TESTBANK FOR LEMONE & BURKE’S MEDICAL-
Chapter 1
SURGICAL NURSING: CLINICAL REASONING IN
HOSPITAL CLIENT CARE 7TH EDITION/ALL
1. The caregiver is caring for four Hospital clients on a medical–surgical unit. Which
CHAPTERS 1-52 Hospital client should the caregiver see initially?
1. A Hospital client admitted with hepatitis A who has had severe
diarrhea for thelast 24 hours
2. A Hospital client admitted with pneumonia who is has small
amounts ofyellow productive sputum
3. A Hospital client admitted with fever of unknown origin (FUO)
who hasbeen without fever for the last 48 hours
4. A Hospital client admitted with a wound infection whose WBC is
8,500 mm3ACCURATE ANSWER:-1
Reasoning:->>>The caregiver must decide which Hospital client should be seen on the
initial rounds of the day. The caregiver must remember that the first
Hospital client to be seen should be the Hospital client who needs the attention
of the caregiver initially. A Hospital client with hepatitis A does experience
diarrhea,but diarrhea for the last 24 hours could cause the Hospital client to
have a problem withdehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
EnvironmentNursing Process: Planning
2. The caregiver is preparing to administer influenza vaccines to a mass drive-through
clinic. Which statement by a Hospital client would indicate further questioning prior to
giving the Hospital 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.”
ACCURATE ANSWER:-3
Reasoning:->>>Influenza vaccines are recommended for person at high risk for serious
sequelae of influenza. The caregiver should be aware that Hospital client with a
sensitivity to eggs should not receive the vaccine. Vaccines prepared from
chicken or duck embryos are contraindicated in Hospital clients who are allergic
to eggs.
,Cognitive Level: Application Standard precautions were published in 1996 that provide guidelines
Hospital client Needs: Safe, Effective Care for the handling of blood and other body fluids. These guidelines are used with
EnvironmentNursing Process: Assessment all Hospital clients, regardless of whether they have a known infectious disease.
Standardprecautions are used
by all healthcare workers who have direct contact with Hospital clients or with
3. The caregiver is caring for four Hospital clients on a medical–surgical unit. The their body fluids. It is not necessary for the caregiver to wear gloves while
secretary gives the caregiver the morning labs. Which of the following labs would delivering food trays to the Hospital client, because there is not contact with the
require that the caregiver call the physician and inform the healthcare provider about the Hospital client.
Hospital client’s abnormalities?
Cognitive Level: Application
1. WBC 14,600 mm3 Hospital client Needs: Safe, Effective Care
2. Serum protein 6.9 g/dL EnvironmentNursing Process: Evaluation
3. I & D (incision and drainage) showing no growth for the last 24 hours
4. Albumin 4.2 g/dL
5. The admitting department alerts the caregiver on a medical–surgical unit thata
ACCURATE ANSWER:-1 Hospital client with active tuberculosis (TB) is being admitted to the unit. Which type
of isolation is appropriate based on the Hospital client’s diagnosis?
Reasoning:->>>When the caregiver is caring for several Hospital clients, all of the
labsshould be checked frequently throughout the shift to assess for any abnormalities. 1. Standard precautions
TheWBC in option 1 is abnormal. (Normal WBC 4,000–10,000 mm3.) All of the other 2. Airborne precautions
lab results are within acceptable range; therefore, the results should not be called in to 3. Droplet precautions
thephysician. 4. Contact precautions
Cognitive Level: Application ACCURATE ANSWER:-2
Hospital client Needs:
Physiologic Integrity Reasoning:->>>In addition to handwashing and standard precautions, the nature and
Nursing Process: spread of some infectious diseases require that special techniques be used to protect
Assessment uninfected Hospital clients and workers. The Hospital client with pulmonary tuberculosis
will be placed in airborne precautions. The Hospital client should be placed in a private
room with special ventilation that does not allow air to circulate to general health center
4. The caregiver is orienting a new graduate. The caregiver is reinforcing the ventilation; a maskor special filter respirators will be used for everyone entering the
importance of standard precautions. Which of the following observations by the room.
caregiver would require further education regardingstandard precautions?
Cognitive Level: Application
1. The graduate caregiver understands to wash hands whenentering Hospital client Needs: Safe, Effective Care
and exiting the Hospital client’s room. EnvironmentNursing Process: Assessment
2. The graduate caregiver wears gloves when serving breakfasttrays to
various Hospital clients.
