BIO 102 Test Bank for Medical-
9 9 9 9 9
Surgical Nursing Critical Thinking in Client Care, 4th Edition P
9 9 9 9 9 9 9 9 9
riscilla LeMon 9
Test Bank for Medical-
9 9 9
Surgical Nursing Critical Thinkingin Client Care, 4t
9 9 9 9 9 9 9
h Edition Priscilla LeMon
9 9 9
Chapter91
1. The9nurse9is9caring9for9four9clients9on9a9medical–
surgical9unit.9Which9client9should9the9nurse9see9initially?
1. A9client9admitted9with9hepatitis9A9who9has9had9severe9diarrhea9for9the9last9
249hours
2. A9client9admitted9with9pneumonia9who9is9has9small9amounts9of9yellow9
productive9sputum
3. A9client9admitted9with9fever9of9unknown9origin9(FUO)9who9has9been9
without9fever9for9the9last9489hours
4. A9client9admitted9with9a9wound9infection9whose9WBC9is98,5009mm3
Answer:91
Rationale:9The9nurse9must9decide9which9client9should9be9seen9on9the9initial9rounds9of9the9
day.9The9nurse9must9remember9that9the9first9client9to9be9seen9should9be9the9client9
who9needs9the9attention9of9the9nurse9initially.9A9client9with9hepatitis9A9does9exper
ience9diarrhea,9but9diarrhea9for9the9last9249hours9could9cause9the9client9to9have9a9p
roblem9with9dehydration9and9experience9a9state9of9fluid9volume9deficit.
Cognitive9Level:9Application
Client9Needs:9Safe,9Effective9Care9Environment9
Nursing9Process:9Planning
2. The9nurse9is9preparing9to9administer9influenza9vaccines9to9a9mass9drive-
through9clinic.9Which9statement9by9a9client9would9indicate9further9questioning9prior9to9gi
ving9the9client9the9influenza9vaccine?
1. “I9am9allergic9to9horse9hair.”
2. “I9try9to9get9my9vaccine9every9year.”
3. “I9am9not9allergic9to9anything9except9eggs.”
4. “My9husband9had9a9severe9allergic9reaction9after9he9received9his9influenza9
vaccine.”
Answer:93
Rationale:9Influenza9vaccines9are9recommended9for9person9at9high9risk9for9serious9sequel
ae9of9influenza.9The9nurse9should9be9aware9that9client9with9a9sensitivity9to9eggs9sh
, BIO 102 Test Bank for Medical-
9 9 9 9 9
Surgical Nursing Critical Thinking in Client Care, 4th Edition P
9 9 9 9 9 9 9 9 9
riscilla LeMon 9
ould9not9receive9the9vaccine.9Vaccines9prepared9from9chicken9or9duck9embryos9ar
e9contraindicated9in9clients9who9are9allergic9to9eggs.
, BIO 102 Test Bank for Medical-
9 9 9 9 9
Surgical Nursing Critical Thinking in Client Care, 4th Edition P
9 9 9 9 9 9 9 9 9
riscilla LeMon 9
Test Bank for Medical-
9 9 9
Surgical Nursing Critical Thinkingin Client Care, 4t
9 9 9 9 9 9 9
h Edition Priscilla LeMon
9 9 9
Cognitive9Level:9Application
Client9Needs:9Safe,9Effective9Care9Environment9
Nursing9Process:9Assessment
3. The9nurse9is9caring9for9four9clients9on9a9medical–
surgical9unit.9The9secretary9gives9the9nurse9the9morning9labs.9Which9of9the9following9lab
s9would9require9that9the9nurse9call9the9physician9and9inform9the9healthcare9provider9about
9the9client’s9abnormalities?
1.9 WBC914,6009mm3
2. Serum9protein96.99g/dL
3. I9&9D9(incision9and9drainage)9showing9no9growth9for9the9last9249hours
4. Albumin94.29g/dL
Answer:91
Rationale:9When9the9nurse9is9caring9for9several9clients,9all9of9the9labs9should9be9checked9fre
quently9throughout9the9shift9to9assess9for9any9abnormalities.9The9WBC9in9option919is9abnor
mal.9(Normal9WBC94,000–
10,0009mm3.)9All9of9the9other9lab9results9are9within9acceptable9range;9therefore,9the9results9
should9not9be9called9in9to9the9physician.
Cognitive9Level:9Application9Clien
t9Needs:9Physiologic9Integrity9Nursi
ng9Process:9Assessment
4. The9nurse9is9orienting9a9new9graduate.9The9nurse9is9reinforcing9the9importance9of9st
andard9precautions.9Which9of9the9following9observations9by9the9nurse9would9require9f
urther9education9regarding9standard9precautions?
1. The9graduate9nurse9understands9to9wash9hands9when9entering9and9exiting9
the9client’s9room.
2. The9graduate9nurse9wears9gloves9when9serving9breakfast9trays9to9various9
clients.
3. The9graduate9nurse9wears9a9gown,9gloves,9and9goggles9when9suctioning9a9
client.
4. The9graduate9nurse9leaves9all9supplies9in9the9room9of9a9client9who9is9in9
contact9isolation.
download9full9file9at9http://testbankinstant.co
m
, BIO 102 Test Bank for Medical-
9 9 9 9 9
Surgical Nursing Critical Thinking in Client Care, 4th Edition P
9 9 9 9 9 9 9 9 9
riscilla LeMon 9
Answer:92
Rationale:9The9nurse9must9have9an9understanding9of9standard9precautions.9Prevention9is9t
he9most9important9measure9to9prevent9nosocomial9infections.9Standard9precaution
s9were9published9in919969that9provide9guidelines9for9the9handling9of
download9full9file9at9http://testbankinstant.co
m
9 9 9 9 9
Surgical Nursing Critical Thinking in Client Care, 4th Edition P
9 9 9 9 9 9 9 9 9
riscilla LeMon 9
Test Bank for Medical-
9 9 9
Surgical Nursing Critical Thinkingin Client Care, 4t
9 9 9 9 9 9 9
h Edition Priscilla LeMon
9 9 9
Chapter91
1. The9nurse9is9caring9for9four9clients9on9a9medical–
surgical9unit.9Which9client9should9the9nurse9see9initially?
