Test Bank -
Medical- Surgical Nursing: Critical
Thinking in Patient Care 5th Edition
,Chapter 1
1. The Nurse Is Caring For Four Patients On A Medical–Surgical Unit. Which Patient
Should The Nurse See Initially?
1.
A Patient Admitted With Hepatitis A Who Has Had Severe Diarrhea For
The Last 24 Hours
2.
A Patient Admitted With Pneumonia Who Is Has Small Amounts Of
Yellow Productive Sputum
3.
A Patient Admitted With Fever Of Unknown Origin (FUO) Who
Has Been Without Fever For The Last 48 Hours
4.
A Patient Admitted With A Wound Infection Whose WBC Is 8,500 Mm3
SELECTED ANSWER: 1
Rationale: The Nurse Must Decide Which Patient Should Be Seen On The Initial Rounds
Of The Day. The Nurse Must Remember That The First Patient To Be Seen
Should Be The Patient Who Needs The Attention Of The Nurse Initially. A
Patient With Hepatitis A Does Experience Diarrhea, But Diarrhea For The Last
24 Hours Could Cause The Patient To Have A Problem With Dehydration And
Experience A State Of Fluid Volume Deficit.
Cognitive Level: Application
Patient 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 Patient Would Indicate Further Questioning Prior To
Giving The Patient 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.”
SELECTED ANSWER: 3
Rationale: Influenza Vaccines Are Recommended For Person At High Risk For Serious
Sequelae Of Influenza. The Nurse Should Be Aware That Patient With A
Sensitivity To Eggs Should Not Receive The Vaccine. Vaccines Prepared From
Chicken Or Duck Embryos Are Contraindicated In Patients Who Are Allergic
To Eggs.
Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
,Nursing Process: Assessment
3. The Nurse Is Caring For Four Patients 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
Patient’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
SELECTED ANSWER: 1
Rationale: When The Nurse Is Caring For Several Patients, 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
Patient 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 Patient’s Room.
2. The Graduate Nurse Wears Gloves When Serving Breakfast Trays To
Various Patients.
3. The Graduate Nurse Wears A Gown, Gloves, And Goggles When
Suctioning A Patient.
4. The Graduate Nurse Leaves All Supplies In The Room Of A Patient
Who Is In Contact Isolation.
SELECTED 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
Patients, Regardless Of Whether They Have A Known Infectious Disease.
Standard Precautions Are Used By All Healthcare Workers Who Have Direct
Contact With Patients Or With Their Body
, Fluids. It Is Not Necessary For The Nurse To Wear Gloves While Delivering
Food Trays To The Patient, Because There Is Not Contact With The Patient.
Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
Nursing Process: Evaluation
5. The Admitting Department Alerts The Nurse On A Medical–Surgical Unit That A
Patient With Active Tuberculosis (TB) Is Being Admitted To The Unit. Which Type Of
Isolation Is Appropriate Based On The Patient’s Diagnosis?
1. Standard Precautions
2. Airborne Precautions
3. Droplet Precautions
4. Contact Precautions
SELECTED 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 Patients And Workers. The Patient With Pulmonary Tuberculosis Will Be
Placed In Airborne Precautions. The Patient 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
Patient Needs: Safe, Effective Care Environment
Nursing Process: Assessment
6. A Patient Is Receiving IV Vancomycin For The Treatment Of Clostridium
Difficile. The Nurse Understands That The Patient Who Develops Flushing,
Tachycardia, And Hypotension During The Infusion Of Vancomycin Indicates:
1. Ototoxicity Effect.
2. Superinfection.
3. Red Man Syndrome.
4. Hives.
SELECTED 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 Staphylococcus Epidermidis. The Nurse Should Infuse This Medication Slowly
Over 60 Minutes Or More To Avoid “Red Man” Syndrome. The Syndrome Is
Characterized By
Medical- Surgical Nursing: Critical
Thinking in Patient Care 5th Edition
,Chapter 1
1. The Nurse Is Caring For Four Patients On A Medical–Surgical Unit. Which Patient
Should The Nurse See Initially?
1.
A Patient Admitted With Hepatitis A Who Has Had Severe Diarrhea For
The Last 24 Hours
2.
A Patient Admitted With Pneumonia Who Is Has Small Amounts Of
Yellow Productive Sputum
3.
A Patient Admitted With Fever Of Unknown Origin (FUO) Who
Has Been Without Fever For The Last 48 Hours
4.
A Patient Admitted With A Wound Infection Whose WBC Is 8,500 Mm3
SELECTED ANSWER: 1
Rationale: The Nurse Must Decide Which Patient Should Be Seen On The Initial Rounds
Of The Day. The Nurse Must Remember That The First Patient To Be Seen
Should Be The Patient Who Needs The Attention Of The Nurse Initially. A
Patient With Hepatitis A Does Experience Diarrhea, But Diarrhea For The Last
24 Hours Could Cause The Patient To Have A Problem With Dehydration And
Experience A State Of Fluid Volume Deficit.
Cognitive Level: Application
Patient 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 Patient Would Indicate Further Questioning Prior To
Giving The Patient 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.”
SELECTED ANSWER: 3
Rationale: Influenza Vaccines Are Recommended For Person At High Risk For Serious
Sequelae Of Influenza. The Nurse Should Be Aware That Patient With A
Sensitivity To Eggs Should Not Receive The Vaccine. Vaccines Prepared From
Chicken Or Duck Embryos Are Contraindicated In Patients Who Are Allergic
To Eggs.
Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
,Nursing Process: Assessment
3. The Nurse Is Caring For Four Patients 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
Patient’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
SELECTED ANSWER: 1
Rationale: When The Nurse Is Caring For Several Patients, 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
Patient 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 Patient’s Room.
2. The Graduate Nurse Wears Gloves When Serving Breakfast Trays To
Various Patients.
3. The Graduate Nurse Wears A Gown, Gloves, And Goggles When
Suctioning A Patient.
4. The Graduate Nurse Leaves All Supplies In The Room Of A Patient
Who Is In Contact Isolation.
SELECTED 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
Patients, Regardless Of Whether They Have A Known Infectious Disease.
Standard Precautions Are Used By All Healthcare Workers Who Have Direct
Contact With Patients Or With Their Body
, Fluids. It Is Not Necessary For The Nurse To Wear Gloves While Delivering
Food Trays To The Patient, Because There Is Not Contact With The Patient.
Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
Nursing Process: Evaluation
5. The Admitting Department Alerts The Nurse On A Medical–Surgical Unit That A
Patient With Active Tuberculosis (TB) Is Being Admitted To The Unit. Which Type Of
Isolation Is Appropriate Based On The Patient’s Diagnosis?
1. Standard Precautions
2. Airborne Precautions
3. Droplet Precautions
4. Contact Precautions
SELECTED 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 Patients And Workers. The Patient With Pulmonary Tuberculosis Will Be
Placed In Airborne Precautions. The Patient 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
Patient Needs: Safe, Effective Care Environment
Nursing Process: Assessment
6. A Patient Is Receiving IV Vancomycin For The Treatment Of Clostridium
Difficile. The Nurse Understands That The Patient Who Develops Flushing,
Tachycardia, And Hypotension During The Infusion Of Vancomycin Indicates:
1. Ototoxicity Effect.
2. Superinfection.
3. Red Man Syndrome.
4. Hives.
SELECTED 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 Staphylococcus Epidermidis. The Nurse Should Infuse This Medication Slowly
Over 60 Minutes Or More To Avoid “Red Man” Syndrome. The Syndrome Is
Characterized By
