Preview Extract
Chapter 2
1. The nurse is reviewing her own lack of ability to recognize changes in the condition of a
particular patient. If the nurse is functioning at the level of a competent nurse, which of the
following will the nurse most likely do?
1. Research an article or a textbook to supply the missing knowledge.
2. Ask another nurse to evaluate her performance.
3. Question her decision to become a nurse.
4. Decide to ask for a transfer to another patient care area.
Answer: Research an article or a textbook to supply the missing knowledge.
Rationale:
At the upper limit of competency, the nurse recognized that she was not an expert about the
patient’s clinical condition. At this level, nurses will research comprehensive reference
materials because of the loss of confidence in others and the feelings of hyper-responsibility
associated with this level. Asking another nurse to evaluate her performance is a
characteristic of an advanced beginner. Questioning her own decision to become a nurse is
not characteristic of any particular level of nurse proficiency. Deciding to ask for a transfer to
another patient care area is not characteristic of any particular level of nurse proficiency.
2. The nurse who is an expert at providing care to adult medical−surgical clients is
transitioning to providing care to adult intensive care clients. The nurse’s skill level will most
likely change to:
1. Advanced beginner.
2. Novice.
3. Competent.
4. Proficiency.
Answer: Advanced beginner.
Rationale:
Even though the nurse is an expert at providing care to the adult medical−surgical client, the
nurse is now in a new clinical setting where there is a need to learn subtle variations of the
clients’ clinical presentations; these are characteristics of an advanced beginner. A novice
nurse is one who has little or no experiential background or understanding; the nurse is not a
novice. It will take some time before the nurse is able to function at the level of competent in
the new clinical setting. It will take some time before the nurse is able to function at the level
of proficient in the new clinical setting.
3. A nurse with a high level of expertise is providing a report to the oncoming nurse about a
particular client. Which of the following statements would exemplify this nurse’s level of
experience?
1. “I saw that the client’s eyes changed focus and I kept the airway open until the seizure
ended.”
2. “I didn’t realize that 2 days of bed rest would make the client so weak.”
3. “I learned that diuretics can cause imbalances of many electrolytes.”
4. “The other nurse helping me told me that I did a good job with the client.”
Answer: “I saw that the client’s eyes changed focus and I kept the airway open until the
seizure ended.”
Rationale:
The expert nurse has a fine-tuned level of practice. The nurse at this level is able to discern
subtle differences in clients’ conditions and acts appropriately as evidenced by the statement
“I saw that the client’s eyes changed focus and kept the airway open until the seizure ended.”
The expert nurse would know that bed rest makes a client weak and that diuretics cause many
electrolyte imbalances. The expert nurse also would not need validation by another nurse.
4. The nurse assesses a client’s bowel sounds because she remembers reading that pain
medications could cause reduced gastrointestinal functioning. This nurse is basing her care on
which of the following?
1. Theoretical knowledge
2. Practice rationality
3. Client response
4. Expertise
Answer: Theoretical knowledge
Rationale:
Theoretical knowledge is that which is obtained through studying scientific research and
knowledge. Practical knowledge may be compared to, though not completely separated from,
theoretical knowledge. Discovery and experiential learning favor the prepared,
knowledgeable practitioner who is engaged in learning both practical and theoretical
knowledge. Client response is assessing a client’s outcome to an intervention. Expertise is a
level of nursing proficiency.
5. A patient with a history of rapid heart rate tells the nurse, “I hold my breath and bear down
when I feel my heart is beating too fast.” Which nursing intervention might be indicated for
this patient?
1. Ask the health care provider to prescribe a stool softener.
2. Restrict fluids.
3. Weigh daily.
4. Provide diuretics as prescribed.
Answer: Ask the health care provider to prescribe a stool softener.
Rationale:
Holding one’s breath and bearing down is often done during a difficult bowel evacuation;
however, the same action can cause the heart rate to decrease to an unsafe level when the
heart is not beating too fast. Using that theoretical knowledge in a practical situation, the
nurse requests a stool softener for the patient. A stool softener will reduce the likelihood that
the patient will experience difficult bowel evacuation, thus decreasing the risk that the patient
will engage in the action when the heart rate is normal. There is no evidence to suggest that
fluid restriction, daily weights, or diuretics would address the implications related to the
patient’s breath holding and bearing down when trying to reduce a rapid heart rate.
6. A client receiving pain medication is sleepy yet able to be aroused. The client’s activity
level is “out of bed to a chair and ambulate in the hallway four times a day.” If the nurse
applies practical knowledge, which of the following should be done?
