Ignatavicius: Medical-Surgical Nursing, 6th Edition

Chapter 1: Introduction to Medical-Surgical Nursing

Test Bank

		MULTIPLE CHOICE

	1.	Which action demonstrates that the nurse understands the purpose of the Rapid Response Team?
a.	The nurse monitors the client for changes in postoperative status such as wound infection.	
b.	The nurse documents all observed changes in the client and maintains a postoperative flowsheet.	
c.	The nurse notifies the physician of the client’s change in blood pressure from 140 to 102 mm Hg systolic.	
d.	The nurse notifies the physician of the client’s increase in restlessness after medication change.	

ANS:	C
The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team, who respond to client arrests, it intervenes rapidly for those who are beginning to decline clinically. It would be appropriate for the RRT to intervene when the client has experienced a 38-point drop in his blood pressure. Monitoring the client’s postoperative status, maintaining a postoperative flowsheet, and notifying the physician of a change in the client’s status after a medication change would not be considered activities of the Rapid Response Team.

DIF:	Cognitive Level: Comprehension	REF:	p. 3	
OBJ:	Learning Outcome 3		
TOP:	Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC:	Integrated Process: Nursing Process (Assessment)

	2.	What is the nurse’s first action when beginning client education?
a.	Begins teaching sessions as soon as possible prior to discharge to ensure adequate teaching time	
b.	Determines the client’s interest in learning prior to initiation of teaching sessions	
c.	Assesses client’s learning capabilities as well as those of his family members as a group	
d.	If client shows no interest in learning, documents attempt and notifies physician	

ANS:	B
The nurse should first assess the client’s learning needs and barriers to learning when initiating education. The nurse should not make assumptions and should assess each client individually. If the client has no interest in learning, the nurse should wait for another time or setting before beginning health teaching. Although important, scheduling teaching sessions as early as possible prior to discharge, determining the learning capabilities of the client, and notifying the physician of the client’s disinterest in learning would be less important.

DIF:	Cognitive Level: Comprehension	REF:	p. 4	
OBJ:	Learning Outcome 5		
TOP:	Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)	MSC:	Integrated Process: Teaching/Learning	

	3.	Which action shows an understanding of the principle of self-determination?
a.	The nurse allows a postoperative client to decide to take medication with fruit juice rather than water.	
b.	The nurse allows a teenager to decide not to tell her parents that her persistent vaginal bleeding is related to an abortion.	
c.	The nurse allows a parent to decide not to proceed with a lifesaving operation for a 12-year-old client.	
d.	The nurse allows an older client with dementia to decide not to take medication throughout the shift.	

ANS:	A
Respect for people is one of three basic ethical principles that nurses and other health care professionals should use as a basis for clinical decision making. Respect implies that clients are treated as autonomous individuals capable of making informed decisions about their care. This client autonomy is referred to as self-determination, or self-management. This is best illustrated by allowing a client to decide to take medication with fruit juice rather than water. The other answer choices would not illustrate self-determination appropriately and might possibly endanger the client’s life.

DIF:	Cognitive Level: Application	REF:	N/A for Application and above
OBJ:	Learning Outcome 6		
TOP:	Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC:	Integrated Process: Nursing Process (Assessment)

	4.	The nurse is initiating a series of teaching sessions with an older client. What is the nurse’s highest priority action prior to beginning the session?
a.	Ensure that the client’s family are present and will participate.	
b.	Make certain that the client is wearing his glasses.	
c.	Have printed handouts ready to use during the session.	
d.	Schedule the session for early evening after the client’s meal and before his medication.	

ANS:	B
The most important action will be to ensure that the client is wearing his glasses. His ability to see adequately will outweigh his need for the presence of his family, his use of printed handouts, and his hunger (or lack thereof).

DIF:	Cognitive Level: Application	REF:	N/A for Application and above
OBJ:	Learning Outcome 8		
TOP:	Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)	MSC:	Integrated Process: Teaching/Learning	

	5.	Which action demonstrates the nurse is using critical thinking when planning a menu for a Vietnamese client who is newly diagnosed with diabetes?
a.	Asking the client what food he would eat on a standard diabetic menu	
b.	Asking family members to make selections for the client from a diabetic menu	
c.	Calling a Vietnamese interpreter when teaching the client	
d.	Researching the Vietnamese culture prior to discussing diabetic meal planning	

ANS:	D
Critical thinking is best illustrated through the nurse researching Vietnamese culture and native cooking prior to discussing meal planning. This shows that the nurse is interested and involved in the client’s care. The nurse can then suggest foods from the standard diabetic menu to the client and his family. An interpreter could be called, if necessary, but does not show the use of critical thought.

