Test Bank for Medical Surgical Nursing Critical Thinking in
Client Care,4th Edition Priscilla LeMon(100% Verified)
Chapter 1
1. The nurse\ is\ caring\ for\ four\ clients\ on\ a\ medical–surgical\ unit.\ Which\ client\ should\ the\
nurse\ see\ initially?
1. A\ client\ admitted\ with\ hepatitis\ A\ who\ has\ had\ severe\ diarrhea\ for\ the\ last\
24\ hours
2. A\client\ admitted\ with\ pneumonia\ who\ is\ has\ small\ amounts\ of\ yellow\
productive\ sputum
3. A\ client\ admitted\ with\ fever\ of\ unknown\ origin\ (FUO)\ who\ has\ been\
without\ fever\ for\ the\ last\ 48\ hours
4. A\client\ admitted\ with\ a\ wound\ infection\ whose\ WBC\ is\ 8,500\ mm3
Answer:\ 1
Rationale:\ The\ nurse\ must\ decide\ which\ client\ should\ be\ seen\ on\ the\ initial\ rounds\ of\ the\
day.\ The\ nurse\ must\ remember\ that\ the\ first\ client\ to\ be\ seen\ should\ be\ the\ client\
who\ needs\ the\ attention\ of\ the\ nurse\ initially.\ A\ client\ with\ hepatitis\ A\ does\
experience\ diarrhea,\ but\ diarrhea\ for\ the\ last\ 24\ hours\ could\ cause\ the\ client\ to\
have\ a\ problem\ with\ dehydration\ and\ experience\ a\ state\ of\ fluid\ volume\ deficit.
Cognitive\ Level:\Application
Client\ Needs:\Safe,\Effective\Care\Environment\
Nursing\ Process:\ Planning
2. The\ nurse\ is\ preparing\ to\ administer\ influenza\ vaccines\ to\ a\ mass\ drive-through\ clinic.\
Which\ statement\ by\ a\ client\ would\ indicate\ further\ questioning\ prior\ to\ giving\ the\ client\
the\ influenza\ vaccine?
1. “I\ am\ allergic\ to\ horse\ hair.”
2. “I\ try\ to\ get\ my\ vaccine\ every\ year.”
3. “I\ am\ not\ allergic\ to\ anything\ except\ eggs.”
4. “My\husband\ had\ a\ severe\ allergic\ reaction\ after\ he\ received\ his\ influenza\
vaccine.”
Answer:\ 3
Rationale:\ Influenza\ vaccines\ are\ recommended\ for\ person\ at\ high\ risk\ for\ serious\
sequelae\ of\ influenza.\ The\ nurse\ should\ be\ aware\ that\ client\ with\ a\ sensitivity\ to\
eggs\ should\ not\ receive\ the\ vaccine.\ Vaccines\ prepared\ from\ chicken\ or\ duck\
embryos\ are\ contraindicated\ in\ clients\ who\ are\ allergic\ to\ eggs.
Cognitive\ Level:\Application
,Test Bank for Medical Surgical Nursing Critical Thinking in
Client Care,4th Edition Priscilla LeMon(100% Verified)
Client\ Needs:\Safe,\Effective\Care\Environment\
Nursing\ Process:\ Assessment
3. The\ nurse\ is\ caring\ for\ four\ clients\ on\ a\ medical–surgical\ unit.\ The\ secretary\ gives\ the\
nurse\ the\ morning\ labs.\ Which\ of\ the\ following\ labs\ would\ require\ that\ the\ nurse\ call\ the\
physician\ and\ inform\ the\ healthcare\ provider\ about\ the\ client’s\ abnormalities?
1. WBC\ 14,600\ mm3
2. Serum\ protein\ 6.9\ g/dL
3. I\ &\ D\ (incision\ and\ drainage)\ showing\ no\ growth\ for\ the\ last\ 24\ hours
4. Albumin\ 4.2\ g/dL
Answer:\ 1
Rationale:\ When\ the\ nurse\ is\ caring\ for\ several\ clients,\ all\ of\ the\ labs\ should\ be\ checked\
frequently\ throughout\ the\ shift\ to\ assess\ for\ any\ abnormalities.\ The\ WBC\ in\ option\ 1\ is\
abnormal.\ (Normal\ WBC\ 4,000–10,000\ mm3.)\ All\ of\ the\ other\ lab\ results\ are\ within\
acceptable\ range;\ therefore,\ the\ results\ should\ not\ be\ called\ in\ to\ the\ physician.
