Test Bank for Understanding
Medical-Surgical Nursing 6th
Edition Linda S. Williams
Paula D. Hopper
,Chapter 1
1. 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. Thetynursetyistypreparingtytotyadministertyinfluenzatyvaccinestytotyatymasstydrive-
throughtyclinic.Wty hichtystatementtybytyatyclienttywouldtyindicatetyfurthertyquestioningtypriortytoty
givingtythetyclienttythetyinfluenzatyvaccine?
1. “Ityamtyallergictytotyhorsetyhair.”
2. “Itytrytytotygettymytyvaccinetyeverytyyear.”
3. “Ityamtynottyallergictytotyanythingtyexcepttyeggs.”
4. “Mytyhusbandtyhadtyatyseveretyallergictyreactiontyaftertyhetyreceivedtyhistyinfluen
zatvy accine.”
Answer:ty3
Rationale:tyInfluenzatyvaccinestyaretyrecommendedtyfortypersontyattyhightyrisktyfortyserioustyse
quelaetyoftyinfluenza.tyThetynursetyshouldtybetyawaretythattyclienttywithtyatysensitivitytytoty
eggstyshouldtynottyreceivetythetyvaccine.tyVaccinestypreparedtyfromtychickentyortyduckt
yembryostyaretycontraindicatedtyintyclientstywhotyaretyallergictytotyeggs.
CognitivetyLevel:tyApplication
,ClienttyNeeds:tySafe,tyEffectivetyCaretyEnvironment
NursingtyProcess:tyAssessment
3. Thetynursetyistycaringtyfortyfourtyclientstyontyatymedical–
surgicaltyunit.tyThetysecretarytygivestythenty ursetythetymorningtylabs.tyWhichtyoftythetyfollowingtyl
abstywouldtyrequiretythattythetynursetycalltythetpy hysiciantyandtyinformtythetyhealthcaretyprovidertya
bouttythetyclient’styabnormalities?
1.t y WBCty14,600tymm3
2. Serumtyproteinty6.9tyg/dL
3. Ity&tyDty(incisiontyandtydrainage)tyshowingtynotygrowthtyfortythetylastty24tyhours
4. Albuminty4.2tyg/dL
Answer:ty1
Rationale:tyWhentythetynursetyistycaringtyfortyseveraltyclients,tyalltyoftythetylabstyshouldtybetychecke
dtfy requentlytythroughouttythetyshifttytotyassesstyfortyanytyabnormalities.tyThetyWBCtyintyoptionty1ty
istyabnormal.ty(NormaltyWBCty4,000–
10,000tymm3.)tyAlltyoftythetyothertylabtyresultstyaretywithintyacceptabletyrange;tytherefore,tythetyres
ultstyshouldtynottybetycalledtyintytotythetyphysician.
CognitivetyLevel:tyApplicationtyClie
nttyNeeds:tyPhysiologictyIntegrityN
ty ur
singtyProcess:tyAssessment
4. Thetynursetyistyorientingtyatynewtygraduate.tyThetynursetyistyreinforcingtythetyimportancetyo
ftystandardtyprecautions.tyWhichtyoftythetyfollowingtyobservationstybytythetynursetywouldtyreq
uiretfy urthertyeducationtyregardingtystandardtyprecautions?
1. Thetygraduatetynursetyunderstandstytotywashtyhandstywhentyenteringtyandtyexiti
ngtty hetyclient’styroom.
2. Thetygraduatetynursetywearstyglovestywhentyservingtybreakfasttytraystytotyvario
ustcy lients.
3. Thetygraduatetynursetywearstyatygown,tygloves,tyandtygogglestywhentysuctioningt
yatc
y lient.
4. Thetygraduatetynursetyleavestyalltysuppliestyintythetyroomtyoftyatyclienttywhotyist
yintycontacttyisolation.
Answer:ty2
Rationale:tyThetynursetymusttyhavetyantyunderstandingtyoftystandardtyprecautions.tyPreventiontyis
tythetymosttyimportanttymeasuretytotypreventtynosocomialtyinfections.tyStandardtyprecaut
ionstyweretypublishedtyinty1996tythattyprovidetyguidelinestyfortythetyhandlingtyoftybloodtya
ndtyothertybodytyfluids.tyThesetyguidelinestyaretyusedtywithtyalltyclients,tyregardlesstoy ftywhe
thertytheytyhavetyatyknowntyinfectioustydisease.tyStandardtyprecautionstyaretyused
, bytyalltyhealthcaretyworkerstywhotyhavetydirecttycontacttywithtyclientstyortywithtytheirtybody
fluids.tyIttyistynottynecessarytyfortythetynursetytotyweartyglovestywhiletydeliveringtyfoodtytray
stty otythetyclient,tybecausetytheretyistynottycontacttywithtythetyclient.
