TESTBANK FOR LEMONE
n7 & n7BURKE’S n7 n7
MEDICAL- SURGICAL NURSING: CLINICAL
n7 n
7 n7 n7
REASONING IN HOSPITAL CLIENT CARE 7TH
n7 n7 n7 n7 n7 n7
EDITION/ALL CHAPTERS 1-52
n7 n7 n7
,Chapter 1 n7
1. The caregiver is caring for four Hospital clients on a medical–surgical unit.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
WhichHospital client should the caregiver see initially?
n7 7
n n7 n7 n7 n7 n7 n7
1. A Hospital client admitted with hepatitis A who has had severe
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
diarrhea for thelast 24 hours
n7 n7 n7 n7 n7 n7
2. A Hospital client admitted with pneumonia who is has small
n7 n7 n7 n7 n7 n7 n7 n7 n7
amounts ofyellow productive sputum
n7 n7 n7 n7 n7
3. A Hospital client admitted with fever of unknown origin
n7 n7 n7 n7 n7 n7 n7 n7
(FUO) who hasbeen without fever for the last 48 hours
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
4. A Hospital client admitted with a wound infection whose WBC is
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
n7 8,500 mm3ACCURATE ANSWER:-1
n7 n7 n7
Reasoning:->>>The caregiver must decide which Hospital client should be seen on n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
theinitial rounds of the day. The caregiver must remember that the first
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Hospital client to be seen should be the Hospital client who needs the
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
attention of the caregiver initially. A Hospital client with hepatitis A does
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
experience diarrhea,but diarrhea for the last 24 hours could cause the
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Hospital client to have a problem withdehydration and experience a state
n7 n7 n7 n7 n7 n7 n7 7
n n7 n7 n7 n7
of fluid volume deficit.
n7 n7 n7 n7
Cognitive Level: Application
n7 n7
Hospital client Needs: Safe, Effective Care
n7 n7 n7 n7 n7
EnvironmentNursing Process: Planning
n7 n7 n7 n7
2. The caregiver is preparing to administer influenza vaccines to a mass drive-
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
through clinic. Which statement by a Hospital client would indicate further
7
n n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
questioning prior togiving the Hospital client the influenza vaccine?
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
1. ―I am allergic to horse hair.‖
n7 n7 n7 n7 n7
2. ―I try to get my vaccine every year.‖
n7 n7 n7 n7 n7 n7 n7
3. ―I am not allergic to anything except eggs.‖
n7 n7 n7 n7 n7 n7 n7
4. ―My husband had a severe allergic reaction after he received his
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
influenzavaccine.‖
n7 n7
ACCURATE ANSWER:-3 n7
Reasoning:->>>Influenza vaccines are recommended for person at high risk for n7 n7 n7 n7 n7 n7 n7 n7 n7
serious sequelae of influenza. The caregiver should be aware that Hospital
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
client with asensitivity to eggs should not receive the vaccine. Vaccines
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
prepared from chicken or duck embryos are contraindicated in Hospital
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
clients who are allergic to eggs.
n7 n7 n7 n7 n7 n7
,Cognitive Level: Application n7 n7
Hospital client Needs: Safe, Effective Care
n7 n7 n7 n7 n7
EnvironmentNursing Process: Assessment
n7 n7 n7 n7
3. The caregiver is caring for four Hospital clients on a medical–surgical unit. The
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
secretary gives the caregiver the morning labs. Which of the following labs would
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
require that the caregiver call the physician and inform the healthcare provider
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
about the Hospital client‘s abnormalities?
n7 n7 n7 n7 n7
1. WBC 14,600 mm3
n 7 n7 n7
2. Serum protein 6.9 g/dL n7 n7 n7
3. I & D (incision and drainage) showing no growth for the last 24 hours
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
4. Albumin 4.2 n7
g/dLACCURATE ANSWER:-
n7 7
n n7
1
Reasoning:->>>When the caregiver is caring for several Hospital clients, all of n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
the labs should be checked frequently throughout the shift to assess for any
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
abnormalities. The WBC in option 1 is abnormal. (Normal WBC 4,000–10,000
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
mm3.) All of the other lab results are within acceptable range; therefore, the
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
results should not be called in to thephysician.
