Test Bank for LeMone and Burke’s Medical-Surgical Nursing: Clinical Reasoning in Hospital Client Care (7th Edition) – Complete Chapters 1–52

TESTBANK FOR LEMONE
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MEDICAL- SURGICAL NURSING: CLINICAL
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REASONING IN HOSPITAL CLIENT CARE 7TH
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EDITION/ALL CHAPTERS 1-52
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,Chapter 1 vb




1. The caregiver is caring for four Hospital clients on a medical–surgical unit.
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WhichHospital client should the caregiver see initially?
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1. A Hospital client admitted with hepatitis A who has had severe
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diarrhea for thelast 24 hours
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2. A Hospital client admitted with pneumonia who is has small
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amounts ofyellow productive sputum
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3. A Hospital client admitted with fever of unknown origin
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(FUO) who hasbeen without fever for the last 48 hours
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4. A Hospital client admitted with a wound infection whose WBC is
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vb 8,500 mm3ACCURATE ANSWER:-1
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Reasoning:->>>The caregiver must decide which Hospital client should be seen on vb vb vb vb vb vb vb vb vb vb


theinitial rounds of the day. The caregiver must remember that the first
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Hospital client to be seen should be the Hospital client who needs the
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attention of the caregiver initially. A Hospital client with hepatitis A does
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experience diarrhea,but diarrhea for the last 24 hours could cause the
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Hospital client to have a problem withdehydration and experience a state
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of fluid volume deficit.
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Cognitive Level: Applicationvb vb


Hospital client Needs: Safe, Effective Care
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EnvironmentNursing Process: Planning
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2. The caregiver is preparing to administer influenza vaccines to a mass drive-
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through clinic. Which statement by a Hospital client would indicate further
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questioning prior togiving the Hospital client 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
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influenzavaccine.”
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ACCURATE ANSWER:-3 vb




Reasoning:->>>Influenza vaccines are recommended for person at high risk for vb vb vb vb vb vb vb vb vb


serious sequelae of influenza. The caregiver should be aware that Hospital
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client with asensitivity to eggs should not receive the vaccine. Vaccines
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prepared from chicken or duck embryos are contraindicated in Hospital
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clients who are allergic to eggs.
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,Cognitive Level: Application vb vb




Hospital client Needs: Safe, Effective Care
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EnvironmentNursing Process: Assessment
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3. The caregiver is caring for four Hospital clients on a medical–surgical unit. The
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secretary gives the caregiver the morning labs. Which of the following labs would
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require that the caregiver call the physician and inform the healthcare provider
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about the Hospital client’s abnormalities?
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1. WBC 14,600 mm3
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2. Serum protein 6.9 g/dL vb vb vb


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




g/dLACCURATE ANSWER:-
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1

Reasoning:->>>When the caregiver is caring for several Hospital clients, all of vb vb vb vb vb vb vb vb vb vb


the labs should be checked frequently throughout the shift to assess for any
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abnormalities. The WBC in option 1 is abnormal. (Normal WBC 4,000–10,000
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mm3.) All of the other lab results are within acceptable range; therefore, the
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results should not be called in to thephysician.
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Cognitive Level: vb


ApplicationHospital client
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Needs: Physiologic
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Integrity Nursing Process:
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Assessment


4. The caregiver is orienting a new graduate. The caregiver is reinforcing
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the importance of standard precautions. Which of the following
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observations by the caregiver would require further education
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regardingstandard precautions?
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1. The graduate caregiver understands to wash hands
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whenentering and exiting the Hospital client’s room.
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2. The graduate caregiver wears gloves when serving breakfasttrays
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to various Hospital clients.
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3. The graduate caregiver wears a gown, gloves, and goggles
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whensuctioning a Hospital client.
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4. The graduate caregiver leaves all supplies in the room of
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aHospital client who is in contact isolation.
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Reasoning:->>>The caregiver must have an understanding of standard precautions. vb vb vb vb vb vb vb vb


Prevention is the most important measure to prevent nosocomial
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infections. Standard precautions were published in 1996 that provide
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guidelines vb




for the handling of blood and other body fluids. These guidelines are used
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with all Hospital clients, regardless of whether they have a known infectious
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disease. Standardprecautions are used
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by all healthcare workers who have direct contact with Hospital clients or
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with their body fluids. It is not necessary for the caregiver to wear gloves
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while delivering food trays to the Hospital client, because there is not
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contact with the Hospital client.
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Cognitive Level: Application vb vb


Hospital client Needs: Safe, Effective Care
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EnvironmentNursing Process: Evaluation
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5. The admitting department alerts the caregiver on a medical–surgical unit thata
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Hospital client with active tuberculosis (TB) is being admitted to the unit. Which
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type of isolation is appropriate based on the Hospital client’s diagnosis?
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1. Standard precautions vb


2. Airborne precautions vb


3. Droplet precautions vb


4. Contact

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


Hospital client Needs: Safe, Effective Care
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EnvironmentNursing Process: Assessment
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6. A Hospital client is receiving IV vancomycin for the treatment of
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Clostridium difficile.The caregiver understands that the Hospital client who
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