1
MEDICAL-SURGICAL NURSING IN CLIENT CARE CRITICAL
THINKING BIO 102 TEST BANK EXAM QUESTIONS AND
ANSWERS COVERING COMPLETE CHAPTERS 1-52
Chapter 1
• A client develops hyperthermia related to a diagnosis of Pneumonia.
Which of thefollowing nursing interventions would be effective in the
treatment of hyperthermia? Select all that apply.
1. Increase the temperature of the room environment to prevent
shivering.
2. Use ice packs and a tepid bath as needed.
3. Administer antipyretic medications per physician’s orders.
4. Promote frequent rest periods to increase energy reserve.
5. Restrict fluids during periods of hyperthermia because of
the risk ofelectrolyte imbalance.
Answer: 2; 3; 4
Rationale: Hyperthemia is an expected consequence of the infectious
disease process.Fever can produce mild, short-term effects or, when
prolonged, can cause life-threatening effects. The nurse should
administer antipyretic medications as indicated for elevated
temperatures. The nurse should use ice packs, cool/tepidbaths, or
hypothermia blanket with caution. The nurse should enforce
frequentrest periods because rest increases energy reserve, which is
depleted by an increased metabolic, heart, and respiratory rate. The
nurse should encourage fluids rather than restrict fluids because of
the risk of electrolyte imbalance.
Cognitive Level: Assessment
Client Needs: Physiological
IntegrityNursing Process:
Implementation
,2
• The nurse is assessing a client’s wound for signs and symptoms of
inflammation.Which of the following would alert the nurse that the
client is exhibiting signs of inflammation? Select all that apply.
1. Leg edema
2. Leg cool to touch
3. Severe pain from swelling
4. Decreased peripheral pulses
5. Severe erythema
of legAnswer: 1; 3; 5
Rationale: Regardless of the cause, location, or extent of the injury, the
acute inflammatory response follows the sequence of vascular response,
cellular and phagocytic response, and healing. Many manifestations of
inflammation are produced byinflammatory mediators such as histamines
and prostaglandins released when tissue is damaged. The cardinal signs of
inflammation include erythema, local heat caused by the increased blood
flow to the injured area (hyperemia), swelling due to accumulated fluidat
site, pain from tissue swelling and chemical irritation of nerve endings, and
loss of function caused by the swelling and pain.
Cognitive Level: Application
Client Needs: Physiological
IntegrityNursing Process:
Assessment
Alternate item format – Select all that apply
Which of the following manifestations would the nurse expect to see
with a client who has had previous knee surgery who suffered a surgical
infection with signs of systemicmanifestations? Select all that apply.
1.
Erythema
2.
WBC 14,200 mm3
3.
Pain at the surgical site
4.
10% Bands
5.
Respiratory rate of 16
,3
6.
Pulse
114Answer: 2; 3; 6
Rationale: The client is post–surgical repair of the knee. The nurse should
be able to distinguish between local reactions and system reactions. An
elevated WBC and 10% bands are indicative of an infection. Vital sign
changes typically associated with an infection include an elevation in
temperature and tachycardia. Local manifestations include erythema,
warmth, pain, edema, and functional impairment, whereas systemic
manifestations include elevated temperature above 100.4°F, pulse greater
than 90/min.,respiratory rate greater than 20, and WBC greater than
12,000 mm3 or > 10% bands.
• The nurse is caring for four clients on a medical–surgical unit. Which
client should thenurse see initially?
1.
A client admitted with hepatitis A who has had severe
diarrhea for the last24 hours
2.
A client admitted with pneumonia who is has small
amounts of yellowproductive sputum
3.
A client admitted with fever of unknown origin (FUO) who
has beenwithout 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 theday. The nurse must remember that the first client to
be seen should be the clientwho 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
, 4
EnvironmentNursing Process: Planning
• 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?
• “I am allergic to horse hair.”
• “I try to get my vaccine every year.”
• “I am not allergic to anything except eggs.”
• “My husband had a severe allergic reaction after he received
his influenzavaccine.”