n7 n7 n7 n7 n7 n7 n7 n7 7
n
Cognitive Level: n7
ApplicationHospital client
n7 n7 n7
Needs: Physiologic
n7 n7
Integrity Nursing Process:
n7 n7 n7
Assessment
4. The caregiver is orienting a new graduate. The caregiver is reinforcing
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
the importance of standard precautions. Which of the following
n7 n7 n7 n7 n7 n7 n7 n7 n7
observations by the caregiver would require further education
n7 n7 n7 n7 n7 n7 n7 n7
regardingstandard precautions?
n7 n7 n7
1. The graduate caregiver understands to wash hands
n7 n7 n7 n7 n7 n7
whenentering and exiting the Hospital client‘s room.
n7 n7 n7 n7 n7 n7 n7 n7
2. The graduate caregiver wears gloves when serving breakfasttrays
n7 n7 n7 n7 n7 n7 n7 7
n
to various Hospital clients.
n7 n7 n7 n7
3. The graduate caregiver wears a gown, gloves, and goggles
n7 n7 n7 n7 n7 n7 n7 n7
whensuctioning a Hospital client.
n7 n7 n7 n7 n7
4. The graduate caregiver leaves all supplies in the room of
n7 n7 n7 n7 n7 n7 n7 n7 n7
aHospital client who is in contact isolation.
n7 n7 n7 n7 n7 n7 n7 n7
, ACCURATE ANSWER:-2 n7
Reasoning:->>>The caregiver must have an understanding of standard precautions. n7 n7 n7 n7 n7 n7 n7 n7
Prevention is the most important measure to prevent nosocomial
n7 n7 n7 n7 n7 n7 n7 n7 n7
infections. Standard precautions were published in 1996 that provide
n7 n7 n7 n7 n7 n7 n7 n7 n7
guidelines n7
for the handling of blood and other body fluids. These guidelines are used
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
with all Hospital clients, regardless of whether they have a known infectious
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
disease. Standardprecautions are used
n7 n7 n7 n7 n7
by all healthcare workers who have direct contact with Hospital clients or
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
with their body fluids. It is not necessary for the caregiver to wear gloves
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
while delivering food trays to the Hospital client, because there is not
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
contact with the Hospital client.
n7 n7 n7 n7 n7
Cognitive Level: Application n7 n7
Hospital client Needs: Safe, Effective Care
n7 n7 n7 n7 n7
EnvironmentNursing Process: Evaluation
n7 n7 n7 n7
5. The admitting department alerts the caregiver on a medical–surgical unit thata
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 7
n
Hospital client with active tuberculosis (TB) is being admitted to the unit. Which
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
type of isolation is appropriate based on the Hospital client‘s diagnosis?
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
1. Standard precautions n7
2. Airborne precautions n7
3. Droplet precautions n7
4. Contact
n7 precautionsACCURATE n7
n7 ANSWER:-2
Reasoning:->>>In addition to handwashing and standard precautions, the nature and
n7 n7 n7 n7 n7 n7 n7 n7 n7
spread of some infectious diseases require that special techniques be used to protect
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
uninfected Hospital clients and workers. The Hospital client with pulmonary
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
tuberculosis will be placed in airborne precautions. The Hospital client should be
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
placed in a private room with special ventilation that does not allow air to circulate
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
to general health center ventilation; a maskor special filter respirators will be used
n7 n7 n7 n7 n7 n7 n7 7
n n7 n7 n7 n7 n7 n7
for everyone entering the room.
