Medical-Surgical Nursing: Critical Thinking in Client Care 4th Edition Test Bank Updated Latest 2026–2027 Comprehensive Exam Preparation Resource for Nursing Students Focused on Adult Health, Clinical Reasoning, and Medical-Surgical Patient Care.

Test Bank for Medical Surgical Nursing Critical Thinking in
Client Care,4th Edition Priscilla LeMon(100% Verified)

Chapter 1


1. The nurse is caring for four clients on a medical–surgical unit. Which client should the
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nurse see initially?
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1. A client admitted with hepatitis A who has had severe diarrhea for the last
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24 hours T



2. A client admitted with pneumonia who is has small amounts of yellow
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productive sputum T



3. A client admitted with fever of unknown origin (FUO) who has been
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without fever for the last 48 hours T T T T T T



4. A client admitted with a wound infection whose WBC is 8,500 mm3
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Answer: 1 T




Rationale: The nurse must decide which client should be seen on the initial rounds of the
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day. The nurse must remember that the first client to be seen should be the client
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who needs the attention of the nurse initially. A client with hepatitis A does
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experience diarrhea, but diarrhea for the last 24 hours could cause the client to
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have a problem with dehydration and experience a state of fluid volume deficit.
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Cognitive Level: Application T T



Client Needs: Safe, Effective Care Environment
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Nursing Process: Planning
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2. The nurse is preparing to administer influenza vaccines to a mass drive-through clinic.
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Which statement by a client would indicate further questioning prior to giving the client
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the influenza vaccine?
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1. “I am allergic to horse hair.”
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2. “I try to get my vaccine every year.”
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3. “I am not allergic to anything except eggs.”
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4. “My husband had a severe allergic reaction after he received his influenza
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vaccine.”

Answer: 3 T




Rationale: Influenza vaccines are recommended for person at high risk for serious
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sequelae of influenza. The nurse should be aware that client with a sensitivity to
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eggs should not receive the vaccine. Vaccines prepared from chicken or duck
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embryos are contraindicated in clients who are allergic to eggs.
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Cognitive Level: Application T T

,Test Bank for Medical Surgical Nursing Critical Thinking in
Client Care,4th Edition Priscilla LeMon(100% Verified)

Client Needs: Safe, Effective Care Environment
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Nursing Process: Assessment
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3. The nurse is caring for four clients on a medical–surgical unit. The secretary gives the
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nurse the morning labs. Which of the following labs would require that the nurse call the
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physician and inform the healthcare provider about the client’s abnormalities?
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1. WBC 14,600 mm3 T T



2. Serum protein 6.9 g/dL T T T



3. I & D (incision and drainage) showing no growth for the last 24 hours
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4. Albumin 4.2 g/dL T T




Answer: 1 T




Rationale: When the nurse is caring for several clients, all of the labs should be checked
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frequently throughout the shift to assess for any abnormalities. The WBC in option 1 is
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abnormal. (Normal WBC 4,000–10,000 mm3.) All of the other lab results are within
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acceptable range; therefore, the results should not be called in to the physician.
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Cognitive Level: Application T T T



Client Needs: Physiologic Integrity
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Nursing Process: Assessment
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4. The nurse is orienting a new graduate. The nurse is reinforcing the importance of
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standard precautions. Which of the following observations by the nurse would require
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further education regarding standard precautions?
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1. The graduate nurse understands to wash hands when entering and exiting
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the client’s room. T T



2. The graduate nurse wears gloves when serving breakfast trays to various
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clients.
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a
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client.
4. The graduate nurse leaves all supplies in the room of a client who is in
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contact isolation. T




Answer: 2 T




Rationale: The nurse must have an understanding of standard precautions. Prevention is
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the most important measure to prevent nosocomial infections. Standard
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precautions were published in 1996 that provide guidelines for the handling of
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blood and other body fluids. These guidelines are used with all clients, regardless
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of whether they have a known infectious disease. Standard precautions are used
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,Test Bank for Medical Surgical Nursing Critical Thinking in
Client Care,4th Edition Priscilla LeMon(100% Verified)

by all healthcare workers who have direct contact with clients or with their body
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fluids. It is not necessary for the nurse to wear gloves while delivering food trays
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to the client, because there is not contact with the client.
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Cognitive Level: Application T T



Client Needs: Safe, Effective Care Environment
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Nursing Process: Evaluation T T




5. The admitting department alerts the nurse on a medical–surgical unit that a client with
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active tuberculosis (TB) is being admitted to the unit. Which type of isolation is
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appropriate based on the client’s diagnosis? T T T T T




1. Standard precautions T



2. Airborne precautions T



3. Droplet precautions T



4. Contact precautions T




Answer: 2 T




In addition to handwashing and standard precautions, the nature and spread of some
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infectious diseases require that special techniques be used to protect uninfected clients and
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workers. The client with pulmonary tuberculosis will be placed in airborne precautions.
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The client should be placed in a private room with special ventilation that does not allow
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air to circulate to general hospital ventilation; a mask or special filter respirators will be
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used for everyone entering the room.
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Cognitive Level: Application T T



Client Needs: Safe, Effective Care Environment
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Nursing Process: Assessment T T




6. A client is receiving IV vancomycin for the treatment of Clostridium difficile. The
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nurse understands that the client who develops flushing, tachycardia, and hypotension
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during the infusion of vancomycin indicates:
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1. Ototoxicity effect. T



2. Superinfection.
3. Red man syndrome. T T



4. Hives.

Answer: 3 T




Rationale: Vancomycin inhibits cell wall synthesis, and is used for serious infections. It is
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only effective against gram-positive bacteria, especially Staphylococcus aureus and
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, Test Bank for Medical Surgical Nursing Critical Thinking in
Client Care,4th Edition Priscilla LeMon(100% Verified)

Staphylococcus epidermidis. The nurse should infuse this medication slowly over 60
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minutes or more to avoid “red man” syndrome. The syndrome is characterized by
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erythematous rash, flushing, tachycardia, and hypotension. Clients can become dizzy and
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agitated.

Cognitive Level: Application
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Client Needs: Physiological Integrity
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Nursing Process: Evaluation
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7. The physician has ordered for the client to receive a trough blood level to evaluate the
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therapeutic effect of an antibiotic. The nurse understands that the trough should be
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ordered:

1. A few minutes before the next scheduled dose of medication.
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2. 1–2 hours after the oral administration of the medication.
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3. 30 minutes after the IV administration.
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4. During the infusion of the antibiotic. T T T T T




Answer: 1 T




Rationale: Antibiotic peak and trough levels monitor therapeutic blood levels of the
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prescribed medication. The therapeutic range—the minimum and maximum blood levels
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at which the drug is effective—is known for a given drug. By measuring blood levels at
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the predicted peak (1–2 hours after oral administration, 1 hour after intramuscular
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administration, and 30 minutes after IV administration) and trough (usually a few minutes
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before the next scheduled dose), it is also possible to determine whether the drug is
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reaching a toxic or harmful level during therapy, increasing the likelihood of adverse
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effects.

Cognitive Level: Application
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Client Needs: Safe, Effective Care Environment
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Nursing Process: Assessment
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8. The nurse needs to change a dressing on the client’s abdomen. Which of the following
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techniques should be implemented?
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1. Contact precautions T



2. Standard precautions T



3. Droplet precautions T



4. Airborne precautions T




Answer: 2 T