Cognitive\ Level:\ Application\
Client\Needs:\Physiologic\Integrity\
Nursing\ Process:\ Assessment
4. The\ nurse\ is\ orienting\ a\ new\ graduate.\ The\ nurse\ is\ reinforcing\ the\ importance\ of\
standard\ precautions.\ Which\ of\ the\ following\ observations\ by\the\ nurse\ would\ require\
further\ education\ regarding\ standard\ precautions?
1. The\ graduate\ nurse\ understands\ to\ wash\ hands\ when\ entering\ and\ exiting\
the\ client’s\ room.
2. The\ graduate\ nurse\ wears\ gloves\ when\ serving\ breakfast\ trays\ to\ various\
clients.
3. The\ graduate\ nurse\ wears\ a\ gown,\ gloves,\ and\ goggles\ when\ suctioning\ a\
client.
4. The\ graduate\ nurse\ leaves\ all\ supplies\ in\ the\ room\ of\ a\ client\ who\ is\ in\
contact\ isolation.
Answer:\ 2
Rationale:\ The\ nurse\ must\ have\ an\ understanding\ of\ standard\ precautions.\ Prevention\ is\
the\ most\ important\ measure\ to\ prevent\ nosocomial\ infections.\ Standard\
precautions\ were\ published\ in\ 1996\ that\ provide\ guidelines\ for\ the\ handling\ of\
blood\ and\ other\ body\ fluids.\ These\ guidelines\ are\ used\ with\ all\ clients,\ regardless\
of\ whether\ they\ have\ a\ known\ infectious\ disease.\ Standard\ precautions\ are\ used
,Test Bank for Medical Surgical Nursing Critical Thinking in
Client Care,4th Edition Priscilla LeMon(100% Verified)
by\ all\ healthcare\ workers\ who\ have\ direct\ contact\ with\ clients\ or\ with\ their\ body\
fluids.\ It\ is\ not\ necessary\ for\ the\ nurse\ to\ wear\ gloves\ while\ delivering\ food\ trays\
to\ the\ client,\ because\ there\ is\ not\ contact\ with\ the\ client.
Cognitive\ Level:\Application
Client\ Needs:\Safe,\Effective\Care\Environment\
Nursing\ Process:\ Evaluation
5. The\ admitting\ department\ alerts\ the\ nurse\ on\ a\ medical–surgical\ unit\ that\ a\ client\ with\
active\ tuberculosis\ (TB)\ is\ being\ admitted\ to\ the\ unit.\ Which\ type\ of\ isolation\ is\
appropriate\ based\ on\ the\ client’s\ diagnosis?
1. Standard\ precautions
2. Airborne\ precautions
3. Droplet\ precautions
4. Contact\ precautions
Answer:\ 2
In\ addition\ to\ handwashing\ and\ standard\ precautions,\ the\ nature\ and\ spread\ of\ some\
infectious\ diseases\ require\ that\ special\ techniques\ be\ used\ to\ protect\ uninfected\ clients\
and\ workers.\ The\ client\ with\ pulmonary\ tuberculosis\ will\ be\ placed\ in\ airborne\
precautions.\ The\ client\ should\ be\ placed\ in\ a\ private\ room\ with\ special\ ventilation\ that\
does\ not\ allow\ air\ to\ circulate\ to\ general\ hospital\ ventilation;\ a\ mask\ or\ special\ filter\
respirators\ will\ be\ used\ for\ everyone\ entering\ the\ room.
Cognitive\ Level:\Application
Client\ Needs:\Safe,\Effective\Care\Environment\
Nursing\ Process:\ Assessment
6. A\client\ is\ receiving\ IV\ vancomycin\ for\ the\ treatment\ of\ Clostridium\ difficile.\ The\
nurse\ understands\ that\ the\ client\ who\ develops\ flushing,\ tachycardia,\ and\ hypotension\
during\ the\ infusion\ of\ vancomycin\ indicates:
1. Ototoxicity\ effect.
2. Superinfection.
3. Red\ man\ syndrome.
4. Hives.
Answer:\ 3
Rationale:\Vancomycin\ inhibits\ cell\ wall\ synthesis,\ and\ is\ used\ for\ serious\ infections.\ It\ is\
only\ effective\ against\ gram-positive\ bacteria,\ especially\ Staphylococcus\ aureus\ and
, Test Bank for Medical Surgical Nursing Critical Thinking in
Client Care,4th Edition Priscilla LeMon(100% Verified)
Staphylococcus\ epidermidis.\ The\ nurse\ should\ infuse\ this\ medication\ slowly\ over\ 60\
minutes\ or\ more\ to\ avoid\ “red\ man”\ syndrome.\ The\ syndrome\ is\ characterized\ by\
erythematous\ rash,\ flushing,\ tachycardia,\ and\ hypotension.\ Clients\ can\ become\ dizzy\and\
agitated.
