Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing
Ignatavicius: Medical-Surgical Nursing, 10th Edition

MULTIPLE CHOICE

	1.	A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new nurse that which is the priority when working as a professional nurse?
a.	Attending to holistic client needs	
b.	Ensuring client safety	
c.	Not making medication errors	
d.	Providing client-focused care	

ANS:	B
All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Health care errors have been widely reported for 25 years, many of which result in client injury, death, and increased health care costs. There are several national and international organizations that have either recommended or mandated safety initiatives. Every nurse has the responsibility to guard the client’s safety. The other actions are important for quality nursing, but they are not as vital as providing safety. Not making medication errors does provide safety, but is too narrow in scope to be the best answer.

DIF:	Understanding			TOP:	Integrated Process: Nursing Process: Intervention
KEY:	Client safety	
MSC:	Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

	2.	A nurse is orienting a new client and family to the medical-surgical unit. What information does the nurse provide to best help the client promote his or her own safety?
a.	Encourage the client and family to be active partners.	
b.	Have the client monitor hand hygiene in caregivers.	
c.	Offer the family the opportunity to stay with the client.	
d.	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 safety 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			TOP:	Integrated Process: Teaching/Learning
KEY:	Client safety	
MSC:	Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

	3.	A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nurse take first?
a.	Call the Rapid Response Team.	
b.	Document and continue to monitor.	
c.	Notify the primary health care provider.	
d.	Repeat the blood pressure 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 would call the RRT. Changes in blood pressure, mental status, heart rate, temperature, oxygen saturation, and last 2 hours’ urine output are particularly significant and are part of the Modified Early Warning System guide. Documentation is vital, but the nurse must do more than document. The primary health care provider would be notified, but this is not more important than calling the RRT. The client’s blood pressure would be reassessed frequently, but the priority is getting the rapid care to the client.

DIF:	Applying	TOP:	Integrated Process: Communication and Documentation
KEY:	Rapid Response Team (RRT), Clinical judgment	
MSC:	Client Needs Category: Physiological Integrity: Physiological Adaptation

	4.	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 client’s basic needs are met.	
c.	Tells the client and family about all upcoming tests.	
d.	Thoroughly orients the client and family to the room.	

ANS:	A
Showing respect for the client and family’s preferences and needs is essential to ensure a holistic or “whole-person” approach to care. By assessing the effect of the client’s 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			TOP:	Integrated Process: Culture and Spirituality
KEY:	Client-centered care, Culture	MSC:	Client Needs Category: Psychosocial Integrity

	5.	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?
a.	Bring a list of all medications and what they are for.	
b.	Keep the provider’s phone number by the telephone.	
c.	Make sure that all providers wash hands before entering the room.	
d.	Write down the name of each caregiver who comes in the room.	

ANS:	A
Medication reconciliation is a formal process in which the client’s actual current medications are compared to the prescribed medications at the time of admission, transfer, or discharge. This National client Safety Goal is important to reduce medication errors. The client would not have to be responsible for providers washing their hands, and even if the client does so, this is too narrow to be the most important action to prevent errors. Keeping the provider’s phone number nearby and documenting everyone who enters the room also do not guarantee safety.

DIF:	Applying	TOP:	Integrated Process: Teaching/Learning	
KEY:	Client safety, Informatics	
MSC:	Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

	6.	Which action by the nurse working with a client best demonstrates respect for autonomy?
a.	Asks if the client has questions before signing a consent.	
b.	Gives the client accurate information when questioned.	
c.	Keeps the promises made to the client and family.	
d.	Treats the client fairly compared to other clients.	

ANS:	A
Autonomy is self-determination. The client would make decisions regarding care. When the nurse obtains a signature on the consent form, assessing if the client still has questions is vital, because without full information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.

DIF:	Applying	TOP:	Integrated Process: Caring	KEY:	Ethics, Autonomy
MSC:	Client Needs Category: Safe and Effective Care Environment: Management of Care

	7.	A nurse asks a more seasoned colleague to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) community. What answer by the faculty is most accurate?
a.	Avoid embarrassing the client by asking questions.	
b.	Don’t make assumptions about his or her health needs.	
c.	Most LGBTQ people do not want to share information.	
d.	No differences exist in communicating with this population.	

ANS:	B
Many members of the LGBTQ community have faced discrimination from health care providers and may be reluctant to seek health care. The nurse would never make assumptions about the needs of members of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any health care need is more likely to answer honestly.

DIF:	Understanding			TOP:	Integrated Process: Teaching/Learning
KEY:	Health care disparities, LGBTQ	MSC:	Client Needs Category: Psychosocial Integrity

	8.	A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed opioid pain medication. Which statement comprises the background portion of the SBAR format for communication?
a.	“I would like you to order a different pain medication.”	
b.	“This client has allergies to morphine and codeine.”	
c.	“Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.”	
d.	“This client had a vaginal hysterectomy 2 days ago.”	

ANS:	B
SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment, and Recommendation. Appropriate background information includes allergies to medications the on-call health care provider might order. Situation describes what is happening right now that must be communicated; the client’s surgery 2 days ago would be considered background. Assessment would include an analysis of the client’s problem; none of the options has assessment information. Asking for a different pain medication is a recommendation. Recommendation is a statement of what is needed or what outcome is desired.

