Medical Surgical Nursing Critical Thinking in Client Care 7th Edition by Priscilla LeMone Karen M. Burke and Gerene Bauldoff Test Bank Updated Latest 2026–2027 Adult Health Nursing Clinical Care Critical Thinking NCLEX Exam Questions with Verified Answers

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Nursing Y




Critica Thinking in Client Care
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Y Test Bank Y




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,Chapter 1 Y




1. The nurse is caring for four clients on a medical–surgical unit. Which client should
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the nurse see initially?
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1. A client admitted with hepatitis A who has had severe diarrhea for the last
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24 hours FY




2. A client admitted with pneumonia who is has small amounts of yellow
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productive sputum FY




3. A client admitted with fever of unknown origin (FUO) who has been without
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fever for the last 48 hours FY FY FY FY FY




4. A client admitted with a wound infection whose WBC is 8,500 mm3
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Answer: 1 FY




Rationale: The nurse must decide which client should be seen on the initial rounds of the
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day. The nurse must remember that the first client to be seen should be the client
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who needs the attention of the nurse initially. A client with hepatitis A does
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experience diarrhea, but diarrhea for the last 24 hours could cause the client to
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have a problem with dehydration and experience a state of fluid volume deficit.
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Cognitive Level: Application
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Client Needs: Safe, Effective Care Environment Nursing
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Process: Planning
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2. The nurse is preparing to administer influenza vaccines to a mass drive-through
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clinic. Which statement by a client would indicate further questioning prior to giving the
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client the influenza vaccine?
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1. “I am allergic to horse hair.”
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2. “I try to get my vaccine every year.”
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3. “I am not allergic to anything except eggs.”
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4. “My husband had a severe allergic reaction after he received his influenza
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vaccine.”

Answer: 3 FY




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,Rationale: Influenza vaccines are recommended for person at high risk for serious
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sequelae of influenza. The nurse should be aware that client with a sensitivity to
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eggs should not receive the vaccine. Vaccines prepared from chicken or duck
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embryos are contraindicated in clients who are allergic to eggs.
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Cognitive Level: Application FY FY




Client Needs: Safe, Effective Care Environment
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Nursing Process: Assessment
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3. The nurse is caring for four clients on a medical–surgical unit. The secretary gives
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the nurse the morning labs. Which of the following labs would require that the nurse call
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the physician and inform the healthcare provider about the client’s abnormalities?
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1. WBC 14,600 mm3 FY FY




2. Serum protein 6.9 g/dL FY FY FY




3. I & D (incision and drainage) showing no growth for the last 24 hours
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4. Albumin 4.2 g/dL FY FY




Answer: 1 FY




Rationale: When the nurse is caring for several clients, all of the labs should be checked
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frequently throughout the shift to assess for any abnormalities. The WBC in option 1 is
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abnormal. (Normal WBC 4,000–10,000 mm3.) All of the other lab results are within
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acceptable range; therefore, the results should not be called in to the physician.
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Cognitive Level: Application FY FY




Client Needs: Physiologic Integrity
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Nursing Process: Assessment
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4. The nurse is orienting a new graduate. The nurse is reinforcing the importance of
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standard precautions. Which of the following observations by the nurse would require
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further education regarding standard precautions?
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1. The graduate nurse understands to wash hands when entering and exiting
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the client’s room. FY FY




2. The graduate nurse wears gloves when serving breakfast trays to various
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clients.
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a
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client.



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, 4. The graduate nurse leaves all supplies in the room of a client who is in FY FY FY FY FY FY FY FY FY FY FY FY FY FY FY




contact isolation. FY




Answer: 2 FY




Rationale: The nurse must have an understanding of standard precautions. Prevention is
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the most important measure to prevent nosocomial infections. Standard
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precautions were published in 1996 that provide guidelines for the handling of FY FY FY FY FY FY FY FY FY FY FY FY




blood and other body fluids. These guidelines are used with all clients, regardless of
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whether they have a known infectious disease. Standard precautions are used FY FY FY FY FY FY FY FY FY FY FY




by all healthcare workers who have direct contact with clients or with their body
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fluids. It is not necessary for the nurse to wear gloves while delivering food trays to
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the client, because there is not contact with the client.
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Cognitive Level: Application FY FY




Client Needs: Safe, Effective Care Environment
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Nursing Process: EvaluationFY FY




5. The admitting department alerts the nurse on a medical–surgical unit that a client
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with active tuberculosis (TB) is being admitted to the unit. Which type of isolation is
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appropriate based on the client’s diagnosis? FY FY FY FY FY




1. Standard precautions FY




2. Airborne precautions FY




3. Droplet precautions FY




4. Contact precautions FY




Answer: 2 FY




In addition to handwashing and standard precautions, the nature and spread of some
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infectious diseases require that special techniques be used to protect uninfected clients
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and workers. The client with pulmonary tuberculosis will be placed in airborne
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precautions. The client should be placed in a private room with special ventilation that
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does not allow air to circulate to general hospital ventilation; a mask or special filter
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respirators will be used for everyone entering the room. FY FY FY FY FY FY FY FY




Cognitive Level: Application FY FY




Client Needs: Safe, Effective Care Environment
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Nursing Process: AssessmentFY FY




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