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 toeggs 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
Nursing Process: Assessment
• 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
Answer: 1
MEDICAL-SURGICAL NURSING IN CLIENT CARE CRITICAL
THINKING BIO 102 TEST BANK EXAM QUESTIONS AND
ANSWERS COVERING COMPLETE CHAPTERS 1-52
Chapter 1
• A client develops hyperthermia related to a diagnosis of Pneumonia.
Which of thefollowing nursing interventions would be effective in the
treatment of hyperthermia? Select all that apply.
1. Increase the temperature of the room environment to prevent
shivering.
2. Use ice packs and a tepid bath as needed.
3. Administer antipyretic medications per physician’s orders.
4. Promote frequent rest periods to increase energy reserve.
5. Restrict fluids during periods of hyperthermia because of
the risk ofelectrolyte imbalance.
Answer: 2; 3; 4
Rationale: Hyperthemia is an expected consequence of the infectious
disease process.Fever can produce mild, short-term effects or, when
prolonged, can cause life-threatening effects. The nurse should
administer antipyretic medications as indicated for elevated
temperatures. The nurse should use ice packs, cool/tepidbaths, or
hypothermia blanket with caution. The nurse should enforce
frequentrest periods because rest increases energy reserve, which is
depleted by an increased metabolic, heart, and respiratory rate. The
nurse should encourage fluids rather than restrict fluids because of
the risk of electrolyte imbalance.
Cognitive Level: Assessment
Client Needs: Physiological
IntegrityNursing Process:
Implementation
,2
• The nurse is assessing a client’s wound for signs and symptoms of
inflammation.Which of the following would alert the nurse that the
client is exhibiting signs of inflammation? Select all that apply.
1. Leg edema
2. Leg cool to touch
3. Severe pain from swelling
4. Decreased peripheral pulses
5. Severe erythema
of legAnswer: 1; 3; 5
Rationale: Regardless of the cause, location, or extent of the injury, the
acute inflammatory response follows the sequence of vascular response,
cellular and phagocytic response, and healing. Many manifestations of
inflammation are produced byinflammatory mediators such as histamines
and prostaglandins released when tissue is damaged. The cardinal signs of
inflammation include erythema, local heat caused by the increased blood
flow to the injured area (hyperemia), swelling due to accumulated fluidat
site, pain from tissue swelling and chemical irritation of nerve endings, and
loss of function caused by the swelling and pain.
Cognitive Level: Application
Client Needs: Physiological
IntegrityNursing Process:
Assessment
Alternate item format – Select all that apply
Which of the following manifestations would the nurse expect to see
with a client who has had previous knee surgery who suffered a surgical
infection with signs of systemicmanifestations? Select all that apply.
1.
Erythema
2.
WBC 14,200 mm3
3.
Pain at the surgical site
4.
10% Bands
5.
Respiratory rate of 16
,3
6.
Pulse
114Answer: 2; 3; 6
Rationale: The client is post–surgical repair of the knee. The nurse should
be able to distinguish between local reactions and system reactions. An
elevated WBC and 10% bands are indicative of an infection. Vital sign
changes typically associated with an infection include an elevation in
temperature and tachycardia. Local manifestations include erythema,
warmth, pain, edema, and functional impairment, whereas systemic
manifestations include elevated temperature above 100.4°F, pulse greater
than 90/min.,respiratory rate greater than 20, and WBC greater than
12,000 mm3 or > 10% bands.
• The nurse is caring for four clients on a medical–surgical unit. Which
client should thenurse see initially?
1.
A client admitted with hepatitis A who has had severe
diarrhea for the last24 hours
2.
A client admitted with pneumonia who is has small
amounts of yellowproductive sputum
3.
A client admitted with fever of unknown origin (FUO) who
has beenwithout 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 theday. The nurse must remember that the first client to
be seen should be the clientwho 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
, 4
EnvironmentNursing Process: Planning
• 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?
• “I am allergic to horse hair.”
• “I try to get my vaccine every year.”
• “I am not allergic to anything except eggs.”
• “My husband had a severe allergic reaction after he received
his influenzavaccine.”
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 toeggs 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
Nursing Process: Assessment
• 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
Answer: 1
