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-
2 2
Surgical Nursing
MULTIPLE CHOICE
1. A nurse2wishes2to provide client-
centered2care2in all interactions. Which action by the nurse2best demonstrates this concept?
a. Assesses for2 cultural2 influences affecting health care
b. Ensures that2all2the clients basic needs are2met
c. Tells the client2and family2about all2upcoming tests
d. Thoroughly orients the client2 and family2 to the2room
CORRECT2ANSWER: A
Competency in2client-
focused2care2is demonstrated when2the nurse focuses on communication, culture, respect2compassion, client2educ
ation, and empowerment. By assessing the effect of2the 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 not2providing empowering2education. Orienting the client and family2to the2room2is an2im
portant2safety2measure, but2not2directly2related to demonstrating client-centered care.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-
centered2care| culture MSC: Integrated Process: Caring2NOT: Client
Needs Category: Psychosocial Integrity
2. A nurse2is caring for2a postoperative2client2on2the surgical unit. The clients blood2pressure was 142/762mm2H
g 30 minutes ago, and2now is 88/50 mm2Hg. What action2by the nurse is best?
a. Call2the Rapid2 Response2Team.
b. Document2and2continue to monitor.
c. Notify2the primary care provider.
d. Repeat blood2 pressure2measurement2 in215 minutes.
CORRECT2ANSWER: A
The purpose of2the Rapid2Response Team (RRT) is to intervene when clients are deteriorating before they su
ffer either2respiratory2or2cardiac arrest. Since the client has2manifested a2significant2change, the2nurse should2call2t
he RRT. Changes in2blood pressure, mental status, heart rate, and pain2are2particularly significant.
Documentation is vital, but the nurse must2do more than2document. The primary care provider2should be
notified, but this is not2the2priority2over2calling the RRT. The2clients blood pressure2should be2reassessed fre
quently, but2the priority is getting the rapid care to the client.
DIF: Applying/Application REF: 3
KEY: Rapid Response Team2(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-
2 2
Surgical Nursing
MULTIPLE CHOICE
1. A nurse2wishes2to provide client-
centered2care2in all interactions. Which action by the nurse2best demonstrates this concept?
a. Assesses for2 cultural2 influences affecting health care
b. Ensures that2all2the clients basic needs are2met
c. Tells the client2and family2about all2upcoming tests
d. Thoroughly orients the client2 and family2 to the2room
CORRECT2ANSWER: A
Competency in2client-
focused2care2is demonstrated when2the nurse focuses on communication, culture, respect2compassion, client2educ
ation, and empowerment. By assessing the effect of2the 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 not2providing empowering2education. Orienting the client and family2to the2room2is an2im
portant2safety2measure, but2not2directly2related to demonstrating client-centered care.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-
centered2care| culture MSC: Integrated Process: Caring2NOT: Client
Needs Category: Psychosocial Integrity
2. A nurse2is caring for2a postoperative2client2on2the surgical unit. The clients blood2pressure was 142/762mm2H
g 30 minutes ago, and2now is 88/50 mm2Hg. What action2by the nurse is best?
a. Call2the Rapid2 Response2Team.
b. Document2and2continue to monitor.
c. Notify2the primary care provider.
d. Repeat blood2 pressure2measurement2 in215 minutes.
CORRECT2ANSWER: A
The purpose of2the Rapid2Response Team (RRT) is to intervene when clients are deteriorating before they su
ffer either2respiratory2or2cardiac arrest. Since the client has2manifested a2significant2change, the2nurse should2call2t
he RRT. Changes in2blood pressure, mental status, heart rate, and pain2are2particularly significant.
Documentation is vital, but the nurse must2do more than2document. The primary care provider2should be
notified, but this is not2the2priority2over2calling the RRT. The2clients blood pressure2should be2reassessed fre
quently, but2the priority is getting the rapid care to the client.
DIF: Applying/Application REF: 3
KEY: Rapid Response Team2(RRT)| medical emergencies MS
