TEST BANK FOR MEDICAL SURGICAL NURSING CRITICAL THINKING IN CLIENT CARE 4TH EDITION
PRISCILLA LEMON
TEST BANK FOR MEDICAL SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE 4TH EDITION PRISCILLA LEMON
,TEST BANK FOR MEDICAL SURGICAL NURSING CRITICAL THINKING IN CLIENT CARE 4TH EDITION
PRISCILLA LEMON
Chapter 1
1.QUESTION & ANSWER The nurse is caring for four clients on a medical–surgical unit. Which
client should the nurse see initially?
1. A client admitted with hepatitis A who has had severe diarrhea for the last 24 hours
2. A client admitted with pneumonia who is has small amounts of yellow productive sputum
3. A client admitted with fever of unknown origin (FUO) who has been without fever for the last 48
hours
4. A client admitted with a wound infection whose WBC is 8,500 mm3
Answer: 1
Rationale: The nurse must decide which client should be seen on the initial rounds of the day. The nurse
must remember that the first client to be seen should be the client who needs the attention of the nurse
initially. A client with hepatitis A does experience diarrhea, but diarrhea for the last 24 hours could
cause the client to have a problem with dehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environment Nursing Process: Planning
2. QUESTION & ANSWER The nurse is preparing to administer influenza vaccines to a mass drive-
through clinic. Which statement by a client would indicate further questioning prior to giving the 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.”
,TEST BANK FOR MEDICAL SURGICAL NURSING CRITICAL THINKING IN CLIENT CARE 4TH EDITION
PRISCILLA LEMON
4. “My husband had a severe allergic reaction after he received his influenza
vaccine.”
Answer: 3
Rationale: Influenza vaccines are recommended for person at high risk for serious sequelae of influenza.
The nurse should be aware that client with a sensitivity to eggs should not receive the vaccine. Vaccines
prepared from chicken or duck embryos are contraindicated in clients who are allergic to eggs.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environment
Nursing Process: Assessment
3. QUESTION & ANSWER The nurse is caring for four clients on a medical–surgical unit. The
secretary gives the nurse the morning labs. Which of the following labs would require that the nurse call
the physician and inform the healthcare provider about the client’s abnormalities?
1. WBC 14,600 mm3
2. Serum protein 6.9 g/dL
3. I & D (incision and drainage) showing no growth for the last 24 hours
4. Albumin 4.2 g/dL
Answer: 1
Rationale: When the nurse is caring for several clients, all of the labs should be checked frequently
throughout the shift to assess for any abnormalities. The WBC in option 1 is abnormal. (Normal WBC
4,000–10,000 mm3.) All of the other lab results are within acceptable range; therefore, the results
should not be called in to the physician.
, TEST BANK FOR MEDICAL SURGICAL NURSING CRITICAL THINKING IN CLIENT CARE 4TH EDITION
PRISCILLA LEMON
Cognitive Level: Application Client Needs: Physiologic Integrity Nursing Process: Assessment
4. QUESTION & ANSWER The nurse is orienting a new graduate. The nurse is reinforcing the
importance of standard precautions. Which of the following observations by the nurse would require
further education regarding standard precautions?
1. The graduate nurse understands to wash hands when entering and exiting
the client’s room.
2. The graduate nurse wears gloves when serving breakfast trays to various clients.
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a client.
4. The graduate nurse leaves all supplies in the room of a client who is in contact isolation.
Answer: 2
Rationale: The nurse must have an understanding of standard precautions. Prevention is the most
important measure to prevent nosocomial infections. Standard precautions were published in 1996 that
provide guidelines for the handling of blood and other body fluids. These guidelines are used with all
clients, regardless of whether they have a known infectious disease. Standard precautions are used by
all healthcare workers who have direct contact with clients or with their body
fluids. It is not necessary for the nurse to wear gloves while delivering food trays to the client, because
there is not contact with the client.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environment Nursing Process: Evaluation
PRISCILLA LEMON
TEST BANK FOR MEDICAL SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE 4TH EDITION PRISCILLA LEMON
,TEST BANK FOR MEDICAL SURGICAL NURSING CRITICAL THINKING IN CLIENT CARE 4TH EDITION
PRISCILLA LEMON
Chapter 1
1.QUESTION & ANSWER The nurse is caring for four clients on a medical–surgical unit. Which
client should the nurse see initially?
1. A client admitted with hepatitis A who has had severe diarrhea for the last 24 hours
2. A client admitted with pneumonia who is has small amounts of yellow productive sputum
3. A client admitted with fever of unknown origin (FUO) who has been without fever for the last 48
hours
4. A client admitted with a wound infection whose WBC is 8,500 mm3
Answer: 1
Rationale: The nurse must decide which client should be seen on the initial rounds of the day. The nurse
must remember that the first client to be seen should be the client who needs the attention of the nurse
initially. A client with hepatitis A does experience diarrhea, but diarrhea for the last 24 hours could
cause the client to have a problem with dehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environment Nursing Process: Planning
2. QUESTION & ANSWER The nurse is preparing to administer influenza vaccines to a mass drive-
through clinic. Which statement by a client would indicate further questioning prior to giving the 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.”
,TEST BANK FOR MEDICAL SURGICAL NURSING CRITICAL THINKING IN CLIENT CARE 4TH EDITION
PRISCILLA LEMON
4. “My husband had a severe allergic reaction after he received his influenza
vaccine.”
Answer: 3
Rationale: Influenza vaccines are recommended for person at high risk for serious sequelae of influenza.
The nurse should be aware that client with a sensitivity to eggs should not receive the vaccine. Vaccines
prepared from chicken or duck embryos are contraindicated in clients who are allergic to eggs.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environment
Nursing Process: Assessment
3. QUESTION & ANSWER The nurse is caring for four clients on a medical–surgical unit. The
secretary gives the nurse the morning labs. Which of the following labs would require that the nurse call
the physician and inform the healthcare provider about the client’s abnormalities?
1. WBC 14,600 mm3
2. Serum protein 6.9 g/dL
3. I & D (incision and drainage) showing no growth for the last 24 hours
4. Albumin 4.2 g/dL
Answer: 1
Rationale: When the nurse is caring for several clients, all of the labs should be checked frequently
throughout the shift to assess for any abnormalities. The WBC in option 1 is abnormal. (Normal WBC
4,000–10,000 mm3.) All of the other lab results are within acceptable range; therefore, the results
should not be called in to the physician.
, TEST BANK FOR MEDICAL SURGICAL NURSING CRITICAL THINKING IN CLIENT CARE 4TH EDITION
PRISCILLA LEMON
Cognitive Level: Application Client Needs: Physiologic Integrity Nursing Process: Assessment
4. QUESTION & ANSWER The nurse is orienting a new graduate. The nurse is reinforcing the
importance of standard precautions. Which of the following observations by the nurse would require
further education regarding standard precautions?
1. The graduate nurse understands to wash hands when entering and exiting
the client’s room.
2. The graduate nurse wears gloves when serving breakfast trays to various clients.
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a client.
4. The graduate nurse leaves all supplies in the room of a client who is in contact isolation.
Answer: 2
Rationale: The nurse must have an understanding of standard precautions. Prevention is the most
important measure to prevent nosocomial infections. Standard precautions were published in 1996 that
provide guidelines for the handling of blood and other body fluids. These guidelines are used with all
clients, regardless of whether they have a known infectious disease. Standard precautions are used by
all healthcare workers who have direct contact with clients or with their body
fluids. It is not necessary for the nurse to wear gloves while delivering food trays to the client, because
there is not contact with the client.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environment Nursing Process: Evaluation
