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Timby's Introductory Medical-Surgical Nursing 13th Edition Moreno Test Bank
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Timby's Introductory Medical-SurgicalNursing 13th Edition Moreno Test Bank
A+
, 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 a professional nurse?
◦ Attending to holistic client needs
◦ Ensuring client safety
◦ Not making medication errors
◦ Providing client- focused care ANS: 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 clients have 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 own safety?
◦ 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. ANS: 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 is the most critical. The other actions
are
◦
◦ very limited in scope and do not provide the broad protection that being 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 blood pressure
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 measurement in 15 minutes. ANS: 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
◦
◦ A nurse wishes to provide client-centered care in all interactions. Which action 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 and family to the room ANS: 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
◦ A client is going to be admitted for a scheduled surgical procedure. Which action 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 who comes in the room. ANS: 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 they take 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 for autonomy?
◦ Asks if the client has questions before signing a consent
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