3. The graduate caregiver wears a gown, gloves, and goggles when 6. A Hospital client is receiving IV vancomycin for the treatment of Clostridium
suctioning a Hospital client. difficile.The caregiver understands that the Hospital client who develops
4. The graduate caregiver leaves all supplies in the room of aHospital flushing, tachycardia, and hypotension during the infusion of vancomycin
client who is in contact isolation. indicates:
ACCURATE ANSWER:-2 1. Ototoxicity effect.
2. Superinfection.
Reasoning:->>>The caregiver must have an understanding of standard precautions. 3. Red man syndrome.
Prevention is the most important measure to prevent nosocomial infections. 4. Hives.
, ACCURATE ANSWER:-2
ACCURATE ANSWER:-3
Reasoning:->>>Vancomycin inhibits cell wall synthesis, and is used for serious infections. It Reasoning:->>>Standard precautions are used on all Hospital clients, regardless of
whether they have a know infectious disease. Standard precautions are used by all
is only effective against gram-positive bacteria, especially Staphylococcus aureus and healthcare workerswho have direct contact with Hospital clients or with their body
Staphylococcus epidermidis. The caregiver should infuse this medication slowlyover 60 fluids. Since the Hospital client has an abdominal dressing, the caregiver will use
minutes or more to avoid “red man” syndrome. The syndrome is characterized by standard precautions.
erythematous rash, flushing, tachycardia, and hypotension. Hospital clients can become
dizzy andagitated. Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
Cognitive Level: Application EnvironmentNursing Process: Planning
Hospital client Needs: Physiological
IntegrityNursing Process: Evaluation
9. The physician has ordered for the caregiver to obtain a sputum specimen. The
7. The physician has ordered for the Hospital client to receive a trough blood level to caregiver understands that the sputum specimen should becollected:
evaluatethe therapeutic effect of an antibiotic. The caregiver understands that the
trough should be ordered: 1. Immediately after the first dose of antibiotic is administered.
2. 30 minutes after the first dose of antibiotics is administered.
1. A few minutes before the next scheduled dose of medication. 3. During the first dose of antibiotics.
2. 1–2 hours after the oral administration of the medication. 4. Before the first dose of antibiotics is administered.
3. 30 minutes after the IV administration.
4. During the infusion of the antibiotic. ACCURATE ANSWER:-4
ACCURATE ANSWER:-1 Reasoning:->>>When the physician orders a specimen to be collected, the caregiver should
collect the specimen before the first dose of antibiotics is administered, to ensure adequate
Reasoning:->>>Antibiotic peak and trough levels monitor therapeutic blood levels of the organisms for culture.
prescribed medication. The therapeutic range—the minimum and maximum blood levels
at which the drug is effective—is known for a given drug. By measuring blood levels at Cognitive Level: Comprehension
the predicted peak (1–2 hours after oral administration, 1 hour after intramuscular Hospital client Needs: Safe, Effective Care
administration, and 30 minutes after IV administration) and trough (usually a few minutes EnvironmentNursing Process: Planning
before the next scheduled dose), it is also possible to determine whether the drug is
reaching a toxic or harmful level during therapy, increasing the likelihood of adverse
effects. 10. Which of the following manifestations indicates a systemic reaction associated with
an inflammatory response?
Cognitive Level: Application
Hospital client Needs: Safe, Effective Care 1. Erythema
EnvironmentNursing Process: Assessment 2. Pain
3. Tachypnea (RR 26)
4. Edema
8. The caregiver needs to change a dressing on the Hospital client’s abdomen. Which of
the following techniques should be implemented? ACCURATE
1. Contact precautions ANSWER:-3
2. Standard precautions
3. Droplet precautions Reasoning:->>>If the caregiver observes a systemic reaction, the Hospital client will exhibit
4. Airborne precautions manifestations including temperature, increased pulse, tachypnea, and leukocytosis.
, Erythema, warmth, pain, edema, and functional impairment indicate a local reaction. ACCURATE ANSWER:-1; 3; 5
Cognitive Level: Application
Reasoning:->>>Regardless of the cause, location, or extent of the injury, the acute
inflammatory response follows the sequence of vascular response, cellular and
Hospital client Needs: Physiological phagocytic response, and healing. Many manifestations of inflammation are produced by
IntegrityNursing Process: Assessment inflammatory 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 fluid
at site, pain from tissue swelling and chemical irritation of nerve endings, and loss of
11. A Hospital client develops hyperthermia related to a diagnosis of Pneumonia. function caused by the swelling and pain.