n7 n7 n7 n7 n7
Cognitive Level: Application n7 n7
Hospital client Needs: Safe, Effective Care
n7 n7 n7 n7 n7
EnvironmentNursing Process: Assessment
n7 n7 n7 n7
6. A Hospital client is receiving IV vancomycin for the treatment of
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Clostridium difficile.The caregiver understands that the Hospital client who
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
n7 & n7BURKE’S n7 n7
MEDICAL- SURGICAL NURSING: CLINICAL
n7 n
7 n7 n7
REASONING IN HOSPITAL CLIENT CARE 7TH
n7 n7 n7 n7 n7 n7
EDITION/ALL CHAPTERS 1-52
n7 n7 n7
,Chapter 1 n7
1. The caregiver is caring for four Hospital clients on a medical–surgical unit.
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
WhichHospital client should the caregiver see initially?
n7 7
n n7 n7 n7 n7 n7 n7
1. A Hospital client admitted with hepatitis A who has had severe
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
diarrhea for thelast 24 hours
n7 n7 n7 n7 n7 n7
2. A Hospital client admitted with pneumonia who is has small
n7 n7 n7 n7 n7 n7 n7 n7 n7
amounts ofyellow productive sputum
n7 n7 n7 n7 n7
3. A Hospital client admitted with fever of unknown origin
n7 n7 n7 n7 n7 n7 n7 n7
(FUO) who hasbeen without fever for the last 48 hours
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
4. A Hospital client admitted with a wound infection whose WBC is
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
n7 8,500 mm3ACCURATE ANSWER:-1
n7 n7 n7
Reasoning:->>>The caregiver must decide which Hospital client should be seen on n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
theinitial rounds of the day. The caregiver must remember that the first
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Hospital client to be seen should be the Hospital client who needs the
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
attention of the caregiver initially. A Hospital client with hepatitis A does
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
experience diarrhea,but diarrhea for the last 24 hours could cause the
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Hospital client to have a problem withdehydration and experience a state
n7 n7 n7 n7 n7 n7 n7 7
n n7 n7 n7 n7
of fluid volume deficit.
n7 n7 n7 n7
Cognitive Level: Application
n7 n7
Hospital client Needs: Safe, Effective Care
n7 n7 n7 n7 n7
EnvironmentNursing Process: Planning
n7 n7 n7 n7
2. The caregiver is preparing to administer influenza vaccines to a mass drive-
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
through clinic. Which statement by a Hospital client would indicate further
7
n n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
questioning prior togiving the Hospital client the influenza vaccine?
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
1. ―I am allergic to horse hair.‖
n7 n7 n7 n7 n7
2. ―I try to get my vaccine every year.‖
n7 n7 n7 n7 n7 n7 n7
3. ―I am not allergic to anything except eggs.‖
n7 n7 n7 n7 n7 n7 n7
4. ―My husband had a severe allergic reaction after he received his
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
influenzavaccine.‖
n7 n7
ACCURATE ANSWER:-3 n7
Reasoning:->>>Influenza vaccines are recommended for person at high risk for n7 n7 n7 n7 n7 n7 n7 n7 n7
serious sequelae of influenza. The caregiver should be aware that Hospital
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
client with asensitivity to eggs should not receive the vaccine. Vaccines
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
prepared from chicken or duck embryos are contraindicated in Hospital
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
clients who are allergic to eggs.
n7 n7 n7 n7 n7 n7
,Cognitive Level: Application n7 n7
Hospital client Needs: Safe, Effective Care
n7 n7 n7 n7 n7
EnvironmentNursing Process: Assessment
n7 n7 n7 n7
3. The caregiver is caring for four Hospital clients on a medical–surgical unit. The
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
secretary gives the caregiver the morning labs. Which of the following labs would
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
require that the caregiver call the physician and inform the healthcare provider
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
about the Hospital client‘s abnormalities?
n7 n7 n7 n7 n7
1. WBC 14,600 mm3
n 7 n7 n7
2. Serum protein 6.9 g/dL n7 n7 n7
3. I & D (incision and drainage) showing no growth for the last 24 hours
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
4. Albumin 4.2 n7
g/dLACCURATE ANSWER:-
n7 7
n n7
1
Reasoning:->>>When the caregiver is caring for several Hospital clients, all of n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
the labs should be checked frequently throughout the shift to assess for any
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
abnormalities. The WBC in option 1 is abnormal. (Normal WBC 4,000–10,000
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
mm3.) All of the other lab results are within acceptable range; therefore, the
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
results should not be called in to thephysician.