1. Continue to assess the client and assist the client out of bed when less sleepy.
2. Provide a cold compress to the client’s face and assist to a sitting position.
3. Have another health care provider assist the nurse to ambulate the client in the hallway.
4. Assist the client to a sitting position and transfer to a chair.
Answer: Continue to assess the client and assist the client out of bed when less sleepy.
Rationale:
The client is sleepy but able to be aroused. The nurse should not attempt to get the client out
of bed to ambulate while in this condition. The nurse should not attempt to wake the client up
with a cold compress, nor should the nurse assist the client to a sitting position and transfer to
a chair. It is unsafe for the nurse and another health care provider to ambulate the client while
the client is sleepy.
7. While caring for an intensive care client, the nurse stops to conduct endotracheal
suctioning after noticing the client had become restless. Afterward, the client is quiet and
relaxed. This nurse based care on which of the following?
1. Phronesis
2. Techne or rational-technical thought
3. Client response
4. Practical knowledge
Answer: Phronesis
Rationale:
Phronesis is applying an intervention based upon clinical judgment. Rational-technical
thought is a strategy for those areas of science and technology that can be standardized.
Client response is the outcome of implementing an intervention based on practical
knowledge. Practical knowledge is implementing an intervention based upon the client’s
condition.
8. A client with diabetes had a normal glucose level in the morning but is demonstrating signs
of a low blood glucose level now. Which of the following interventions would be considered
as nonstandardized for the care of this client?
1. Assess the client’s blood glucose level now and intervene accordingly.
2. Assess the client’s blood glucose level at the scheduled time.
3. Provide the client with scheduled medications.
4. Asses for pain and provide medication as appropriate.
Answer: Assess the client’s blood glucose level now and intervene accordingly.
Rationale:
The measuring of a client’s blood glucose level can either be standardized or
nonstandardized. The measurement is standardized when it is prescribed and done at
predetermined times according to medication and meals. The client is demonstrating a
symptom of a low blood glucose level at a time that does not correspond with prescribed
times, medications, or meals. The nurse should assess the client’s blood glucose level now
and intervene accordingly. The nurse should not wait to assess the client nor ignore the
client’s symptoms and provide medications. There is no evidence to suggest that this client is
demonstrating pain.
9. A client has an intravenous catheter for medication administration. The nurse learned to
assess for a blood return and then provide the medication. Which of the following
interventions should be done if the blood return is absent?
1. Assess for the placement of the catheter before providing the medication, and change the
catheter if necessary.
2. Provide the medication.
3. Hold the medication for the next oncoming nurse to provide.
4. Document that the client refused the medication.
Answer: Assess for the placement of the catheter before providing the medication, and
change the catheter if necessary.
Rationale:
The standard intervention would be for the nurse to assess for a blood return and then provide
the medication; however, according to the client’s clinical picture, the catheter is not
functioning. The nurse should assess for the catheter’s placement and change the catheter if
necessary before providing the medication. The nurse should not ignore the client’s clinical
picture and provide the medication. The nurse should also not hold the medication and ask
the next nurse to provide. The client did not refuse the medication and should not be
documented as such.
10. A client recovering from a total hip replacement tells the nurse that she knows she has to
get out of bed to walk but the pain is very severe right now and she is scared. Which of the
following should the nurse do?
1. Assess the client’s pain and contact the health care provider because the pain level has
suddenly increased.
2. Provide pain medication and assist the client out of bed.
3. Permit the client to rest and assist her out of bed in an hour.
4. Contact physical therapy for assistance with getting the client out of bed.
Answer: Assess the client’s pain and contact the health care provider because the pain level
has suddenly increased.
Rationale:
The client’s pain level has suddenly increased, which could indicate a change in the client’s
status. The nurse should assess the pain level and contact the health care provider. The nurse
should not just provide medication and assist the client out of bed anyway. The nurse should
not leave the client to rest and assist her out of bed in an hour. Contacting physical therapy
for assistance is not a wise option because the client’s pain level has suddenly increased,
which could indicate a change in the clinical picture.
11. A client tells the nurse that the skin of his intravenous infusion feels cold and there is
some fluid leaking on the bed. Which of the following should the nurse do?
1. Assess the intravenous infusion catheter, stop the infusion, apply comfort measures, and
treat the site per organization policies.
2. Clean the leaking fluid from the client’s skin and change the bed linens.
3. Wrap the intravenous site with gauze to absorb leakage.
4. Tell the client that the fluid was in the refrigerator and that cold skin is expected.
Answer: Assess the intravenous infusion catheter, stop the infusion, apply comfort measures,
and treat the site per organization policies.