Which of the following nursing interventions would be effective in the treatment of
hyperthermia? Select all that apply. Cognitive Level: Application
Hospital client Needs: Physiological
1. Increase the temperature of the room environment to prevent shivering. IntegrityNursing Process: Assessment
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. Alternate item format – Select all that apply
5. Restrict fluids during periods of hyperthermia because of the risk of
electrolyte imbalance. Which of the following manifestations would the caregiver expect to see with a
Hospital client who has had previous knee surgery who suffered a surgical infection
ACCURATE ANSWER:-2; 3; 4 with signs of systemic manifestations? Select all that apply.
1. Erythema
Reasoning:->>>Hyperthemia is an expected consequence of the infectious disease process. 2. WBC 14,200 mm3
Fever can produce mild, short-term effects or, when prolonged, can cause life- 3. Pain at the surgical site
threatening effects. The caregiver should administer antipyretic medications as 4. 10% Bands
indicated for elevated temperatures. The caregiver shoulduse ice packs, 5. Respiratory rate of 16
cool/tepid baths, or hypothermia blanket with caution. The caregiver should 6. Pulse 114
enforce frequent rest periods because rest increases energy reserve, which is
depleted by an increased metabolic, heart, and respiratory rate. The caregiver ACCURATE ANSWER:-2; 3;
should encourage fluids rather than restrict fluids because of the risk of
electrolyte imbalance. 6
Cognitive Level: Assessment Reasoning:->>>The Hospital client is post–surgical repair of the knee. The caregiver
Hospital client Needs: Physiological should be able to distinguish between local reactions and system reactions. An elevated
IntegrityNursing Process: Implementation 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,
12. The caregiver is assessing a Hospital client’s wound for signs and symptoms of whereas systemic manifestations include elevated temperature above 100.4°F, pulse
inflammation. Which of the following would alert the caregiver that the Hospital greater than 90/min., respiratory rate greater than 20, and WBC greater than 12,000 mm3
client is exhibiting signs of inflammation? Select all that apply. or > 10% bands.
1. Leg edema
2. Leg cool to touch
3. Severe pain from swelling Cognitive Level: Application
4. Decreased peripheral pulses Hospital client Needs: Physiological Integrity
5. Severe erythema of leg Nursing Process: Assessment
Chapter 1
SURGICAL NURSING: CLINICAL REASONING IN
HOSPITAL CLIENT CARE 7TH EDITION/ALL
1. The caregiver is caring for four Hospital clients on a medical–surgical unit. Which
CHAPTERS 1-52 Hospital client should the caregiver see initially?
1. A Hospital client admitted with hepatitis A who has had severe
diarrhea for thelast 24 hours
2. A Hospital client admitted with pneumonia who is has small
amounts ofyellow productive sputum
3. A Hospital client admitted with fever of unknown origin (FUO)
who hasbeen without fever for the last 48 hours
4. A Hospital client admitted with a wound infection whose WBC is
8,500 mm3ACCURATE ANSWER:-1
Reasoning:->>>The caregiver must decide which Hospital client should be seen on the
initial rounds of the day. The caregiver must remember that the first
Hospital client to be seen should be the Hospital client who needs the attention
of the caregiver initially. A Hospital client with hepatitis A does experience
diarrhea,but diarrhea for the last 24 hours could cause the Hospital client to
have a problem withdehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
EnvironmentNursing Process: Planning
2. The caregiver is preparing to administer influenza vaccines to a mass drive-through
clinic. Which statement by a Hospital client would indicate further questioning prior to
giving the Hospital 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.”
ACCURATE ANSWER:-3
Reasoning:->>>Influenza vaccines are recommended for person at high risk for serious
sequelae of influenza. The caregiver should be aware that Hospital client with a
sensitivity to eggs should not receive the vaccine. Vaccines prepared from
chicken or duck embryos are contraindicated in Hospital clients who are allergic
to eggs.
,Cognitive Level: Application Standard precautions were published in 1996 that provide guidelines
Hospital client Needs: Safe, Effective Care for the handling of blood and other body fluids. These guidelines are used with
EnvironmentNursing Process: Assessment all Hospital clients, regardless of whether they have a known infectious disease.
Standardprecautions are used
by all healthcare workers who have direct contact with Hospital clients or with
3. The caregiver is caring for four Hospital clients on a medical–surgical unit. The their body fluids. It is not necessary for the caregiver to wear gloves while
secretary gives the caregiver the morning labs. Which of the following labs would delivering food trays to the Hospital client, because there is not contact with the
require that the caregiver call the physician and inform the healthcare provider about the Hospital client.