DIF:	Cognitive Level: Application	REF:	N/A for Application and above
OBJ:	Learning Outcome 9		
TOP:	Client Needs Category: Physiological Integrity (Basic Care and Comfort)
MSC:	Integrated Process: Teaching/Learning	

	6.	A middle-aged woman is referred for a mammogram. What level of illness prevention is being practiced in this situation?
a.	Primary prevention	
b.	Secondary prevention	
c.	Tertiary prevention	
d.	Self-prevention	

ANS:	B
Screening examinations are considered part of secondary prevention because some cases of disease will be uncovered with examinations that have normal results. In primary prevention, interventions are delivered to avoid or delay disease onset. Tertiary prevention involves rehabilitation that occurs after a disease state stabilizes.

DIF:	Cognitive Level: Application	REF:	N/A for Application and above
OBJ:	Learning Outcome 2		
TOP:	Client Needs Category: Health Promotion and Maintenance (Disease Prevention)
MSC:	Integrated Process: Nursing Process (Implementation)

	7.	Which action by the nurse demonstrates the best practice for nursing documentation on a computerized record?
a.	Deleting all documentation errors on the computerized record	
b.	Using red color font to denote all significant events that have occurred	
c.	Waiting until the end of the shift to record a summary of information	
d.	Noting an error by putting one line through it and initialing	

ANS:	D
The best practice for nursing documentation is to put one line through the error and initial it. The other practices listed are ineffective and are not recommended.

DIF:	Cognitive Level: Application	REF:	N/A for Application and above
OBJ:	Learning Outcome 11		
TOP:	Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control)	MSC:	Integrated Process: Communication and Documentation

	8.	A client is scheduled for a mastectomy. As she is about to receive the preoperative medication, she tells the nurse that she does not want to have her breast removed but wants a lumpectomy. Which response indicates that the nurse is acting as a client advocate?
a.	Telling the client that her surgeon is excellent and knows what is best for her condition	
b.	Calling the surgeon to come and explain all treatment options to the client	
c.	Holding the client’s hand and offering to pray with her for a good outcome to the surgery	
d.	Arranging for a postoperative visit from a cancer survivor	

ANS:	B
Clients have the right to be fully informed about their treatment plans and to change their minds. A client expressing doubt, uncertainty, or a change of feeling about a treatment plan should be supported by the nurse, heard by the health care provider, and be an active participant in treatment planning. The nurse would be functioning best as a client advocate by notifying the surgeon that the client wants a different treatment option. The nurse would not be acting as a client advocate by providing vague reassurance, arranging for a cancer survivor to come meet with the client, or offering to pray with the client because none of these options would address the client’s desire for a different treatment option.

DIF:	Cognitive Level: Application	REF:	N/A for Application and above
OBJ:	Learning Outcome 7		
TOP:	Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC:	Integrated Process: Caring

	9.	What assessment data should be collected first from a client admitted to the emergency department with a lacerated artery?
a.	Information regarding next of kin to notify in case the client dies	
b.	History about what medications the client is currently taking	
c.	Measurement of blood pressure, pulse, and capillary refill time	
d.	Assessment of rate and depth of respiration to ensure that the airway is patent	

ANS:	B
In establishing an emergency database, assessment first focuses on the immediate problem, especially with a high probability for a life-threatening consequence. Determining the client’s current medications is of higher priority than notifying next of kin, determining capillary refill time, or measuring the rate and depth of respirations.

DIF:	Cognitive Level: Application	REF:	N/A for Application and above
OBJ:	Learning Outcome 9		
TOP:	Client Needs Category: Physiological Integrity (Physiological Adaptation)
MSC:	Integrated Process: Nursing Process (Assessment)

	10.	The client’s primary health care provider is an advanced practice nurse in an ambulatory care setting. Which intervention can the client expect to receive from a nurse in an ambulatory care setting?
a.	Drawing blood for preoperative testing	
b.	Teaching the client how to change the dressing on an incisional biopsy site	
c.	Obtaining the client’s signature on the surgical consent form before surgery	
d.	Performing a physical examination and taking the health history of a new client	

ANS:	B
Client teaching is a primary role of the nurse. Obtaining a surgical consent is the responsibility of the person performing the surgery. Blood drawing, taking histories, and performing physicals may be done by the nurse but are not primary nursing responsibilities.

