UNDERSTANDING MEDICAL-SURGICAL NURSING
7TH EDITION BY PAULA D. WILLIAMS, LINDA S. &
HOPPER WITH RATIONALES
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, 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 ANS: 1
Rat ionale: 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.
C ognitive 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.‖
ANS: 3
Rat ionale: 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.
C ognitive Level: Application
Client Needs: Safe, Effective Care Environment Nursing Process: Assessment
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,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
ANS: 1
Rat ionale: 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.
C ognitive 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.
ANS: 2
Rat ionale: 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 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.
C ognitive 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?
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, 1. Standard Precautions
2. Airborne Precautions
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