Cognitive\ Level:\Application
Client\Needs:\Physiological\Integrity\
Nursing\ Process:\ Evaluation
7. The\ physician\ has\ ordered\ for\ the\ client\ to\ receive\ a\ trough\ blood\ level\ to\ evaluate\ the\
therapeutic\ effect\ of\ an\ antibiotic.\ The\ nurse\ understands\ that\ the\ trough\ should\ be\
ordered:
1. A\few\ minutes\ before\ the\ next\ scheduled\ dose\ of\ medication.
2. 1–2\ hours\ after\ the\ oral\ administration\ of\ the\ medication.
3. 30\ minutes\ after\ the\ IV\ administration.
4. During\ the\ infusion\ of\ the\ antibiotic.
Answer:\ 1
Rationale:\ Antibiotic\ peak\ and\ trough\ levels\ monitor\ therapeutic\ blood\ levels\ of\ the\
prescribed\ medication.\ The\ therapeutic\ range—the\ minimum\ and\ maximum\ blood\ levels\
at\ which\ the\ drug\ is\ effective—is\ known\ for\ a\ given\ drug.\ By\ measuring\ blood\ levels\ at\
the\ predicted\ peak\ (1–2\ hours\ after\ oral\ administration,\ 1\ hour\ after\ intramuscular\
administration,\ and\ 30\ minutes\ after\ IV\ administration)\ and\ trough\ (usually\ a\ few\ minutes\
before\ the\ next\ scheduled\ dose),\ it\ is\ also\ possible\ to\ determine\ whether\ the\ drug\ is\
reaching\ a\ toxic\ or\ harmful\ level\ during\ therapy,\ increasing\ the\ likelihood\ of\ adverse\
effects.
Cognitive\ Level:\Application
Client\ Needs:\Safe,\Effective\Care\Environment\
Nursing\ Process:\ Assessment
8. The\ nurse\ needs\ to\ change\ a\ dressing\ on\ the\ client’s\ abdomen.\ Which\ of\ the\ following\
techniques\ should\ be\ implemented?
1. Contact\ precautions
2. Standard\ precautions
3. Droplet\ precautions
4. Airborne\ precautions
Answer:\ 2
Client Care,4th Edition Priscilla LeMon(100% Verified)
Chapter 1
1. The nurse\ is\ caring\ for\ four\ clients\ on\ a\ medical–surgical\ unit.\ Which\ client\ should\ the\
nurse\ see\ initially?
1. A\ client\ admitted\ with\ hepatitis\ A\ who\ has\ had\ severe\ diarrhea\ for\ the\ last\
24\ hours
2. A\client\ admitted\ with\ pneumonia\ who\ is\ has\ small\ amounts\ of\ yellow\
productive\ sputum
3. A\ client\ admitted\ with\ fever\ of\ unknown\ origin\ (FUO)\ who\ has\ been\
without\ fever\ for\ the\ last\ 48\ hours
4. A\client\ admitted\ with\ a\ wound\ infection\ whose\ WBC\ is\ 8,500\ mm3
Answer:\ 1
Rationale:\ The\ nurse\ must\ decide\ which\ client\ should\ be\ seen\ on\ the\ initial\ rounds\ of\ the\
day.\ The\ nurse\ must\ remember\ that\ the\ first\ client\ to\ be\ seen\ should\ be\ the\ client\
who\ needs\ the\ attention\ of\ the\ nurse\ initially.\ A\ client\ with\ hepatitis\ A\ does\
experience\ diarrhea,\ but\ diarrhea\ for\ the\ last\ 24\ hours\ could\ cause\ the\ client\ to\
have\ a\ problem\ with\ dehydration\ and\ experience\ a\ state\ of\ fluid\ volume\ deficit.
Cognitive\ Level:\Application
Client\ Needs:\Safe,\Effective\Care\Environment\
Nursing\ Process:\ Planning
2. The\ nurse\ is\ preparing\ to\ administer\ influenza\ vaccines\ to\ a\ mass\ drive-through\ clinic.\
Which\ statement\ by\ a\ client\ would\ indicate\ further\ questioning\ prior\ to\ giving\ the\ client\
the\ influenza\ vaccine?
1. “I\ am\ allergic\ to\ horse\ hair.”
2. “I\ try\ to\ get\ my\ vaccine\ every\ year.”
3. “I\ am\ not\ allergic\ to\ anything\ except\ eggs.”