DIF:	Cognitive Level: Knowledge	REF:	p. 4	
OBJ:	Learning Outcome 5		
TOP:	Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC:	Integrated Process: Nursing Process (Planning)

	11.	How does a community nurse–run clinic differ from a physician’s office practice setting?
a.	Clients at community nurse–run clinics are not eligible to receive care elsewhere.	
b.	Physicians’ offices rarely use advanced practice nurses.	
c.	The care provided is limited to interventions for nursing diagnoses.	
d.	The primary health care providers are advanced practice nurses.	

ANS:	D
The primary health care providers at community nursing centers are advanced practice nurses (most often, certified nurse practitioners and certified nurse-midwives) who are authorized to intervene in specified medical diagnoses. It is not accurate to say that clients receiving care at nursing community centers are not eligible to receive care elsewhere, that such centers have advanced practice nurses as providers, or that physician’s offices are usually associated with large university medical centers.

DIF:	Cognitive Level: Application	REF:	N/A for Application and above
OBJ:	Learning Outcome 5		
TOP:	Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC:	Integrated Process: Nursing Process (Planning)

	12.	Which client is most likely to require transitional subacute care before being discharged to the home setting?
a.	The client with stable human immune deficiency virus (HIV) infection	
b.	The client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) colonization of the nares	
c.	The client requiring deep wound management	
d.	The client who was hospitalized for 1 week	

ANS:	C
Although disorders of clients requiring subacute care can encompass all these conditions, transitional care is considered as an alternative to a prolonged hospital stay before discharge home or to a long-term care facility. Transitional subacute care is provided to the client with a deep wound if it continued management before discharge. The stable client with HIV infection would receive medical and/or surgical subacute care, whereas the client who is ventilator dependent or who has a progressive neurologic disorder would require chronic subacute care.

DIF:	Cognitive Level: Comprehension	REF:	p. 4	
OBJ:	Learning Outcome 5		
TOP:	Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC:	Integrated Process: Nursing Process (Planning)

	13.	A client arrives at the health clinic and expresses concern over being assessed by a nurse practitioner instead of a physician. The nurse develops a teaching plan for the client on the differences between a nurse practitioner and a physician. Other than educational preparation, what is the main difference between health care provided by a nurse practitioner and that provided by a physician?
a.	Federal law permits only physicians to prescribe medications.	
b.	Nurse practitioners are limited to providing interventions centered on nursing diagnoses.	
c.	Nurse practitioners provide care from a wellness model, and physicians more often focus on illness care.	
d.	There is no difference in scope and liability in the health care provided by nurse practitioners and physicians.	

ANS:	C
Nurse practitioners (NPs) work from a wellness model focused on empowering clients to stay well and care for themselves.

DIF:	Cognitive Level: Application	REF:	N/A for Application and above
OBJ:	Learning Outcome 7		
TOP:	Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC:	Integrated Process: Nursing Process (Planning)

	14.	Which statement best describes the process of nursing case management?
a.	The coordination of care services to at-risk populations	
b.	A collaborative process to promote quality and cost-effective care	
c.	The implementation of care to acutely ill, underserved populations	
d.	A cost-effective model of care delivery that meets the needs of specially defined groups	

ANS:	B
The process of case management involves collaboration to assess, plan, implement, coordinate, monitor, and evaluate services to meet health care needs in a manner that promotes quality and cost-effective outcomes. It does not solely involve coordination of care services to at-risk populations, implementation of care to acutely ill and underserved clientele, nor a cost-effective model of care delivery that will meet the needs of specially defined groups.

DIF:	Cognitive Level: Comprehension	REF:	p. 5	
OBJ:	Learning Outcome 7		
TOP:	Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC:	Integrated Process: Nursing Process (Planning)

	15.	Which client is best served by a case manager?
a.	An older woman with chronic cystitis	
b.	A middle-aged man with moderate hypertension	
c.	An older woman with chronic congestive heart failure and diabetes mellitus	
d.	A young adult with a fractured ankle from a sports injury and seasonal allergies	

ANS:	C
The case management process is reserved for clients who have complex health problems (high risk) and incur a high cost to the health care system. Clients with chronic cystitis, moderate hypertension, and a fractured ankle would probably not incur high costs to the health care system.