Hospital client’s abnormalities?
Cognitive Level: Application
1. WBC 14,600 mm3 Hospital client Needs: Safe, Effective Care
2. Serum protein 6.9 g/dL EnvironmentNursing Process: Evaluation
3. I & D (incision and drainage) showing no growth for the last 24 hours
4. Albumin 4.2 g/dL
5. The admitting department alerts the caregiver on a medical–surgical unit thata
ACCURATE ANSWER:-1 Hospital client with active tuberculosis (TB) is being admitted to the unit. Which type
of isolation is appropriate based on the Hospital client’s diagnosis?
Reasoning:->>>When the caregiver is caring for several Hospital clients, all of the
labsshould be checked frequently throughout the shift to assess for any abnormalities. 1. Standard precautions
TheWBC in option 1 is abnormal. (Normal WBC 4,000–10,000 mm3.) All of the other 2. Airborne precautions
lab results are within acceptable range; therefore, the results should not be called in to 3. Droplet precautions
thephysician. 4. Contact precautions
Cognitive Level: Application ACCURATE ANSWER:-2
Hospital client Needs:
Physiologic Integrity Reasoning:->>>In addition to handwashing and standard precautions, the nature and
Nursing Process: spread of some infectious diseases require that special techniques be used to protect
Assessment uninfected Hospital clients and workers. The Hospital client with pulmonary tuberculosis
will be placed in airborne precautions. The Hospital client should be placed in a private
room with special ventilation that does not allow air to circulate to general health center
4. The caregiver is orienting a new graduate. The caregiver is reinforcing the ventilation; a maskor special filter respirators will be used for everyone entering the
importance of standard precautions. Which of the following observations by the room.
caregiver would require further education regardingstandard precautions?
Cognitive Level: Application
1. The graduate caregiver understands to wash hands whenentering Hospital client Needs: Safe, Effective Care
and exiting the Hospital client’s room. EnvironmentNursing Process: Assessment
2. The graduate caregiver wears gloves when serving breakfasttrays to
various Hospital clients.
3. The graduate caregiver wears a gown, gloves, and goggles when 6. A Hospital client is receiving IV vancomycin for the treatment of Clostridium
suctioning a Hospital client. difficile.The caregiver understands that the Hospital client who develops
4. The graduate caregiver leaves all supplies in the room of aHospital flushing, tachycardia, and hypotension during the infusion of vancomycin
client who is in contact isolation. indicates:
ACCURATE ANSWER:-2 1. Ototoxicity effect.
2. Superinfection.
Reasoning:->>>The caregiver must have an understanding of standard precautions. 3. Red man syndrome.
Prevention is the most important measure to prevent nosocomial infections. 4. Hives.
, ACCURATE ANSWER:-2
ACCURATE ANSWER:-3
Reasoning:->>>Vancomycin inhibits cell wall synthesis, and is used for serious infections. It Reasoning:->>>Standard precautions are used on all Hospital clients, regardless of
whether they have a know infectious disease. Standard precautions are used by all
is only effective against gram-positive bacteria, especially Staphylococcus aureus and healthcare workerswho have direct contact with Hospital clients or with their body
Staphylococcus epidermidis. The caregiver should infuse this medication slowlyover 60 fluids. Since the Hospital client has an abdominal dressing, the caregiver will use
minutes or more to avoid “red man” syndrome. The syndrome is characterized by standard precautions.
erythematous rash, flushing, tachycardia, and hypotension. Hospital clients can become
dizzy andagitated. Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
Cognitive Level: Application EnvironmentNursing Process: Planning
Hospital client Needs: Physiological
IntegrityNursing Process: Evaluation
9. The physician has ordered for the caregiver to obtain a sputum specimen. The
7. The physician has ordered for the Hospital client to receive a trough blood level to caregiver understands that the sputum specimen should becollected:
evaluatethe therapeutic effect of an antibiotic. The caregiver understands that the
trough should be ordered: 1. Immediately after the first dose of antibiotic is administered.
2. 30 minutes after the first dose of antibiotics is administered.
1. A few minutes before the next scheduled dose of medication. 3. During the first dose of antibiotics.
2. 1–2 hours after the oral administration of the medication. 4. Before the first dose of antibiotics is administered.
3. 30 minutes after the IV administration.