4. “My\husband\ had\ a\ severe\ allergic\ reaction\ after\ he\ received\ his\ influenza\
vaccine.”
Answer:\ 3
Rationale:\ Influenza\ vaccines\ are\ recommended\ for\ person\ at\ high\ risk\ for\ serious\
sequelae\ of\ influenza.\ The\ nurse\ should\ be\ aware\ that\ client\ with\ a\ sensitivity\ to\
eggs\ should\ not\ receive\ the\ vaccine.\ Vaccines\ prepared\ from\ chicken\ or\ duck\
embryos\ are\ contraindicated\ in\ clients\ who\ are\ allergic\ to\ eggs.
Cognitive\ Level:\Application
,Test Bank for Medical Surgical Nursing Critical Thinking in
Client Care,4th Edition Priscilla LeMon(100% Verified)
Client\ Needs:\Safe,\Effective\Care\Environment\
Nursing\ Process:\ Assessment
3. The\ nurse\ is\ caring\ for\ four\ clients\ on\ a\ medical–surgical\ unit.\ The\ secretary\ gives\ the\
nurse\ the\ morning\ labs.\ Which\ of\ the\ following\ labs\ would\ require\ that\ the\ nurse\ call\ the\
physician\ and\ inform\ the\ healthcare\ provider\ about\ the\ client’s\ abnormalities?
1. WBC\ 14,600\ mm3
2. Serum\ protein\ 6.9\ g/dL
3. I\ &\ D\ (incision\ and\ drainage)\ showing\ no\ growth\ for\ the\ last\ 24\ hours
4. Albumin\ 4.2\ g/dL
Answer:\ 1
Rationale:\ When\ the\ nurse\ is\ caring\ for\ several\ clients,\ all\ of\ the\ labs\ should\ be\ checked\
frequently\ throughout\ the\ shift\ to\ assess\ for\ any\ abnormalities.\ The\ WBC\ in\ option\ 1\ is\
abnormal.\ (Normal\ WBC\ 4,000–10,000\ mm3.)\ All\ of\ the\ other\ lab\ results\ are\ within\
acceptable\ range;\ therefore,\ the\ results\ should\ not\ be\ called\ in\ to\ the\ physician.
Cognitive\ Level:\ Application\
Client\Needs:\Physiologic\Integrity\
Nursing\ Process:\ Assessment
4. The\ nurse\ is\ orienting\ a\ new\ graduate.\ The\ nurse\ is\ reinforcing\ the\ importance\ of\
standard\ precautions.\ Which\ of\ the\ following\ observations\ by\the\ nurse\ would\ require\
further\ education\ regarding\ standard\ precautions?
1. The\ graduate\ nurse\ understands\ to\ wash\ hands\ when\ entering\ and\ exiting\
the\ client’s\ room.
2. The\ graduate\ nurse\ wears\ gloves\ when\ serving\ breakfast\ trays\ to\ various\
clients.
3. The\ graduate\ nurse\ wears\ a\ gown,\ gloves,\ and\ goggles\ when\ suctioning\ a\
client.
4. The\ graduate\ nurse\ leaves\ all\ supplies\ in\ the\ room\ of\ a\ client\ who\ is\ in\
contact\ isolation.
Answer:\ 2
Rationale:\ The\ nurse\ must\ have\ an\ understanding\ of\ standard\ precautions.\ Prevention\ is\
the\ most\ important\ measure\ to\ prevent\ nosocomial\ infections.\ Standard\
precautions\ were\ published\ in\ 1996\ that\ provide\ guidelines\ for\ the\ handling\ of\
blood\ and\ other\ body\ fluids.\ These\ guidelines\ are\ used\ with\ all\ clients,\ regardless\
of\ whether\ they\ have\ a\ known\ infectious\ disease.\ Standard\ precautions\ are\ used
,Test Bank for Medical Surgical Nursing Critical Thinking in
Client Care,4th Edition Priscilla LeMon(100% Verified)
by\ all\ healthcare\ workers\ who\ have\ direct\ contact\ with\ clients\ or\ with\ their\ body\
fluids.\ It\ is\ not\ necessary\ for\ the\ nurse\ to\ wear\ gloves\ while\ delivering\ food\ trays\
to\ the\ client,\ because\ there\ is\ not\ contact\ with\ the\ client.
Cognitive\ Level:\Application
Client\ Needs:\Safe,\Effective\Care\Environment\
Nursing\ Process:\ Evaluation
5. The\ admitting\ department\ alerts\ the\ nurse\ on\ a\ medical–surgical\ unit\ that\ a\ client\ with\
active\ tuberculosis\ (TB)\ is\ being\ admitted\ to\ the\ unit.\ Which\ type\ of\ isolation\ is\
appropriate\ based\ on\ the\ client’s\ diagnosis?
