COMPLETE TEST BANK:
Medical-Surgical Nursing: Critical Thinking in Client
Care 4th Edition
by Priscilla LeMone
,1. The nurse is caring for four patients on a medical–surgical unit, Which patient should
the nurse see first?
1. A patient admitted with hepatitis A who has had severe diarrhea for the
last24 hours
2. A patient admitted with pneumonia who is has small amounts of
yellowproductive sputum
3. A patient admitted with fever of unknown origin (FUO) who has
beenwithout fever for the last 48 hours
4. A patient admitted with a wound infection whose WBC is 8,500 mm3
Answer: 1
Rationale: The nurse must decide which patient ought to be seen on the initial rounds of
the day, The nurse must remember that the first patient to be seen ought to be the
patientwho needs the attention of the nurse initially, A patient with hepatitis A
does experience diarrhea, but diarrhea for the last 24 hours could cause the
patient to have a problem with dehydration and experience a state of fluid volume
deficit,
Cognitive Level: Application
Patient Needs: Safe, Effective Care
EnvironmentNursing Process: Planning
2. The nurse is getting ready to administer influenza vaccines to a mass drive-through
clinic,Which statement by a patient would indicate further questioning prior to giving
the patient 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,”
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 ought to be aware that patient with a sensitivity
toeggs ought to not receive the vaccine, Vaccines get readyd from chicken or
duck embryos are contraindicated in patients who are allergic to eggs,
,Cognitive Level: Application
, Patient Needs: Safe, Effective Care
EnvironmentNursing Process: Assessment
3. The nurse is caring for four patients on a medical–surgical unit, The secretary gives
the nurse the morning labs, Which of the following labs would require that the nurse call
thephysician and inform the healthcare provider about the patient’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 patients, all of the labs ought to 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 ought to not be called in to the physician,
Cognitive Level: Application
Patient Needs: Physiologic
IntegrityNursing Process:
Assessment
4. 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 patient’s room,
2. The graduate nurse wears gloves when serving breakfast trays to various
patients,
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a
patient,
4. The graduate nurse leaves all supplies in the room of a patient who is
incontact 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 patients,
regardlessof whether they have a known infectious disease, Standard precautions
are used
Medical-Surgical Nursing: Critical Thinking in Client
Care 4th Edition
by Priscilla LeMone
,1. The nurse is caring for four patients on a medical–surgical unit, Which patient should
the nurse see first?
1. A patient admitted with hepatitis A who has had severe diarrhea for the
last24 hours
2. A patient admitted with pneumonia who is has small amounts of
yellowproductive sputum
3. A patient admitted with fever of unknown origin (FUO) who has
beenwithout fever for the last 48 hours
4. A patient admitted with a wound infection whose WBC is 8,500 mm3
Answer: 1
Rationale: The nurse must decide which patient ought to be seen on the initial rounds of
the day, The nurse must remember that the first patient to be seen ought to be the
patientwho needs the attention of the nurse initially, A patient with hepatitis A
does experience diarrhea, but diarrhea for the last 24 hours could cause the
patient to have a problem with dehydration and experience a state of fluid volume
deficit,
Cognitive Level: Application
Patient Needs: Safe, Effective Care
EnvironmentNursing Process: Planning
2. The nurse is getting ready to administer influenza vaccines to a mass drive-through
clinic,Which statement by a patient would indicate further questioning prior to giving
the patient 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,”
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 ought to be aware that patient with a sensitivity
toeggs ought to not receive the vaccine, Vaccines get readyd from chicken or
duck embryos are contraindicated in patients who are allergic to eggs,
,Cognitive Level: Application
, Patient Needs: Safe, Effective Care
EnvironmentNursing Process: Assessment
3. The nurse is caring for four patients on a medical–surgical unit, The secretary gives
the nurse the morning labs, Which of the following labs would require that the nurse call
thephysician and inform the healthcare provider about the patient’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 patients, all of the labs ought to 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 ought to not be called in to the physician,
Cognitive Level: Application
Patient Needs: Physiologic
IntegrityNursing Process:
Assessment
4. 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 patient’s room,
2. The graduate nurse wears gloves when serving breakfast trays to various
patients,
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a
patient,
4. The graduate nurse leaves all supplies in the room of a patient who is
incontact 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 patients,
regardlessof whether they have a known infectious disease, Standard precautions
are used
