Test Bank for Medical Surgical Nursing; Critical Thinking in Client Care 4th Edition (Pearson; 2007) by Priscilla Lemon, all 52 Chapters Covered
TEST BANK
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,Test Bank for Medical Surgical Nursing; Critical Thinking in Client Care 4th Edition (Pearson; 2007) by Priscilla Lemon, all 52 Chapters Covered
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. am allergic to horse
2. try to get my vaccine every
3. am not allergic to anything except
4. husband had a severe allergic reaction after he received his influenza
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
Client Needs: Safe, Effective Care Environment
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,Test Bank for Medical Surgical Nursing; Critical Thinking in Client Care 4th Edition (Pearson; 2007) by Priscilla Lemon, all 52 Chapters Covered
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
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
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 by all
healthcare workers who have direct contact with clients or with their body
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, Test Bank for Medical Surgical Nursing; Critical Thinking in Client Care 4th Edition (Pearson; 2007) by Priscilla Lemon, all 52 Chapters Covered
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)
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 Staphylococcus epidermidis. The nurse should infuse
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TEST BANK
~1~
,Test Bank for Medical Surgical Nursing; Critical Thinking in Client Care 4th Edition (Pearson; 2007) by Priscilla Lemon, all 52 Chapters Covered
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. am allergic to horse
2. try to get my vaccine every
3. am not allergic to anything except
4. husband had a severe allergic reaction after he received his influenza
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
Client Needs: Safe, Effective Care Environment
~2~
,Test Bank for Medical Surgical Nursing; Critical Thinking in Client Care 4th Edition (Pearson; 2007) by Priscilla Lemon, all 52 Chapters Covered
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
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
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 by all
healthcare workers who have direct contact with clients or with their body
~3~
, Test Bank for Medical Surgical Nursing; Critical Thinking in Client Care 4th Edition (Pearson; 2007) by Priscilla Lemon, all 52 Chapters Covered
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)
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 Staphylococcus epidermidis. The nurse should infuse
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