TESTBANK FOR LEMONE & BURKE’S MEDICAL-
SURGICAL NURSING: CLINICAL REASONING IN
HOSPITAL CLIENT CARE 7TH EDITION/ALL
CHAPTERS 1-52
,Chapter 1 tv
1. The caregiver is caring for four Hospital clients on a medical–
tv tv tv tv tv tv tv tv tv tv
surgical unit. WhichHospital client should the caregiver see initially?
tv tv tv tv tv tv tv tv tv
1. AHospital client admitted with hepatitis A who has had severe diarrhe
tv tv tv tv tv tv tv tv tv tv tv
a for thelast 24 hours tv tv tv tv tv
2. AHospital client admitted with pneumonia who is has small am
tv tv tv tv tv tv tv tv tv tv
ounts ofyellow productive sputum tv tv tv tv
3. AHospital client admitted with fever of unknown origin (FUO)
tv tv tv tv tv tv tv tv tv tv
who hasbeen without fever for the last 48 hours tv tv tv tv tv tv tv tv tv
4. A Hospital client admitted with a wound infection whose WBC is 8,
tv tv tv tv tv tv tv tv tv tv tv
500 mm3ACCURATE ANSWER:-1
tv tv tv
Reasoning:-
>>>The caregiver must decide which Hospital client should be seen on theinitial r
tv tv tv tv tv tv tv tv tv tv tv tv tv
ounds of the day. The caregiver must remember that the first tv tv tv tv tv tv tv tv tv tv
Hospital client to be seen should be the Hospital client who needs the attentio tv tv tv tv tv tv tv tv tv tv tv tv tv
n of the caregiver initially. A Hospital client with hepatitis A does experience di
tv tv tv tv tv tv tv tv tv tv tv tv tv
arrhea,but diarrhea for the last 24 hours could cause the Hospital client to have
tv tv tv tv tv tv tv tv tv tv tv tv tv tv t
a problem withdehydration and experience a state of fluid volume deficit.
v tv tv tv tv tv tv tv tv tv tv tv
Cognitive Level: Application tv tv
Hospital client Needs: Safe, Effective Care Environme
tv tv tv tv tv tv
ntNursing Process: Planning
tv tv tv
2. The caregiver is preparing to administer influenza vaccines to a mass drive-
tv tv tv tv tv tv tv tv tv tv tv
through clinic. Which statement by a Hospital client would indicate further questionin
tv tv tv tv tv tv tv tv tv tv tv tv
g prior togiving the Hospital client the influenza vaccine?
tv tv tv tv tv tv tv tv tv
1. “I am allergic to horse hair.”
tv tv tv tv tv
2. “I try to get my vaccine every year.”
tv tv tv tv tv tv tv
3. “I am not allergic to anything except eggs.”
tv tv tv tv tv tv tv
4. “My husband had a severe allergic reaction after he received his influenzav
tv tv tv tv tv tv tv tv tv tv tv tv
accine.”
ACCURATE ANSWER:-3 tv
Reasoning:-
>>>Influenza vaccines are recommended for person at high risk for serious sequela tv tv tv tv tv tv tv tv tv tv tv
e of influenza. The caregiver should be aware that Hospital client with asensitivi
tv tv tv tv tv tv tv tv tv tv tv tv tv
ty to eggs should not receive the vaccine. Vaccines prepared from chicken or duc
tv tv tv tv tv tv tv tv tv tv tv tv tv
k embryos are contraindicated in Hospital clients who are allergic to eggs.
tv tv tv tv tv tv tv tv tv tv tv
,Cognitive Level: Application tv tv
Hospital client Needs: Safe, Effective Care Environme
tv tv tv tv tv tv
ntNursing Process: Assessment
tv tv tv
3. The caregiver is caring for four Hospital clients on a medical–
tv tv tv tv tv tv tv tv tv tv
surgical unit. The secretary gives the caregiver the morning labs. Which of the following
tv tv tv tv tv tv tv tv tv tv tv tv tv
labs would require that the caregiver call the physician and inform the healthcare provi
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
der about the Hospital client’s abnormalities?
tv tv tv tv tv
1. t v WBC 14,600 mm3 tv tv
2. Serum protein 6.9 g/dL tv tv tv
3. I & D (incision and drainage) showing no growth for the last 24 hours
tv tv tv tv tv tv tv tv tv tv tv tv tv
4. Albumin 4.2 g/dL tv tv tv
ACCURATE ANSWER:-1 tv
Reasoning:-
>>>When the caregiver is caring for several Hospital clients, all of the labsshould be ch
tv tv tv tv tv tv tv tv tv tv tv tv tv tv tv
ecked frequently throughout the shift to assess for any abnormalities. The WBC in opt
tv tv tv tv tv tv tv tv tv tv tv tv tv
ion 1 is abnormal. (Normal WBC 4,000–
tv tv tv tv tv tv
10,000 mm3.) All of the other labresults are within acceptable range; therefore, the res
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
ults should not be called in to thephysician.
