TEST BANK - Timby's Introductory Medical-Surgical
Nursing, 13th Edition (Donnelly-Moreno),
Verified Chapters 1 - 72, Complete
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Chapter 1 Concepts and Trends in Healthcare
◦ A new nurse is working with a preceptor on an inpatient medical-surgical unit.
The preceptor advises the student that which is the priority when working as
aprofessional nurse?
◦ Attending to holistic client needs
◦ Ensuring client safety
◦ Not making medication errors
◦ Providing client-
focused care
ANSWER: B
◦ All actions are appropriate for the professional nurse. However,
ensuring client safety is the priority. Up to 98,000 deaths result each year from
errors in hospital care, according to the 2000 Institute of Medicine report. Many
more clientshave suffered injuries and less serious outcomes. Every nurse has the
responsibility to guard the clients safety.
◦ DIF: Understanding/Comprehension REF: 2
KEY: Patient safety MSC: Integrated Process: Nursing
Process: Intervention
◦ NOT: Client Needs Category: Safe and Effective Care
Environment: Safety and Infection Control
◦ 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
ownsafety?
◦ Encourage the client and family to be active partners.
◦ Have the client monitor hand hygiene in caregivers.
◦ Offer the family the opportunity to stay with the client.
◦ Tell the client to always wear his or
her armband.
ANSWER: A
◦ Each action could be important for the client or family to
perform.However, encouraging the client to be active in his or her health care as
a partner isthe most critical. The other actions are
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◦ very limited in scope and do not provide the broad protection
thatbeing active and involved does.
, ◦ DIF: Understanding/Comprehension REF: 3
KEY: Patient safety MSC: Integrated Process: Teaching/
Learning
◦ NOT: Client Needs Category: Safe and Effective Care
,Environment: Safety and Infection Control
◦ A nurse is caring for a postoperative client on the surgical unit. The clients
bloodpressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg.
What action by the nurse is best?
◦ Call the Rapid Response Team.
◦ Document and continue to monitor.
◦ Notify the primary care provider.
◦ Repeat blood pressure
measurementin 15 minutes.
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
theclient has manifested a significant change, the nurse should call the RRT.
Changes inblood 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
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◦ A nurse wishes to provide client-centered care in all interactions.
Whichaction by the nurse best demonstrates this concept?
◦ Assesses for cultural influences affecting health care
◦ Ensures that all the clients basic needs are met
◦ Tells the client and family about all upcoming tests
◦ Thoroughly orients the client
andfamily to the room
ANSWER: A
◦ Competency in client-focused care is demonstrated when the
nursefocuses on communication, culture, respect, compassion, client
education, and empowerment. By assessing the effect of the
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◦ clients culture on health care, this nurse is practicing client-focused
care. Providing for basic needs does not demonstrate this competence. Simply
tellingthe 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
◦ A client is going to be admitted for a scheduled surgical procedure.
Whichaction does the nurse explain is the most important thing the
client can do to protect against errors?
◦ Bring a list of all medications and what they are for.
◦ Keep the doctors phone number by the telephone.
◦ Make sure all providers wash hands before entering the room.
◦ Write down the name of each caregiver
whocomes in the room.
ANSWER: A
◦ Medication errors are the most common type of health care
mistake. The Joint Commissions Speak Up campaign encourages clients to help
ensure their safety. One recommendation is for clients to know all their medications
and why theytake them. This will help prevent medication errors.
◦ DIF: Applying/Application REF: 4
◦ KEY: Speak Up campaign| patient safety MSC: Integrated
Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective
Care Environment: Safety and Infection Control
◦ Which action by the nurse working with a client best demonstrates respect
forautonomy?
◦ Asks if the client has questions before signing a consent
◦ Gives the client accurate information when questioned
◦ Keeps the promises made to the client and family
◦ Treats the client fairly
compared to other
clients
ANSWER: A
◦ Autonomy is self-determination. The client should make decisions
regarding care. When the nurse obtains a signature on the consent form, assessing
ifthe client still has questions is vital, because without full information the client
cannotpractice autonomy. Giving accurate information is practicing with veracity.
Keeping promises is upholding fidelity. Treating the
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◦ client fairly is providing social justice.
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◦ DIF: Applying/Application REF: 4
◦ KEY: Autonomy| ethical principles MSC: Integrated Process: Caring
, ◦ NOT: Client Needs Category: Safe and Effective Care Environment: Management
of Care