DIF:	Applying	TOP:	Integrated Process: Communication and Documentation
KEY:	Teamwork and collaboration, SBAR			
MSC:	Client Needs Category: Safe and Effective Care Environment: Management of Care

	9.	A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive personnel (AP). Four hours later, the nurse notes that the client’s blood pressure taken by the AP was much higher than previous readings, and the client’s mental status has changed. What action by the nurse would most likely have prevented this negative outcome?
a.	Determining if the AP knew how to take blood pressure	
b.	Double-checking the AP by taking another blood pressure	
c.	Providing more appropriate supervision of the AP	
d.	Taking the blood pressure instead of delegating the task	

ANS:	C
Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated tasks. The nurse would either have asked the AP about the vital signs or instructed the AP to report them right away. An experienced AP would know how to take vital signs and the nurse would not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a AP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the AP.

DIF:	Analyzing	TOP:	Integrated Process: Communication and Documentation
KEY:	Teamwork and collaboration, Delegation		
MSC:	Client Needs Category: Safe and Effective Care Environment: Management of Care

	10.	A newly graduated nurse in the hospital states that because of being so new, participation in quality improvement (QI) projects is not wise. What response by the precepting nurse is best?
a.	“All staff nurses are required to participate in quality improvement here.”	
b.	“Even being new, you can implement activities designed to improve care.”	
c.	“It’s easy to identify what indicators would be used to measure quality.”	
d.	“You should ask to be assigned to the research and quality committee.”	

ANS:	B
The preceptor would try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse information about how to implement QI in daily practice.

DIF:	Applying	TOP:	Integrated Process: Communication and Documentation
KEY:	Systems thinking, Quality improvement		
MSC:	Client Needs Category: Safe and Effective Care Environment: Management of Care

	11.	A nurse is talking with a co-worker who is moving to a new state and needs to find new employment there. What advice by the nurse is best?
a.	Ask the hospitals there about standard nurse–client ratios.	
b.	Choose the hospital that has the newest technology.	
c.	Find a hospital that has achieved Magnet status.	
d.	Work in a facility affiliated with a medical or nursing school.	

ANS:	C
Client Magnet status is awarded by The Joint Commission (TJC) and certifies that nurses can demonstrate how best current evidence guides their practice. New technology doesn’t necessarily mean that the hospital is safe. Affiliation with a health profession school has several advantages, but safety is most important.

DIF:	Understanding			
TOP:	Integrated Process: Communication and Documentation	
KEY:	Evidence-based practice, Magnet status		
MSC:	Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

MULTIPLE RESPONSE

	1.	A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas would the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.)
a.	Collaborating with an interprofessional team	
b.	Implementing evidence-based care	
c.	Providing family-focused care	
d.	Routinely using informatics in practice	
e.	Using quality improvement in client care	
f.	Formalizing systems thinking when implementing care	

ANS:	A, B, D, E
The IOM report lists five broad core competencies that all health care providers should practice. These include collaborating with the interprofessional team, implementing evidence-based practice, providing patient-focused care, using informatics in client care, and using quality improvement in client care. Systems thinking is required for quality improvement but is not a specified part of the IOM report.

DIF:	Remembering			TOP:	Integrated Process: Nursing Process: Assessment
KEY:	Competencies, Institute of Medicine (IOM)		
MSC:	Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

	2.	A nurse is interested in making interprofessional work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.)
a.	Consults with other disciplines on client care.	
b.	Coordinates discharge planning for home safety.	
c.	Participates in comprehensive client rounding.	
d.	Routinely asks other disciplines about client progress.	
e.	Shows the nursing care plans to other disciplines.	
f.	Delegate tasks to unlicensed personnel appropriately.	

ANS:	A, B, C, D, F
Collaborating with the interprofessional team involves planning, implementing, and evaluating client care as a team with all other involved disciplines included. Simply showing other caregivers the nursing care plan is not actively involving them or collaborating with them.

DIF:	Applying	TOP:	Integrated Process: Communication and Documentation
KEY:	Teamwork and collaboration, Interprofessional team	
MSC:	Client Needs Category: Safe and Effective Care Environment: Management of Care

	3.	The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all that apply.)
a.	Cost-saving measures	
b.	Nurse’s expertise	
c.	Client preferences	
d.	Research findings	
e.	Values of the client	
f.	Plan-do-study-act model	

ANS:	B, C, D, E
EBP consists of utilizing current evidence, the client’s values and preferences, and the nurse’s expertise when planning care. It does not include cost-saving measures. The PDSA model is a systematic model for quality improvement, but is not a specific component of EBP.

DIF:	Remembering			TOP:	Integrated Process: Nursing Process: Planning
KEY:	Evidence-based practice (EBP)	
MSC:	Client Needs Category: Safe and Effective Care Environment: Management of Care

	4.	A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.)
a.	Attend hand-off rounds to coach and mentor.	
b.	Create a template of suggested topics to include in report.	
c.	Encourage staff to ask questions during hand-off.	
d.	Give raises based on compliance with reporting.	
e.	Provide education on the SBAR method of communication	

ANS:	A, B, C, E
The SBAR method of communication has been identified as an excellent method of communication between health care professionals. It is a formalized structure consisting of Situation, Background, Assessment, and Recommendation/Request. Using a formalized mechanism for communication helps ensure successful hand-off and fewer client errors. When establishing this new format for report, the most helpful actions by the manager would be to provide initial education on the process, develop a template with suggested topics under each heading, attend rounds to coach and mentor, and encourage staff to ask questions to clarify information. Basing raises on compliance would not be the most helpful method because raises are often determined only once a year and are based on multiple criteria.

DIF:	Applying	TOP:	Integrated Process: Communication and Documentation
KEY:	Teamwork and collaboration, Communication	
MSC:	Client Needs Category: Safe and Effective Care Environment: Management of Care