tv tv tv tv tv tv tv tv
Cognitive Level: Application tv tv tv
Hospital client Needs: Physi tv tv tv
ologic Integrity Nursing Proc
tv tv tv
ess:
Assessment
4. The caregiver is orienting a new graduate. The caregiver is reinforcing the im
tv tv tv tv tv tv tv tv tv tv tv tv
portance of standard precautions. Which of the following observations by the ca
tv tv tv tv tv tv tv tv tv tv tv
regiver would require further education regardingstandard precautions?
tv tv tv tv tv tv tv
1. The graduate caregiver understands to wash hands whenentering
tv tv tv tv tv tv tv tv
and exiting the Hospital client’s room.
tv tv tv tv tv tv
2. The graduate caregiver wears gloves when serving breakfast trays to v
tv tv tv tv tv tv tv tv tv tv
arious Hospital clients. tv tv
3. The graduate caregiver wears a gown, gloves, and goggles whensuctionin
tv tv tv tv tv tv tv tv tv tv
g a Hospital client. tv tv tv
4. The graduate caregiver leaves all supplies in the room of aHospital c
tv tv tv tv tv tv tv tv tv tv tv tv
lient who is in contact isolation. tv tv tv tv tv
ACCURATE ANSWER:-2 tv
, Reasoning:-
>>>The caregiver must have an understanding of standard precautions. Preventio
tv tv tv tv tv tv tv tv tv
n is the most important measure to prevent nosocomial infections. Standard pr
tv tv tv tv tv tv tv tv tv tv tv
ecautions were published in 1996 that provide guidelines tv tv tv tv tv tv tv
for the handling of blood and other body fluids. These guidelines are used with al
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
l Hospital clients, regardless of whether they have a known infectious disease. Sta
tv tv tv tv tv tv tv tv tv tv tv tv
ndardprecautions are used tv tv tv
by all healthcare workers who have direct contact with Hospital clients or with
tv tv tv tv tv tv tv tv tv tv tv tv tv
their body fluids. It is not necessary for the caregiver to wear gloves while delive
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
ring food trays to the Hospital client, because there is not contact with the Hospi
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
tal client. tv
Cognitive Level: Application tv tv
Hospital client Needs: Safe, Effective Care Environme
tv tv tv tv tv tv
ntNursing Process: Evaluation
tv tv tv
5. The admitting department alerts the caregiver on a medical–
tv tv tv tv tv tv tv tv
surgical unit thata Hospital client with active tuberculosis (TB) is being admitted to th
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
e unit. Which type of isolation is appropriate based on the Hospital client’s diagnosis?
tv tv tv tv tv tv tv tv tv tv tv tv tv
1. Standard precautions tv
2. Airborne precautions tv
3. Droplet precautions tv
4. Contact precaution tv
sACCURATE ANSWER:-2
tv tv
Reasoning:-
>>>In addition to handwashing and standard precautions, the nature and spread of some i
tv tv tv tv tv tv tv tv tv tv tv tv tv
nfectious diseases require that special techniques be used to protect uninfected Hospital
tv tv tv tv tv tv tv tv tv tv tv tv
clients and workers. The Hospital client with pulmonary tuberculosis will be placed in a
tv tv tv tv tv tv tv tv tv tv tv tv tv
irborne precautions. The Hospital client should be placed in a private room with special
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
ventilation that does not allow air to circulate to general health center ventilation; a mask
tv tv tv tv tv tv tv tv tv tv tv tv tv tv tv
or special filter respirators will be used for everyone entering the room.
tv tv tv tv tv tv tv tv tv tv tv
Cognitive Level: Application tv tv
Hospital client Needs: Safe, Effective Care Environme
tv tv tv tv tv tv
ntNursing Process: Assessment
tv tv tv
6. A Hospital client is receiving IV vancomycin for the treatment of Clostridium d
tv tv tv tv tv tv tv tv tv tv tv tv
ifficile. The caregiver understands that the Hospital client who develops flushing,
tv tv tv tv tv tv tv tv tv tv t
tachycardia, and hypotension during the infusion of vancomycin indicates:
v tv tv tv tv tv tv tv tv
1. Ototoxicity effect. tv
2. Superinfection.
3. Red man syndrome. tv tv
SURGICAL NURSING: CLINICAL REASONING IN
HOSPITAL CLIENT CARE 7TH EDITION/ALL
CHAPTERS 1-52
,Chapter 1 tv
1. The caregiver is caring for four Hospital clients on a medical–
tv tv tv tv tv tv tv tv tv tv
surgical unit. WhichHospital client should the caregiver see initially?