1. Standard\ precautions
2. Airborne\ precautions
3. Droplet\ precautions
4. Contact\ precautions
Answer:\ 2
In\ addition\ to\ handwashing\ and\ standard\ precautions,\ the\ nature\ and\ spread\ of\ some\
infectious\ diseases\ require\ that\ special\ techniques\ be\ used\ to\ protect\ uninfected\ clients\
and\ workers.\ The\ client\ with\ pulmonary\ tuberculosis\ will\ be\ placed\ in\ airborne\
precautions.\ The\ client\ should\ be\ placed\ in\ a\ private\ room\ with\ special\ ventilation\ that\
does\ not\ allow\ air\ to\ circulate\ to\ general\ hospital\ ventilation;\ a\ mask\ or\ special\ filter\
respirators\ will\ be\ used\ for\ everyone\ entering\ the\ room.
Cognitive\ Level:\Application
Client\ Needs:\Safe,\Effective\Care\Environment\
Nursing\ Process:\ Assessment
6. A\client\ is\ receiving\ IV\ vancomycin\ for\ the\ treatment\ of\ Clostridium\ difficile.\ The\
nurse\ understands\ that\ the\ client\ who\ develops\ flushing,\ tachycardia,\ and\ hypotension\
during\ the\ infusion\ of\ vancomycin\ indicates:
1. Ototoxicity\ effect.
2. Superinfection.
3. Red\ man\ syndrome.
4. Hives.
Answer:\ 3
Rationale:\Vancomycin\ inhibits\ cell\ wall\ synthesis,\ and\ is\ used\ for\ serious\ infections.\ It\ is\
only\ effective\ against\ gram-positive\ bacteria,\ especially\ Staphylococcus\ aureus\ and
, Test Bank for Medical Surgical Nursing Critical Thinking in
Client Care,4th Edition Priscilla LeMon(100% Verified)
Staphylococcus\ epidermidis.\ The\ nurse\ should\ infuse\ this\ medication\ slowly\ over\ 60\
minutes\ or\ more\ to\ avoid\ “red\ man”\ syndrome.\ The\ syndrome\ is\ characterized\ by\
erythematous\ rash,\ flushing,\ tachycardia,\ and\ hypotension.\ Clients\ can\ become\ dizzy\and\
agitated.
Cognitive\ Level:\Application
Client\Needs:\Physiological\Integrity\
Nursing\ Process:\ Evaluation
7. The\ physician\ has\ ordered\ for\ the\ client\ to\ receive\ a\ trough\ blood\ level\ to\ evaluate\ the\
therapeutic\ effect\ of\ an\ antibiotic.\ The\ nurse\ understands\ that\ the\ trough\ should\ be\
ordered:
1. A\few\ minutes\ before\ the\ next\ scheduled\ dose\ of\ medication.
2. 1–2\ hours\ after\ the\ oral\ administration\ of\ the\ medication.
3. 30\ minutes\ after\ the\ IV\ administration.
4. During\ the\ infusion\ of\ the\ antibiotic.
Answer:\ 1
Rationale:\ Antibiotic\ peak\ and\ trough\ levels\ monitor\ therapeutic\ blood\ levels\ of\ the\
prescribed\ medication.\ The\ therapeutic\ range—the\ minimum\ and\ maximum\ blood\ levels\
at\ which\ the\ drug\ is\ effective—is\ known\ for\ a\ given\ drug.\ By\ measuring\ blood\ levels\ at\
the\ predicted\ peak\ (1–2\ hours\ after\ oral\ administration,\ 1\ hour\ after\ intramuscular\
administration,\ and\ 30\ minutes\ after\ IV\ administration)\ and\ trough\ (usually\ a\ few\ minutes\
before\ the\ next\ scheduled\ dose),\ it\ is\ also\ possible\ to\ determine\ whether\ the\ drug\ is\
reaching\ a\ toxic\ or\ harmful\ level\ during\ therapy,\ increasing\ the\ likelihood\ of\ adverse\
effects.
Cognitive\ Level:\Application
Client\ Needs:\Safe,\Effective\Care\Environment\
Nursing\ Process:\ Assessment
8. The\ nurse\ needs\ to\ change\ a\ dressing\ on\ the\ client’s\ abdomen.\ Which\ of\ the\ following\
techniques\ should\ be\ implemented?
1. Contact\ precautions
2. Standard\ precautions
3. Droplet\ precautions
4. Airborne\ precautions
Answer:\ 2