DIF:	Cognitive Level: Comprehension	REF:	p. 5	
OBJ:	Learning Outcome 7		
TOP:	Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC:	Integrated Process: Nursing Process (Planning)

	16.	Which statement indicates that the health care professional requires teaching about clinical pathways?
a.	“Clinical pathways can be used in determining how effective specific treatment plans are.”	
b.	“Although clinical pathways map out a specific plan of care, they are modifiable for variances in client outcomes.”	
c.	“Without implementation of clinical pathways, our agency could not be accredited by TJC.”	
d.	“Involving multiple disciplines in developing clinical pathways allows for a comprehensive plan to achieve the best outcomes.”	

ANS:	C
The Joint Commission does not require the development or implementation of clinical pathways for accreditation. The other statements listed are accurate regarding clinical pathways.

DIF:	Cognitive Level: Comprehension	REF:	p. 2	
OBJ:	Learning Outcome 7		
TOP:	Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC:	Integrated Process: Nursing Process (Planning)

		MULTIPLE RESPONSE

	1.	What health practices will improve and maintain health in adults? (Select all that apply.)
a.	Maintaining a body mass index (BMI) that is appropriate for frame	
b.	Engaging in aerobic exercises for at least 1 hour per week	
c.	Liberally using sunscreen when outdoors	
d.	Getting 4 to 6 hours of sleep every 24 hours	
e.	Managing stress using appropriate coping methods	

ANS:	A, C, E
Regardless of gender, age, or economic status, avoiding obesity, stress, and sun exposure and getting regular sleep of about 8 hours a day have a positive correlation with health promotion in adults. The client will need to exercise for more than 1 hour weekly and needs more than 4 to 6 hours of sleep for maintaining health.

DIF:	Cognitive Level: Comprehension	REF:	p. 2	
OBJ:	Learning Outcome 10		
TOP:	Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC:	Integrated Process: Teaching/Learning	

	2.	Which activity is considered to be within the role of the home care nurse? (Select all that apply.)
a.	Providing direct nursing care to an ill client in the home	
b.	Assessing the community for environmental hazards and health risks	
c.	Consulting with an enterostomal nurse regarding a pressure ulcer	
d.	Teaching family members how to monitor an intravenous infusion pump	
e.	Consulting a nutritionist regarding nutritional needs of a client with a wound	

ANS:	A, C, D, E
Although home care encompasses some aspects of public health nursing and community health nursing, the focus of home care is on the individual client and family, not the community. Therefore, rather than assessing the community, the nurse should be caring for the client, teaching family members, and consulting with a nutritionist.

DIF:	Cognitive Level: Comprehension	REF:	p. 4	
OBJ:	Learning Outcome 5		
TOP:	Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC:	Integrated Process: Nursing Process (Planning)

	3.	Which settings would require maximum implementation of the nurse supervisor role? (Select all that apply.)
a.	Subacute care setting	
b.	Home care setting	
c.	Skilled nursing facility	
d.	Assisted living facility	

ANS:	A, B, C, D
In skilled nursing facilities, subacute care settings, assisted living facilities, and home care setting, there are numerous unlicensed assistive personnel who are delegated various tasks. The registered nurse is responsible for overseeing the actions of such personnel and therefore would implement the supervisor role to its maximal extent.

DIF:	Cognitive Level: Comprehension	REF:	p. 4	
OBJ:	Learning Outcome 5		
TOP:	Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC:	Integrated Process: Nursing Process (Planning)

	4.	Which activities are within the role of the case manager? (Select all that apply.)
a.	Gathering and organizing data about a client from client records and interviews	
b.	Planning care for a client with emphasis on client satisfaction	
c.	Coordinating care among a variety of health care professionals and settings	
d.	Promoting the client's interests while negotiating necessary health care	
e.	Advocating for the client and family throughout the continuum of care	
f.	Using resources for appropriate client health care services	

ANS:	C, D, E, F
The primary roles of the nursing case manager include wide-reaching assessment, planning for timely and cost-effective outcomes, facilitation, and advocacy. Roles of the nursing case manager do not include planning care for a client with emphasis on client satisfaction.

DIF:	Cognitive Level: Comprehension	REF:	p. 5	
OBJ:	Learning Outcome 7		
TOP:	Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC:	Integrated Process: Nursing Process (Planning)