1. A9client9admitted9with9hepatitis9A9who9has9had9severe9diarrhea9for9the9last9
249hours
2. A9client9admitted9with9pneumonia9who9is9has9small9amounts9of9yellow9
productive9sputum
3. A9client9admitted9with9fever9of9unknown9origin9(FUO)9who9has9been9
without9fever9for9the9last9489hours
4. A9client9admitted9with9a9wound9infection9whose9WBC9is98,5009mm3
Answer:91
Rationale:9The9nurse9must9decide9which9client9should9be9seen9on9the9initial9rounds9of9the9
day.9The9nurse9must9remember9that9the9first9client9to9be9seen9should9be9the9client9
who9needs9the9attention9of9the9nurse9initially.9A9client9with9hepatitis9A9does9exper
ience9diarrhea,9but9diarrhea9for9the9last9249hours9could9cause9the9client9to9have9a9p
roblem9with9dehydration9and9experience9a9state9of9fluid9volume9deficit.
Cognitive9Level:9Application
Client9Needs:9Safe,9Effective9Care9Environment9
Nursing9Process:9Planning
2. The9nurse9is9preparing9to9administer9influenza9vaccines9to9a9mass9drive-
through9clinic.9Which9statement9by9a9client9would9indicate9further9questioning9prior9to9gi
ving9the9client9the9influenza9vaccine?
1. “I9am9allergic9to9horse9hair.”
2. “I9try9to9get9my9vaccine9every9year.”
3. “I9am9not9allergic9to9anything9except9eggs.”
4. “My9husband9had9a9severe9allergic9reaction9after9he9received9his9influenza9
vaccine.”
Answer:93
Rationale:9Influenza9vaccines9are9recommended9for9person9at9high9risk9for9serious9sequel
ae9of9influenza.9The9nurse9should9be9aware9that9client9with9a9sensitivity9to9eggs9sh
, BIO 102 Test Bank for Medical-
9 9 9 9 9
Surgical Nursing Critical Thinking in Client Care, 4th Edition P
9 9 9 9 9 9 9 9 9
riscilla LeMon 9
ould9not9receive9the9vaccine.9Vaccines9prepared9from9chicken9or9duck9embryos9ar
e9contraindicated9in9clients9who9are9allergic9to9eggs.
, BIO 102 Test Bank for Medical-
9 9 9 9 9
Surgical Nursing Critical Thinking in Client Care, 4th Edition P
9 9 9 9 9 9 9 9 9
riscilla LeMon 9
Test Bank for Medical-
9 9 9
Surgical Nursing Critical Thinkingin Client Care, 4t
9 9 9 9 9 9 9
h Edition Priscilla LeMon
9 9 9
Cognitive9Level:9Application
Client9Needs:9Safe,9Effective9Care9Environment9
Nursing9Process:9Assessment
3. The9nurse9is9caring9for9four9clients9on9a9medical–
surgical9unit.9The9secretary9gives9the9nurse9the9morning9labs.9Which9of9the9following9lab
s9would9require9that9the9nurse9call9the9physician9and9inform9the9healthcare9provider9about
9the9client’s9abnormalities?
1.9 WBC914,6009mm3
2. Serum9protein96.99g/dL
3. I9&9D9(incision9and9drainage)9showing9no9growth9for9the9last9249hours
4. Albumin94.29g/dL
Answer:91
Rationale:9When9the9nurse9is9caring9for9several9clients,9all9of9the9labs9should9be9checked9fre
quently9throughout9the9shift9to9assess9for9any9abnormalities.9The9WBC9in9option919is9abnor
mal.9(Normal9WBC94,000–
10,0009mm3.)9All9of9the9other9lab9results9are9within9acceptable9range;9therefore,9the9results9
should9not9be9called9in9to9the9physician.
Cognitive9Level:9Application9Clien
t9Needs:9Physiologic9Integrity9Nursi
ng9Process:9Assessment
4. The9nurse9is9orienting9a9new9graduate.9The9nurse9is9reinforcing9the9importance9of9st
andard9precautions.9Which9of9the9following9observations9by9the9nurse9would9require9f
urther9education9regarding9standard9precautions?
1. The9graduate9nurse9understands9to9wash9hands9when9entering9and9exiting9
the9client’s9room.
2. The9graduate9nurse9wears9gloves9when9serving9breakfast9trays9to9various9
clients.
3. The9graduate9nurse9wears9a9gown,9gloves,9and9goggles9when9suctioning9a9
client.
4. The9graduate9nurse9leaves9all9supplies9in9the9room9of9a9client9who9is9in9
contact9isolation.
download9full9file9at9http://testbankinstant.co
m
, BIO 102 Test Bank for Medical-
9 9 9 9 9
Surgical Nursing Critical Thinking in Client Care, 4th Edition P
9 9 9 9 9 9 9 9 9
riscilla LeMon 9
Answer:92
Rationale:9The9nurse9must9have9an9understanding9of9standard9precautions.9Prevention9is9t
he9most9important9measure9to9prevent9nosocomial9infections.9Standard9precaution
s9were9published9in919969that9provide9guidelines9for9the9handling9of
download9full9file9at9http://testbankinstant.co
m
