Tes Bank for Understanding Medical-Surgical J Y. Y. Y. Y. Y
Nursing6thEditionLinda S.WilliamsPaulaD.
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Chapter1 .
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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 24
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2. Aclient admitted with pneumonia who is has small amounts of yellow
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3. A client admitted with fever ofunknown origin (FUO) who has been
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without fever for the last 48 hours . J Y. J Y. J Y. J Y. J Y. J Y.
4. Aclient admitted with a wound infection whose WBC is 8,500 mm3
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Answer: 1 JY.
Rationale: The nurse must decide which client should be seen on the initial rounds o fthe
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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 J Y . J Y.
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 amallergic to horse hair.”
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2. “I tryto 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.”
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Answer: 3 JY.
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 J Y . J Y.
download full filea http://testbankinstant.com Y. Y. .
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, Tes Bank for Understanding Medical-Surgical J Y. Y. Y. Y. Y
Nursing6thEditionLinda S.WilliamsPaulaD.
. Y. Y. Y. Y. Y. Y. Y. Y
Hopper .
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 J Y. JY.
2. Serum protein 6.9 g/dL J
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3. I & D (incision and drainage) showing no growth for the last 24 hours
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4. Albumin 4.2 g/dL J Y. J Y .
Answer: 1 JY.
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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Client Needs: Physiologic Integrity
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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 ofthe following observations bythe 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 J Y. J Y. J Y. J Y. J Y. J
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the client’s room. . J
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2. The graduate nurse wears gloves when serving breakfast trays to various J Y. J Y. J Y. J Y. J Y. J
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clients. .
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a J Y. J Y. J Y. J Y. JY. J Y. J Y. J Y. J Y. JY. J Y. J Y
client. .
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contact isolation. . J Y.
Answer: 2 JY.
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 of
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whether they have a known infectious disease. Standard precautions are used
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, Tes Bank for Understanding Medical-Surgical J Y. Y. Y. Y. Y
Nursing6thEditionLinda S.WilliamsPaulaD.
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Hopper .
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 to
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the client, because there is not contact with the client.
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Client Needs: Safe, Effective Care Environment
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5. The admitting department alerts the nurse ona 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?
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1. Standard precautions JY.
2. Airborne precautions J Y.
3. Droplet precautions J
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4. Contact precautions J Y.
Answer: 2 JY.
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 air
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to circulate to general hospital ventilation; a mask or special filter respirators will be used
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for everyone entering the room.
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Client Needs: Safe, Effective Care Environment
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Nursing Process: Assessment
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6. Aclient 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. Ototoxicityeffect. J .
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2. Superinfection.
3. Red man syndrome. J Y. J
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4. Hives.
Answer: 3 JY.
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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, Tes Bank for Understanding Medical-Surgical J Y. Y. Y. Y. Y
Nursing6thEditionLinda S.WilliamsPaulaD.
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Staphylococcus epidermidis. The nurse should infuse this medication slowly over 60 J
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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.
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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:
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1. Afew minutes before the next scheduled dose of medication.
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2. 1–2 hours after the oral administration of the medication.JY. J Y. J Y. J Y. J
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3. 30 minutes after the IV administration.
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4. During the infusion o f the antibiotic. J Y. J Y. J
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Answer: 1 J Y.
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.
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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 J Y.
2. Standard precautions J
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3. Droplet precautions J
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4. Airborne precautions J Y.
Answer: 2 J Y.
download full filea http://testbankinstant.com Y. Y. .
Y J Y.
Nursing6thEditionLinda S.WilliamsPaulaD.
. Y. Y. Y. Y. Y. Y. Y. Y
Hopper .
Chapter1 .
Y
1. The nurse is caring for four clients on a medical–surgical unit. Which client should*the
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Y. J Y. J Y. J Y. J
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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 24
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hours .
2. Aclient admitted with pneumonia who is has small amounts of yellow
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productive sputum . J Y.
3. A client admitted with fever ofunknown origin (FUO) who has been
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without fever for the last 48 hours . J Y. J Y. J Y. J Y. J Y. J Y.
4. Aclient admitted with a wound infection whose WBC is 8,500 mm3
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Answer: 1 JY.
Rationale: The nurse must decide which client should be seen on the initial rounds o fthe
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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 J Y . J Y.
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 amallergic to horse hair.”
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2. “I tryto 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.”
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Answer: 3 JY.
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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Y. J Y. J
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Cognitive Level: Application J Y . J Y.
download full filea http://testbankinstant.com Y. Y. .
Y J Y.
, Tes Bank for Understanding Medical-Surgical J Y. Y. Y. Y. Y
Nursing6thEditionLinda S.WilliamsPaulaD.
. Y. Y. Y. Y. Y. Y. Y. Y
Hopper .
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 J Y. JY.
2. Serum protein 6.9 g/dL J
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3. I & D (incision and drainage) showing no growth for the last 24 hours
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4. Albumin 4.2 g/dL J Y. J Y .
Answer: 1 JY.
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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4. The nurse is orienting a new graduate. The nurse is reinforcing the importance of
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standard precautions. Which ofthe following observations bythe 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 J Y. J Y. J Y. J Y. J Y. J
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the client’s room. . J
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2. The graduate nurse wears gloves when serving breakfast trays to various J Y. J Y. J Y. J Y. J Y. J
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clients. .
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a J Y. J Y. J Y. J Y. JY. J Y. J Y. J Y. J Y. JY. J Y. J Y
client. .
4. The graduate nurse leaves all supplies in the room of a client who is in J Y. J Y. J Y. J
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contact isolation. . J Y.
Answer: 2 JY.
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 of
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whether they have a known infectious disease. Standard precautions are used
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, Tes Bank for Understanding Medical-Surgical J Y. Y. Y. Y. Y
Nursing6thEditionLinda S.WilliamsPaulaD.
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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 to
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the client, because there is not contact with the client.
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Client Needs: Safe, Effective Care Environment
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5. The admitting department alerts the nurse ona 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?
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1. Standard precautions JY.
2. Airborne precautions J Y.
3. Droplet precautions J
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4. Contact precautions J Y.
Answer: 2 JY.
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 air
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to circulate to general hospital ventilation; a mask or special filter respirators will be used
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for everyone entering the room.
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Client Needs: Safe, Effective Care Environment
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6. Aclient 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. Ototoxicityeffect. J .
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2. Superinfection.
3. Red man syndrome. J Y. J
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4. Hives.
Answer: 3 JY.
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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, Tes Bank for Understanding Medical-Surgical J Y. Y. Y. Y. Y
Nursing6thEditionLinda S.WilliamsPaulaD.
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Staphylococcus epidermidis. The nurse should infuse this medication slowly over 60 J
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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.
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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:
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1. Afew minutes before the next scheduled dose of medication.
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2. 1–2 hours after the oral administration of the medication.JY. J Y. J Y. J Y. J
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3. 30 minutes after the IV administration.
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4. During the infusion o f the antibiotic. J Y. J Y. J
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Answer: 1 J Y.
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.
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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 J Y.
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Answer: 2 J Y.
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