Rationale:
The nurse needs to adjust to the change in the client’s intravenous fluid access site by
assessing the site, stopping the infusion, applying comfort measures, and treating the site
according to organization policies. The nurse should not ignore the client’s complaint of cold
skin and just clean the site and change the bed linens. Wrapping the site with gauze to absorb
the leakage and telling the client that the fluid was in the refrigerator and cold skin is
expected do not reflect adjusting care according to the client’s clinical condition.
12. A client with an illness that causes transient paralysis tells the nurse that he can feel the
bed linens on his legs. Which of the following should the nurse do at this time?
1. Assess the client’s sensory status for changes and improvements.
2. Take the linens off the client’s legs.
3. Tell the client that he is experiencing phantom sensations.
4. Offer pain medication to the client.
Answer: Assess the client’s sensory status for changes and improvement.
Rationale:
The nurse needs to respond to changes in the client’s clinical picture by assessing the client’s
sensory status for changes and improvements. The client has an illness that causes transient
paralysis. The ability of the client to feel the bed linens could mean that his condition is
improving. The nurse should not simply remove the linens from the client’s legs. The nurse
should not discount the client’s report of symptoms by instructing the client on phantom
sensations. The client is not complaining of pain, so the provision of pain medication is not
indicated.
13. A client tells a family member that she does not like her nurse because he does not talk
when he comes into the room and states she will not call for help even if she needs it. Which
of the following does this client’s observation and plan suggest?
1. The nurse will not be aware of the client’s clinical status, which could lead to a safety
issue.
2. The client is misunderstanding the nurse’s silence.
3. The nurse is hiding the client’s true health status.
4. The client is being overly sensitive and should ignore the nurse’s silence.
Answer: The nurse will not be aware of the client’s clinical status, which could lead to a
safety issue.
Rationale:
The nurse and client do not have an established relationship, as evidenced by the nurse’s
silence when entering the client’s room. The client does not like the nurse’s behavior and has
decided that she will not call for help even if she needs it; this could lead to a safety issue and
could also alter the nurse’s judgment about the client’s clinical status. The client is not
necessarily misunderstanding the nurse’s silence or being overly sensitive, but the client
could ask the nurse why he does not talk when he comes into the room. There is no evidence
to suggest that the nurse is hiding the client’s true health status.
14. A client refuses to get out of bed because he wants a specific nurse to help him because
“she knows what do to.” The currently assigned nurse does not help the client out of bed.
Which of the following does this situation suggest?
1. The current nurse is compromising the client’s care.
2. The client is combative.
3. The current nurse is manipulating the client.
4. The client is hiding his real reason for not getting out of bed.
Answer: The current nurse is compromising the client’s care.
Rationale:
The client has a relationship with another nurse and wants that nurse to help him out of bed.
The current nurse should ask the client what the other nurse does so that she can be
successful with the client and help the client out of the bed. Because the nurse does not work
with the client and learn how to get him out of bed, the client’s care is being compromised.
The nurse should not assume that the client is being combative or that the client is hiding
reasons for not getting out of bed. The current nurse is not manipulating the client.
15. A client tells the nurse that he does not want to be bothered for a few hours. The nurse
honors the request and does not assess the client’s vital signs when scheduled. When seeing
the client before the end of the shift, the nurse finds the client unresponsive. Which of the
following does this outcome suggest?
1. The nurse should have planned to provide care with minimal distractions yet maintain
client safety and ongoing assessment.
2. The nurse should adhere to a client’s request regardless of the outcome.
3. The nurse was providing good client care.
4. There was no way to predict that the client’s condition would change and the nurse is not at
fault.
Answer: The nurse should have planned to provide care with minimal distractions yet
maintain client safety and ongoing assessment.
Rationale:
The nurse needs to provide safe and effective care and should have planned to continue care,
keeping in mind the client’s request for minimal distractions. If the nurse had continued to
provide good client care, the client’s condition change might have been detected sooner than
the end of the shift and intervention could have been provided to avoid discovering the client
unresponsive. The nurse should have provided care in spite of the client’s request. Even
though there was no way to predict that the client’s condition would change, if the nurse
would have continued with ongoing assessment, the client’s condition might have been
detected sooner and the client might not have been found unresponsive.
