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DIF:PCognitivePLevel:PComprehension/UnderstandingPREF:Ppp.P2-3

TOP:PClientPNeedsPCategory:PSafePandPEffectivePCarePEnvironmentP(ManagementPofPCare—
CollaborationPwithPInterdisciplinaryPTeam)

MSC:PIntegratedPProcess:PNursingPProcessP(Assessment)

,2. ThePJointPCommissionPfocusesPonPsafetyPinPhealthPcare.PWhichPactionPbyPthePnursePreflectsPThePJ
oint Commission’s main objective?
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a. PerformingPrange-of-motionPexercisesPonPthePclientPthreePtimesPeachPday



b. EnsuringPthatPthePclientPisPeatingP100%PofPthePmealsPservedPtoPhimPorPh
er


c. AssessingPthePclient’sPrespirationsPwhenPadministeringPopioids



d. DelegatingPtoPthePnursingPassistantPtoPgivePthePclientPaPcompletePbathPd
aily


ANS:PC

It is important for the nurse to assess respirations of the client when administering opioids because of
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Pthe possibility of respiratory depression. The other interventions may or may not be necessary inthe
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care of the client and do not focus on safety.
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DIF:PCognitivePLevel:PApplication/ApplyingPorPhigherPREF:PN/A

TOP:PClientPNeedsPCategory:PSafePandPEffectivePCarePEnvironmentP(SafetyPandPInfectionPControl)PMS

C:PIntegratedPProcess:PNursingPProcessP(Assessment)

3. WhichPactionPbyPthePnursePshowsPanPunderstandingPofPthePprinciplePofPself-determination?


a. AllowingPaPpostoperativePclientPtoPdecidePtoPtakePmedicationPwithPfruitPj
uice rather than water
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b. AllowingPaPteenagerPtoPdecidePnotPtoPgoPtoPaPclinicPwhenPtherePisPe
vidence that she is having profuse vaginal bleeding
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c. AllowingPaPparentPtoPdecidePnotPtoPproceedPwithPaPlifesavingPoperationPf
or a 12-year-old client
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, d. AllowingPanPolderPclientPwithPdementiaPtoPdecidePnotPtoPtakePcardiacP
medication throughout the shift P P P




ANS:PA

Respect for people is one of three basic ethical principles that nurses and other health care profession
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als should use as a basis for clinical decision making. Respect implies that clients are treated as auton
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omous individuals capable of making informed decisions about their care. This client autonomy is ref
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erred to as self-determination, or self-
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management, and is best illustrated byallowing a client to decide to take medication with fruit juice ra
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ther than water. The other answer choices would not illustrate self-
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determination appropriately and might possibly endanger the client’s life.
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DIF:PCognitivePLevel:PApplication/ApplyingPorPhigherPREF:PN/A

TOP:PClientPNeedsPCategory:PSafePandPEffectivePCarePEnvironmentP(ManagementPofPCare—
EthicalPPractice)PMSC:PIntegratedPProcess:PNursingPProcessP(Assessment)

4. ThePnursePisPinitiatingPaPseriesPofPteachingPsessionsPwithPanPolderPclient.PWhatPisPthePnurse’sPh
ighest-priority, client-centered action before beginning the session?
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a. EnsurePthatPthePclient’sPfamilyPisPpresentPandPwillPparticipate.



b. MakePcertainPthatPthePclientPisPwearingPhisPglasses.



c. HavePprintedPhandoutsPreadyPtoPusePduringPthePsession.



d. SchedulePthePsessionPforPearlyPeveningPafterPthePclient’sPmeal.



ANS:PB

The most important client-
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centered action is to ensure that the client is wearing his or her glasses.The ability to see adequately
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will outweigh the need for family presence, use of printed handouts,and hunger (or lack thereof).
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DIF:PCognitivePLevel:PApplication/ApplyingPorPhigherPREF:PN/A

TOP:PClientPNeedsPCategory:PHealthPPromotionPandPMaintenanceP(PrinciplesPofPTeaching/Learning)