n7 n7 n7 n7 n7 n7 n7 n7 7
n
Cognitive Level: n7
ApplicationHospital client
n7 n7 n7
Needs: Physiologic
n7 n7
Integrity Nursing Process:
n7 n7 n7
Assessment
4. The caregiver is orienting a new graduate. The caregiver is reinforcing
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
the importance of standard precautions. Which of the following
n7 n7 n7 n7 n7 n7 n7 n7 n7
observations by the caregiver would require further education
n7 n7 n7 n7 n7 n7 n7 n7
regardingstandard precautions?
n7 n7 n7
1. The graduate caregiver understands to wash hands
n7 n7 n7 n7 n7 n7
whenentering and exiting the Hospital client‘s room.
n7 n7 n7 n7 n7 n7 n7 n7
2. The graduate caregiver wears gloves when serving breakfasttrays
n7 n7 n7 n7 n7 n7 n7 7
n
to various Hospital clients.
n7 n7 n7 n7
3. The graduate caregiver wears a gown, gloves, and goggles
n7 n7 n7 n7 n7 n7 n7 n7
whensuctioning a Hospital client.
n7 n7 n7 n7 n7
4. The graduate caregiver leaves all supplies in the room of
n7 n7 n7 n7 n7 n7 n7 n7 n7
aHospital client who is in contact isolation.
n7 n7 n7 n7 n7 n7 n7 n7
, ACCURATE ANSWER:-2 n7
Reasoning:->>>The caregiver must have an understanding of standard precautions. n7 n7 n7 n7 n7 n7 n7 n7
Prevention is the most important measure to prevent nosocomial
n7 n7 n7 n7 n7 n7 n7 n7 n7
infections. Standard precautions were published in 1996 that provide
n7 n7 n7 n7 n7 n7 n7 n7 n7
guidelines n7
for the handling of blood and other body fluids. These guidelines are used
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
with all Hospital clients, regardless of whether they have a known infectious
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
disease. Standardprecautions are used
n7 n7 n7 n7 n7
by all healthcare workers who have direct contact with Hospital clients or
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
with their body fluids. It is not necessary for the caregiver to wear gloves
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
while delivering food trays to the Hospital client, because there is not
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
contact with the Hospital client.
n7 n7 n7 n7 n7
Cognitive Level: Application n7 n7
Hospital client Needs: Safe, Effective Care
n7 n7 n7 n7 n7
EnvironmentNursing Process: Evaluation
n7 n7 n7 n7
5. The admitting department alerts the caregiver on a medical–surgical unit thata
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 7
n
Hospital client with active tuberculosis (TB) is being admitted to the unit. Which
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
type of isolation is appropriate based on the Hospital client‘s diagnosis?
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
1. Standard precautions n7
2. Airborne precautions n7
3. Droplet precautions n7
4. Contact
n7 precautionsACCURATE n7
n7 ANSWER:-2
Reasoning:->>>In addition to handwashing and standard precautions, the nature and
n7 n7 n7 n7 n7 n7 n7 n7 n7
spread of some infectious diseases require that special techniques be used to protect
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
uninfected Hospital clients and workers. The Hospital client with pulmonary
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
tuberculosis will be placed in airborne precautions. The Hospital client should be
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
placed in a private room with special ventilation that does not allow air to circulate
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
to general health center ventilation; a maskor special filter respirators will be used
n7 n7 n7 n7 n7 n7 n7 7
n n7 n7 n7 n7 n7 n7
for everyone entering the room.
n7 n7 n7 n7 n7
Cognitive Level: Application n7 n7
Hospital client Needs: Safe, Effective Care
n7 n7 n7 n7 n7
EnvironmentNursing Process: Assessment
n7 n7 n7 n7
6. A Hospital client is receiving IV vancomycin for the treatment of
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
Clostridium difficile.The caregiver understands that the Hospital client who
n7 n7 n7 n7 n7 n7 n7 n7 n7 n7
