Medical Surgical Nursing 11th Edition
Concepts for Interprofessional
Collaborative Care, by Donna D.
Ignatavicius, All chapters 1 – 69(16
Hypokalemia occurs when there is a decrease in serum potassium. It can be a life-threatening
condition because it often causes rhythm abnormalities. An excess of potassium is referred to as
Hyperkalemia.
DIF: Understanding/Comprehension REF: 18 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
1. The minimum hourly urinary output in a patient should be at least:
a. 5 mL per hour
b. 10 mL per hour
c. 30 mL per hour
d. 60 mL per hour
CORRECT ANSWER: C
30 mL per hour is the minimum hourly urinary output in a normal healthy adult. A decrease in
urinary output i a sign of diminished kidney activity and fluid deficit.
DIF: Understanding/Comprehension REF: 20 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
1. The best indicator of fluid volume changes in the body is:
a. skin dryness
b. weight changes
c. blood pressure
d. pulse rate
,CORRECT ANSWER: C
Changes in weight are the best indicator of fluid volume changes in the body. Monitoring blood
pressure, checking pulse rate and quality, and assessing skin and mucous membranes for
dryness are strong secondary indicators.
DIF: Understanding/Comprehension REF: 20 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
1. Immunity which occurs when antibodies are passed from the mother to the fetus through the
placenta or through breast milk is called:
a. natural passive
b. artifical passive
c. natural active
d. artifical active
CORRECT ANSWER: A
Artifical passive immunity occurs via a specific transfusion. Natural active immunity occurs when
an antigen enters the body and the body creates antibodies to fight off the antigen. Artifical
active immunity occurs via vaccination or immunization.
DIF: Understanding/Comprehension REF: 21-22 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
Medical Surgical Nursing
11th Edition by Donna D. Ignatavicius
Medical Surgical Nursing
11th Edition by Donna D. Ignatavicius
1. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse
best demonstrates 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
, CORRECT ANSWER: A
Competency in client-focused care is demonstrated when the nurse focuses on communication,
culture, respect compassion, client education, and empowerment. By assessing the effect of the
clients culture on health care, this nurse 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. Orienting the client and family to the room is an
important safety measure, but not directly related to demonstrating client-centered care.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated Process: Caring NOT: Client Needs
Category: Psychosocial Integrity
1. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was
142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the 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.
CORRECT ANSWER: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating
before they suffer either respiratory or cardiac arrest. Since the client has manifested a
significant change, the nurse should call the 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 provider
should be notified, but this is not the priority over calling the RRT. The clients blood pressure
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 emergencies MSC: Integrated Process:
Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
1. A nurse is orienting a new client and family to the inpatient unit. What information does the
nurse provide to help the client promote his or her own safety?
a. Encourage the client and family to be active partners.
Concepts for Interprofessional
Collaborative Care, by Donna D.
Ignatavicius, All chapters 1 – 69(16
Hypokalemia occurs when there is a decrease in serum potassium. It can be a life-threatening
condition because it often causes rhythm abnormalities. An excess of potassium is referred to as
Hyperkalemia.
DIF: Understanding/Comprehension REF: 18 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
1. The minimum hourly urinary output in a patient should be at least:
a. 5 mL per hour
b. 10 mL per hour
c. 30 mL per hour
d. 60 mL per hour
CORRECT ANSWER: C
30 mL per hour is the minimum hourly urinary output in a normal healthy adult. A decrease in
urinary output i a sign of diminished kidney activity and fluid deficit.
DIF: Understanding/Comprehension REF: 20 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
1. The best indicator of fluid volume changes in the body is:
a. skin dryness
b. weight changes
c. blood pressure
d. pulse rate
,CORRECT ANSWER: C
Changes in weight are the best indicator of fluid volume changes in the body. Monitoring blood
pressure, checking pulse rate and quality, and assessing skin and mucous membranes for
dryness are strong secondary indicators.
DIF: Understanding/Comprehension REF: 20 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
1. Immunity which occurs when antibodies are passed from the mother to the fetus through the
placenta or through breast milk is called:
a. natural passive
b. artifical passive
c. natural active
d. artifical active
CORRECT ANSWER: A
Artifical passive immunity occurs via a specific transfusion. Natural active immunity occurs when
an antigen enters the body and the body creates antibodies to fight off the antigen. Artifical
active immunity occurs via vaccination or immunization.
DIF: Understanding/Comprehension REF: 21-22 KEY: Assessment
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
Medical Surgical Nursing
11th Edition by Donna D. Ignatavicius
Medical Surgical Nursing
11th Edition by Donna D. Ignatavicius
1. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse
best demonstrates 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
, CORRECT ANSWER: A
Competency in client-focused care is demonstrated when the nurse focuses on communication,
culture, respect compassion, client education, and empowerment. By assessing the effect of the
clients culture on health care, this nurse 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. Orienting the client and family to the room is an
important safety measure, but not directly related to demonstrating client-centered care.
DIF: Understanding/Comprehension REF: 3
KEY: Patient-centered care| culture MSC: Integrated Process: Caring NOT: Client Needs
Category: Psychosocial Integrity
1. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was
142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the 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.
CORRECT ANSWER: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating
before they suffer either respiratory or cardiac arrest. Since the client has manifested a
significant change, the nurse should call the 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 provider
should be notified, but this is not the priority over calling the RRT. The clients blood pressure
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 emergencies MSC: Integrated Process:
Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
1. A nurse is orienting a new client and family to the inpatient unit. What information does the
nurse provide to help the client promote his or her own safety?
a. Encourage the client and family to be active partners.