tv tv tv tv tv tv tv tv tv
1. AHospital client admitted with hepatitis A who has had severe diarrhe
tv tv tv tv tv tv tv tv tv tv tv
a for thelast 24 hours tv tv tv tv tv
2. AHospital client admitted with pneumonia who is has small am
tv tv tv tv tv tv tv tv tv tv
ounts ofyellow productive sputum tv tv tv tv
3. AHospital client admitted with fever of unknown origin (FUO)
tv tv tv tv tv tv tv tv tv tv
who hasbeen without fever for the last 48 hours tv tv tv tv tv tv tv tv tv
4. A Hospital client admitted with a wound infection whose WBC is 8,
tv tv tv tv tv tv tv tv tv tv tv
500 mm3ACCURATE ANSWER:-1
tv tv tv
Reasoning:-
>>>The caregiver must decide which Hospital client should be seen on theinitial r
tv tv tv tv tv tv tv tv tv tv tv tv tv
ounds of the day. The caregiver must remember that the first tv tv tv tv tv tv tv tv tv tv
Hospital client to be seen should be the Hospital client who needs the attentio tv tv tv tv tv tv tv tv tv tv tv tv tv
n of the caregiver initially. A Hospital client with hepatitis A does experience di
tv tv tv tv tv tv tv tv tv tv tv tv tv
arrhea,but diarrhea for the last 24 hours could cause the Hospital client to have
tv tv tv tv tv tv tv tv tv tv tv tv tv tv t
a problem withdehydration and experience a state of fluid volume deficit.
v tv tv tv tv tv tv tv tv tv tv tv
Cognitive Level: Application tv tv
Hospital client Needs: Safe, Effective Care Environme
tv tv tv tv tv tv
ntNursing Process: Planning
tv tv tv
2. The caregiver is preparing to administer influenza vaccines to a mass drive-
tv tv tv tv tv tv tv tv tv tv tv
through clinic. Which statement by a Hospital client would indicate further questionin
tv tv tv tv tv tv tv tv tv tv tv tv
g prior togiving the Hospital client the influenza vaccine?
tv tv tv tv tv tv tv tv tv
1. “I am allergic to horse hair.”
tv tv tv tv tv
2. “I try to get my vaccine every year.”
tv tv tv tv tv tv tv
3. “I am not allergic to anything except eggs.”
tv tv tv tv tv tv tv
4. “My husband had a severe allergic reaction after he received his influenzav
tv tv tv tv tv tv tv tv tv tv tv tv
accine.”
ACCURATE ANSWER:-3 tv
Reasoning:-
>>>Influenza vaccines are recommended for person at high risk for serious sequela tv tv tv tv tv tv tv tv tv tv tv
e of influenza. The caregiver should be aware that Hospital client with asensitivi
tv tv tv tv tv tv tv tv tv tv tv tv tv
ty to eggs should not receive the vaccine. Vaccines prepared from chicken or duc
tv tv tv tv tv tv tv tv tv tv tv tv tv
k embryos are contraindicated in Hospital clients who are allergic to eggs.
tv tv tv tv tv tv tv tv tv tv tv
,Cognitive Level: Application tv tv
Hospital client Needs: Safe, Effective Care Environme
tv tv tv tv tv tv
ntNursing Process: Assessment
tv tv tv
3. The caregiver is caring for four Hospital clients on a medical–
tv tv tv tv tv tv tv tv tv tv
surgical unit. The secretary gives the caregiver the morning labs. Which of the following
tv tv tv tv tv tv tv tv tv tv tv tv tv
labs would require that the caregiver call the physician and inform the healthcare provi
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
der about the Hospital client’s abnormalities?
tv tv tv tv tv
1. t v WBC 14,600 mm3 tv tv
2. Serum protein 6.9 g/dL tv tv tv
3. I & D (incision and drainage) showing no growth for the last 24 hours
tv tv tv tv tv tv tv tv tv tv tv tv tv
4. Albumin 4.2 g/dL tv tv tv
ACCURATE ANSWER:-1 tv
Reasoning:-
>>>When the caregiver is caring for several Hospital clients, all of the labsshould be ch
tv tv tv tv tv tv tv tv tv tv tv tv tv tv tv
ecked frequently throughout the shift to assess for any abnormalities. The WBC in opt
tv tv tv tv tv tv tv tv tv tv tv tv tv
ion 1 is abnormal. (Normal WBC 4,000–
tv tv tv tv tv tv
10,000 mm3.) All of the other labresults are within acceptable range; therefore, the res
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
ults should not be called in to thephysician.