16. A nurse realizes that a client received an incorrectly high dose of a medication. Prior to
investigating the reason, the nurse checks for evidence of the medication’s side effects with
the client. This nurse’s moral agency would be considered:
1. Expert.
2. Low.
3. Well developed.
4. Competent.
Answer: Expert.
Rationale:
Clinical judgment requires moral agency, defined as the ability to effect and influence
situations. Good practice requires that the nurse develop skillful ethical comportment as a
practitioner and that the nurse use good clinical judgment informed by scientific evidence and
technological development. Monitoring the quality of care and preventing imminent
breakdown in practice quality require social communication skills and effective moral
agency, both of which are the client’s frontline defense against errors and the hazards of
hospitalization. The clinician’s capacity for moral agency literally changes with the growth of
clinical judgment, perceptiveness, communication skills, and skillful comportment. The skills
of involvement with the client and engagement with the clinical situation are also learned
developmentally over time and change with level of skill acquisition.
17. The nurse assesses an increased heart rate and rapid shallow respirations in a client. The
nurse documents these findings and begins to provide care to another client. This nurse’s
behavior would indicate:
1. A lack of moral agency.
2. The client is anxious.
3. The client’s symptoms have not changed.
4. The nurse is not concerned about the client’s status.
Answer: A lack of moral agency.
Rationale:
Moral agency is the ability to discern a client’s clinical picture and provide interventions
accordingly. The nurse did not question the vital sign change, which indicates a lack of moral
agency in the nurse. There is no evidence to suggest that the client was anxious, but there is
evidence that the client’s symptoms have changed. The nurse should have been concerned
with the client’s status but was not experienced enough to recognize the changes as
significant.
18. A client in the postanesthesia recovery room is snoring. The nurse provides a warm
blanket and asks that others in the vicinity keep quiet because the client is deeply asleep.
Another nurse comes to the client’s bedside, adjusts the client’s neck to stop the snoring, and
helps the client maintain his airway. Which of the following does the second nurse’s action
suggest?
1. High level of moral agency
2. Low level of moral agency
3. Following the postanesthesia unit care plan for client care
4. Following a critical pathway for postanesthesia client care
Answer: High level of moral agency
Rationale:
Moral agency develops according to experience. The second nurse’s action suggests
experience with snoring; in a postanesthesia client, snoring indicates difficulty maintaining
the airway. The first nurse demonstrated low moral agency by asking others to keep quiet and
providing a warm blanket because this nurse thought the client was sleeping deeply. There is
no evidence to suggest that either nurse was following a care plan or a critical pathway for
the care of a client in the postanesthesia care area.
19. After receiving a report, the nurse reviews all of the activities needed to be completed for
a group of clients. This nurse is conducting which of the following characteristics of a
competent nurse?
1. Planning and analyzing care needs
2. Seeing the big picture of the clinical situation
3. Matching an actual case with a textbook case
4. Establishing role boundaries
Answer: Planning and analyzing care needs
Rationale:
A characteristic of a competent nurse is taking the time to plan and analyze care priorities and
needs. Seeing the big picture of a clinical situation is a characteristic of a proficient nurse.
Matching an actual case with a textbook case is a characteristic of novice nurse. Establishing
role boundaries is a characteristic of an advanced beginning nurse.
20. The nurse relates how excited she was when a client responded to a particular
intervention and how the entire situation was anxiety-producing for her. This nurse is
demonstrating a characteristic of which level of nursing practice?
1. Competent
2. Expert
3. Advanced beginner
4. Novice
Answer: Competent
Rationale:
Nurses at the competent stage feel exhilarated when they perform well and anxiety is tailored
to a particular situation. Expert nurses would not express exhilaration with performance that
is considered expected at that level of performance. Demonstration of exhilaration is not a
characteristic of either an advanced beginner or novice nurse.
21. The nurse observes a lack of urine output in a client recovering from bladder surgery.
Prior to notifying the health care provider, the nurse gently irrigates the tubing and dislodges
a small blood clot. Immediately the client’s urine begins to flow. This nurse’s intervention
demonstrates which level of clinical nursing practice?
1. Expert
2. Novice
3. Advanced beginner
4. Competent
Answer: Expert
Rationale:
The expert nurse will make a distinction about a client’s condition and implement activities to
suit the individual client’s needs. The nurse realized that since the client was recovering from
bladder surgery, there was a chance that a blood clot could be occluding the flow of urine.
The nurse’s action dislodged the clot and resumed the flow of urine. The novice or advanced
beginning nurse would not have had the experience to do this intervention. The competent
nurse might have consulted a textbook prior to implementing this intervention.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