CognitivetyLevel:tyApplication
ClienttyNeeds:tySafe,tyEffectivetyCaretyEnvironmen
ttN
y ursingtyProcess:tyEvaluation
5. Thetyadmittingtydepartmenttyalertstythetynursetyontyatymedical–
surgicaltyunittythattyatyclienttywithaty ctivetytuberculosisty(TB)tyistybeingtyadmittedtytotythetyunit.ty
Whichtytypetyoftyisolationtyistyappropriatetybasedtyontythetyclient’stydiagnosis?
1. Standardtyprecautions
2. Airbornetyprecautions
3. Droplettyprecautions
4. Contacttyprecautions
Answer:ty2
Intyadditiontytotyhandwashingtyandtystandardtyprecautions,tythetynaturetyandtyspreadtyoftysome
tyinfectioustydiseasestyrequiretythattyspecialtytechniquestybetyusedtytotyprotecttyuninfectedtyclie
ntstay ndtyworkers.tyThetyclienttywithtypulmonarytytuberculosistywilltybetyplacedtyintyairbornetyp
recautions.tyThetyclienttyshouldtybetyplacedtyintyatyprivatetyroomtywithtyspecialtyventilationtytha
ttdy oestynottyallowtyairtytotycirculatetytotygeneraltyhospitaltyventilation;tyatymasktyortyspecialtyfilt
ertyrespiratorstywilltybetyusedtyfortyeveryonetyenteringtythetyroom.
CognitivetyLevel:tyApplication
ClienttyNeeds:tySafe,tyEffectivetyCaretyEnvironmen
ttN
y ursingtyProcess:tyAssessment
6. AtyclienttyistyreceivingtyIVtyvancomycintyfortythetytreatmenttyoftyClostridiumtydifficile.tyT
hetynursetyunderstandstythattythetyclienttywhotydevelopstyflushing,tytachycardia,tyandtyhypote
nsiontdy uringtythetyinfusiontyoftyvancomycintyindicates:
1. Ototoxicitytyeffect.
2. Superinfection.
3. Redtymantysyndrome.
4. Hives.
Answer:ty3
Rationale:tyVancomycintyinhibitstycelltywalltysynthesis,tyandtyistyusedtyfortyserioustyinfections.tyItt
yisto
y nlytyeffectivetyagainsttygram-positivetybacteria,tyespeciallytyStaphylococcustyaureustyand
Medical-Surgical Nursing 6th
Edition Linda S. Williams
Paula D. Hopper
,Chapter 1
1. 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. Thetynursetyistypreparingtytotyadministertyinfluenzatyvaccinestytotyatymasstydrive-
throughtyclinic.Wty hichtystatementtybytyatyclienttywouldtyindicatetyfurthertyquestioningtypriortytoty
givingtythetyclienttythetyinfluenzatyvaccine?
1. “Ityamtyallergictytotyhorsetyhair.”
2. “Itytrytytotygettymytyvaccinetyeverytyyear.”
3. “Ityamtynottyallergictytotyanythingtyexcepttyeggs.”
4. “Mytyhusbandtyhadtyatyseveretyallergictyreactiontyaftertyhetyreceivedtyhistyinfluen
zatvy accine.”
Answer:ty3
Rationale:tyInfluenzatyvaccinestyaretyrecommendedtyfortypersontyattyhightyrisktyfortyserioustyse
quelaetyoftyinfluenza.tyThetynursetyshouldtybetyawaretythattyclienttywithtyatysensitivitytytoty
eggstyshouldtynottyreceivetythetyvaccine.tyVaccinestypreparedtyfromtychickentyortyduckt
yembryostyaretycontraindicatedtyintyclientstywhotyaretyallergictytotyeggs.
CognitivetyLevel:tyApplication
,ClienttyNeeds:tySafe,tyEffectivetyCaretyEnvironment
NursingtyProcess:tyAssessment
3. Thetynursetyistycaringtyfortyfourtyclientstyontyatymedical–
surgicaltyunit.tyThetysecretarytygivestythenty ursetythetymorningtylabs.tyWhichtyoftythetyfollowingtyl
abstywouldtyrequiretythattythetynursetycalltythetpy hysiciantyandtyinformtythetyhealthcaretyprovidertya
bouttythetyclient’styabnormalities?
1.t y WBCty14,600tymm3
2. Serumtyproteinty6.9tyg/dL
3. Ity&tyDty(incisiontyandtydrainage)tyshowingtynotygrowthtyfortythetylastty24tyhours
4. Albuminty4.2tyg/dL
Answer:ty1
Rationale:tyWhentythetynursetyistycaringtyfortyseveraltyclients,tyalltyoftythetylabstyshouldtybetychecke
dtfy requentlytythroughouttythetyshifttytotyassesstyfortyanytyabnormalities.tyThetyWBCtyintyoptionty1ty
istyabnormal.ty(NormaltyWBCty4,000–
10,000tymm3.)tyAlltyoftythetyothertylabtyresultstyaretywithintyacceptabletyrange;tytherefore,tythetyres
ultstyshouldtynottybetycalledtyintytotythetyphysician.