tv tv tv tv tv tv tv tv
Cognitive Level: Application tv tv tv
Hospital client Needs: Physi tv tv tv
ologic Integrity Nursing Proc
tv tv tv
ess:
Assessment
4. The caregiver is orienting a new graduate. The caregiver is reinforcing the im
tv tv tv tv tv tv tv tv tv tv tv tv
portance of standard precautions. Which of the following observations by the ca
tv tv tv tv tv tv tv tv tv tv tv
regiver would require further education regardingstandard precautions?
tv tv tv tv tv tv tv
1. The graduate caregiver understands to wash hands whenentering
tv tv tv tv tv tv tv tv
and exiting the Hospital client’s room.
tv tv tv tv tv tv
2. The graduate caregiver wears gloves when serving breakfast trays to v
tv tv tv tv tv tv tv tv tv tv
arious Hospital clients. tv tv
3. The graduate caregiver wears a gown, gloves, and goggles whensuctionin
tv tv tv tv tv tv tv tv tv tv
g a Hospital client. tv tv tv
4. The graduate caregiver leaves all supplies in the room of aHospital c
tv tv tv tv tv tv tv tv tv tv tv tv
lient who is in contact isolation. tv tv tv tv tv
ACCURATE ANSWER:-2 tv
, Reasoning:-
>>>The caregiver must have an understanding of standard precautions. Preventio
tv tv tv tv tv tv tv tv tv
n is the most important measure to prevent nosocomial infections. Standard pr
tv tv tv tv tv tv tv tv tv tv tv
ecautions were published in 1996 that provide guidelines tv tv tv tv tv tv tv
for the handling of blood and other body fluids. These guidelines are used with al
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
l Hospital clients, regardless of whether they have a known infectious disease. Sta
tv tv tv tv tv tv tv tv tv tv tv tv
ndardprecautions are used tv tv tv
by all healthcare workers who have direct contact with Hospital clients or with
tv tv tv tv tv tv tv tv tv tv tv tv tv
their body fluids. It is not necessary for the caregiver to wear gloves while delive
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
ring food trays to the Hospital client, because there is not contact with the Hospi
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
tal client. tv
Cognitive Level: Application tv tv
Hospital client Needs: Safe, Effective Care Environme
tv tv tv tv tv tv
ntNursing Process: Evaluation
tv tv tv
5. The admitting department alerts the caregiver on a medical–
tv tv tv tv tv tv tv tv
surgical unit thata Hospital client with active tuberculosis (TB) is being admitted to th
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
e unit. Which type of isolation is appropriate based on the Hospital client’s diagnosis?
tv tv tv tv tv tv tv tv tv tv tv tv tv
1. Standard precautions tv
2. Airborne precautions tv
3. Droplet precautions tv
4. Contact precaution tv
sACCURATE ANSWER:-2
tv tv
Reasoning:-
>>>In addition to handwashing and standard precautions, the nature and spread of some i
tv tv tv tv tv tv tv tv tv tv tv tv tv
nfectious diseases require that special techniques be used to protect uninfected Hospital
tv tv tv tv tv tv tv tv tv tv tv tv
clients and workers. The Hospital client with pulmonary tuberculosis will be placed in a
tv tv tv tv tv tv tv tv tv tv tv tv tv
irborne precautions. The Hospital client should be placed in a private room with special
tv tv tv tv tv tv tv tv tv tv tv tv tv tv
ventilation that does not allow air to circulate to general health center ventilation; a mask
tv tv tv tv tv tv tv tv tv tv tv tv tv tv tv
or special filter respirators will be used for everyone entering the room.
tv tv tv tv tv tv tv tv tv tv tv
Cognitive Level: Application tv tv
Hospital client Needs: Safe, Effective Care Environme
tv tv tv tv tv tv
ntNursing Process: Assessment
tv tv tv
6. A Hospital client is receiving IV vancomycin for the treatment of Clostridium d
tv tv tv tv tv tv tv tv tv tv tv tv
ifficile. The caregiver understands that the Hospital client who develops flushing,
tv tv tv tv tv tv tv tv tv tv t
tachycardia, and hypotension during the infusion of vancomycin indicates:
v tv tv tv tv tv tv tv tv
1. Ototoxicity effect. tv
2. Superinfection.
3. Red man syndrome. tv tv