4. During the infusion of the antibiotic. ACCURATE ANSWER:-4
ACCURATE ANSWER:-1 Reasoning:->>>When the physician orders a specimen to be collected, the caregiver should
collect the specimen before the first dose of antibiotics is administered, to ensure adequate
Reasoning:->>>Antibiotic peak and trough levels monitor therapeutic blood levels of the organisms for culture.
prescribed medication. The therapeutic range—the minimum and maximum blood levels
at which the drug is effective—is known for a given drug. By measuring blood levels at Cognitive Level: Comprehension
the predicted peak (1–2 hours after oral administration, 1 hour after intramuscular Hospital client Needs: Safe, Effective Care
administration, and 30 minutes after IV administration) and trough (usually a few minutes EnvironmentNursing Process: Planning
before the next scheduled dose), it is also possible to determine whether the drug is
reaching a toxic or harmful level during therapy, increasing the likelihood of adverse
effects. 10. Which of the following manifestations indicates a systemic reaction associated with
an inflammatory response?
Cognitive Level: Application
Hospital client Needs: Safe, Effective Care 1. Erythema
EnvironmentNursing Process: Assessment 2. Pain
3. Tachypnea (RR 26)
4. Edema
8. The caregiver needs to change a dressing on the Hospital client’s abdomen. Which of
the following techniques should be implemented? ACCURATE
1. Contact precautions ANSWER:-3
2. Standard precautions
3. Droplet precautions Reasoning:->>>If the caregiver observes a systemic reaction, the Hospital client will exhibit
4. Airborne precautions manifestations including temperature, increased pulse, tachypnea, and leukocytosis.
, Erythema, warmth, pain, edema, and functional impairment indicate a local reaction. ACCURATE ANSWER:-1; 3; 5
Cognitive Level: Application
Reasoning:->>>Regardless of the cause, location, or extent of the injury, the acute
inflammatory response follows the sequence of vascular response, cellular and
Hospital client Needs: Physiological phagocytic response, and healing. Many manifestations of inflammation are produced by
IntegrityNursing Process: Assessment inflammatory 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 fluid
at site, pain from tissue swelling and chemical irritation of nerve endings, and loss of
11. A Hospital client develops hyperthermia related to a diagnosis of Pneumonia. function caused by the swelling and pain.
Which of the following nursing interventions would be effective in the treatment of
hyperthermia? Select all that apply. Cognitive Level: Application
Hospital client Needs: Physiological
1. Increase the temperature of the room environment to prevent shivering. IntegrityNursing Process: Assessment
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. Alternate item format – Select all that apply
5. Restrict fluids during periods of hyperthermia because of the risk of
electrolyte imbalance. Which of the following manifestations would the caregiver expect to see with a
Hospital client who has had previous knee surgery who suffered a surgical infection
ACCURATE ANSWER:-2; 3; 4 with signs of systemic manifestations? Select all that apply.
1. Erythema
Reasoning:->>>Hyperthemia is an expected consequence of the infectious disease process. 2. WBC 14,200 mm3
Fever can produce mild, short-term effects or, when prolonged, can cause life- 3. Pain at the surgical site
threatening effects. The caregiver should administer antipyretic medications as 4. 10% Bands
indicated for elevated temperatures. The caregiver shoulduse ice packs, 5. Respiratory rate of 16
cool/tepid baths, or hypothermia blanket with caution. The caregiver should 6. Pulse 114
enforce frequent rest periods because rest increases energy reserve, which is
depleted by an increased metabolic, heart, and respiratory rate. The caregiver ACCURATE ANSWER:-2; 3;
should encourage fluids rather than restrict fluids because of the risk of
electrolyte imbalance. 6
Cognitive Level: Assessment Reasoning:->>>The Hospital client is post–surgical repair of the knee. The caregiver
Hospital client Needs: Physiological should be able to distinguish between local reactions and system reactions. An elevated
IntegrityNursing Process: Implementation 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,
12. The caregiver is assessing a Hospital client’s wound for signs and symptoms of whereas systemic manifestations include elevated temperature above 100.4°F, pulse
inflammation. Which of the following would alert the caregiver that the Hospital greater than 90/min., respiratory rate greater than 20, and WBC greater than 12,000 mm3
client is exhibiting signs of inflammation? Select all that apply. or > 10% bands.
1. Leg edema
2. Leg cool to touch
3. Severe pain from swelling Cognitive Level: Application
4. Decreased peripheral pulses Hospital client Needs: Physiological Integrity
5. Severe erythema of leg Nursing Process: Assessment