CognitivetyLevel:tyApplicationtyClie
nttyNeeds:tyPhysiologictyIntegrityN
ty ur
singtyProcess:tyAssessment
4. Thetynursetyistyorientingtyatynewtygraduate.tyThetynursetyistyreinforcingtythetyimportancetyo
ftystandardtyprecautions.tyWhichtyoftythetyfollowingtyobservationstybytythetynursetywouldtyreq
uiretfy urthertyeducationtyregardingtystandardtyprecautions?
1. Thetygraduatetynursetyunderstandstytotywashtyhandstywhentyenteringtyandtyexiti
ngtty hetyclient’styroom.
2. Thetygraduatetynursetywearstyglovestywhentyservingtybreakfasttytraystytotyvario
ustcy lients.
3. Thetygraduatetynursetywearstyatygown,tygloves,tyandtygogglestywhentysuctioningt
yatc
y lient.
4. Thetygraduatetynursetyleavestyalltysuppliestyintythetyroomtyoftyatyclienttywhotyist
yintycontacttyisolation.
Answer:ty2
Rationale:tyThetynursetymusttyhavetyantyunderstandingtyoftystandardtyprecautions.tyPreventiontyis
tythetymosttyimportanttymeasuretytotypreventtynosocomialtyinfections.tyStandardtyprecaut
ionstyweretypublishedtyinty1996tythattyprovidetyguidelinestyfortythetyhandlingtyoftybloodtya
ndtyothertybodytyfluids.tyThesetyguidelinestyaretyusedtywithtyalltyclients,tyregardlesstoy ftywhe
thertytheytyhavetyatyknowntyinfectioustydisease.tyStandardtyprecautionstyaretyused
, bytyalltyhealthcaretyworkerstywhotyhavetydirecttycontacttywithtyclientstyortywithtytheirtybody
fluids.tyIttyistynottynecessarytyfortythetynursetytotyweartyglovestywhiletydeliveringtyfoodtytray
stty otythetyclient,tybecausetytheretyistynottycontacttywithtythetyclient.
CognitivetyLevel:tyApplication
ClienttyNeeds:tySafe,tyEffectivetyCaretyEnvironmen
ttN
y ursingtyProcess:tyEvaluation
5. Thetyadmittingtydepartmenttyalertstythetynursetyontyatymedical–
surgicaltyunittythattyatyclienttywithaty ctivetytuberculosisty(TB)tyistybeingtyadmittedtytotythetyunit.ty
Whichtytypetyoftyisolationtyistyappropriatetybasedtyontythetyclient’stydiagnosis?
1. Standardtyprecautions
2. Airbornetyprecautions
3. Droplettyprecautions
4. Contacttyprecautions
Answer:ty2
Intyadditiontytotyhandwashingtyandtystandardtyprecautions,tythetynaturetyandtyspreadtyoftysome
tyinfectioustydiseasestyrequiretythattyspecialtytechniquestybetyusedtytotyprotecttyuninfectedtyclie
ntstay ndtyworkers.tyThetyclienttywithtypulmonarytytuberculosistywilltybetyplacedtyintyairbornetyp
recautions.tyThetyclienttyshouldtybetyplacedtyintyatyprivatetyroomtywithtyspecialtyventilationtytha
ttdy oestynottyallowtyairtytotycirculatetytotygeneraltyhospitaltyventilation;tyatymasktyortyspecialtyfilt
ertyrespiratorstywilltybetyusedtyfortyeveryonetyenteringtythetyroom.
CognitivetyLevel:tyApplication
ClienttyNeeds:tySafe,tyEffectivetyCaretyEnvironmen
ttN
y ursingtyProcess:tyAssessment
6. AtyclienttyistyreceivingtyIVtyvancomycintyfortythetytreatmenttyoftyClostridiumtydifficile.tyT
hetynursetyunderstandstythattythetyclienttywhotydevelopstyflushing,tytachycardia,tyandtyhypote
nsiontdy uringtythetyinfusiontyoftyvancomycintyindicates:
1. Ototoxicitytyeffect.
2. Superinfection.
3. Redtymantysyndrome.
4. Hives.
Answer:ty3
Rationale:tyVancomycintyinhibitstycelltywalltysynthesis,tyandtyistyusedtyfortyserioustyinfections.tyItt
yisto
y nlytyeffectivetyagainsttygram-positivetybacteria,tyespeciallytyStaphylococcustyaureustyand
