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
Test Bank for Understanding Answer: 1
Rationale: The nurse must decide which client should be seen on the initial rounds of the
Medical-Surgical Nursing 6th 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
Edition Linda S. Williams have a problem with dehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
Paula D. Hopper Client Needs: Safe, Effective Care Environment
Nursing Process: Planning
2. 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.”
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 by all healthcare workers who have direct contact with clients or with their body
Nursing Process: Assessment 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.
3. The nurse is caring for four clients on a medical–surgical unit. The secretary gives the Cognitive Level: Application
nurse the morning labs. Which of the following labs would require that the nurse call the Client Needs: Safe, Effective Care Environment
physician and inform the healthcare provider about the client’s abnormalities? Nursing Process: Evaluation
1. WBC 14,600 mm3
2. Serum protein 6.9 g/dL 5. The admitting department alerts the nurse on a medical–surgical unit that a client with
3. I & D (incision and drainage) showing no growth for the last 24 hours active tuberculosis (TB) is being admitted to the unit. Which type of isolation is
4. Albumin 4.2 g/dL appropriate based on the client’s diagnosis?
Answer: 1 1. Standard precautions
2. Airborne precautions
Rationale: When the nurse is caring for several clients, all of the labs should be checked 3. Droplet precautions
frequently throughout the shift to assess for any abnormalities. The WBC in option 1 is 4. Contact precautions
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. Answer: 2
Cognitive Level: Application In addition to handwashing and standard precautions, the nature and spread of some
Client Needs: Physiologic Integrity infectious diseases require that special techniques be used to protect uninfected clients
Nursing Process: Assessment and workers. The client with pulmonary tuberculosis will be placed in airborne
precautions. The client should be placed in a private room with special ventilation that
does not allow air to circulate to general hospital ventilation; a mask or special filter
4. The nurse is orienting a new graduate. The nurse is reinforcing the importance of respirators will be used for everyone entering the room.
standard precautions. Which of the following observations by the nurse would require
further education regarding standard precautions? Cognitive Level: Application
Client Needs: Safe, Effective Care Environment
1. The graduate nurse understands to wash hands when entering and exiting Nursing Process: Assessment
the client’s room.
2. The graduate nurse wears gloves when serving breakfast trays to various
clients. 6. A client is receiving IV vancomycin for the treatment of Clostridium difficile. The
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a nurse understands that the client who develops flushing, tachycardia, and hypotension
client. during the infusion of vancomycin indicates:
4. The graduate nurse leaves all supplies in the room of a client who is in
contact isolation. 1. Ototoxicity effect.
2. Superinfection.
Answer: 2 3. Red man syndrome.
4. Hives.
Rationale: The nurse must have an understanding of standard precautions. Prevention is
the most important measure to prevent nosocomial infections. Standard Answer: 3
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 Rationale: Vancomycin inhibits cell wall synthesis, and is used for serious infections. It is
of whether they have a known infectious disease. Standard precautions are used only effective against gram-positive bacteria, especially Staphylococcus aureus and
, Test Bank for Understanding Medical-Surgical Test Bank for Understanding Medical-Surgical
Nursing 6th Edition Linda S. Williams Paula D. Nursing 6th Edition Linda S. Williams Paula D.
Hopper Hopper
Staphylococcus epidermidis. The nurse should infuse this medication slowly over 60 Rationale: Standard precautions are used on all clients, regardless of whether they have a
minutes or more to avoid “red man” syndrome. The syndrome is characterized by know infectious disease. Standard precautions are used by all healthcare workers who
erythematous rash, flushing, tachycardia, and hypotension. Clients can become dizzy and have direct contact with clients or with their body fluids. Since the client has an
agitated. abdominal dressing, the nurse will use standard precautions.
Cognitive Level: Application Cognitive Level: Application
Client Needs: Physiological Integrity Client Needs: Safe, Effective Care Environment
Nursing Process: Evaluation Nursing Process: Planning
7. The physician has ordered for the client to receive a trough blood level to evaluate the
therapeutic effect of an antibiotic. The nurse understands that the trough should be 9. The physician has ordered for the nurse to obtain a sputum specimen. The nurse
ordered: understands that the sputum specimen should be collected:
1. A few minutes before the next scheduled dose of medication. 1. Immediately after the first dose of antibiotic is administered.
2. 1–2 hours after the oral administration of the medication. 2. 30 minutes after the first dose of antibiotics is administered.
3. 30 minutes after the IV administration. 3. During the first dose of antibiotics.
4. During the infusion of the antibiotic. 4. Before the first dose of antibiotics is administered.
Answer: 1 Answer: 4
Rationale: Antibiotic peak and trough levels monitor therapeutic blood levels of the Rationale: When the physician orders a specimen to be collected, the nurse should collect
prescribed medication. The therapeutic range—the minimum and maximum blood levels the specimen before the first dose of antibiotics is administered, to ensure adequate
at which the drug is effective—is known for a given drug. By measuring blood levels at organisms for culture.
the predicted peak (1–2 hours after oral administration, 1 hour after intramuscular
administration, and 30 minutes after IV administration) and trough (usually a few minutes Cognitive Level: Comprehension
before the next scheduled dose), it is also possible to determine whether the drug is Client Needs: Safe, Effective Care Environment
reaching a toxic or harmful level during therapy, increasing the likelihood of adverse Nursing Process: Planning
effects.
Cognitive Level: Application 10. Which of the following manifestations indicates a systemic reaction associated with
Client Needs: Safe, Effective Care Environment an inflammatory response?
Nursing Process: Assessment
1. Erythema
2. Pain
8. The nurse needs to change a dressing on the client’s abdomen. Which of the following 3. Tachypnea (RR 26)
techniques should be implemented? 4. Edema
1. Contact precautions Answer: 3
2. Standard precautions
3. Droplet precautions Rationale: If the nurse observes a systemic reaction, the client will exhibit manifestations
4. Airborne precautions including temperature, increased pulse, tachypnea, and leukocytosis. Erythema, warmth,
pain, edema, and functional impairment indicate a local reaction.
Answer: 2
Cognitive Level: Application
, Test Bank for Understanding Medical-Surgical Test Bank for Understanding Medical-Surgical
Nursing 6th Edition Linda S. Williams Paula D. Nursing 6th Edition Linda S. Williams Paula D.
Hopper Hopper
Client Needs: Physiological Integrity Rationale: Regardless of the cause, location, or extent of the injury, the acute
Nursing Process: Assessment inflammatory response follows the sequence of vascular response, cellular and
phagocytic response, and healing. Many manifestations of inflammation are produced by
inflammatory mediators such as histamines and prostaglandins released when tissue is
damaged. The cardinal signs of inflammation include erythema, local heat caused by the
11. A client develops hyperthermia related to a diagnosis of Pneumonia. Which of the increased blood flow to the injured area (hyperemia), swelling due to accumulated fluid
following nursing interventions would be effective in the treatment of hyperthermia? at site, pain from tissue swelling and chemical irritation of nerve endings, and loss of
Select all that apply. function caused by the swelling and pain.
1. Increase the temperature of the room environment to prevent shivering. Cognitive Level: Application
2. Use ice packs and a tepid bath as needed. Client Needs: Physiological Integrity
3. Administer antipyretic medications per physician’s orders. Nursing Process: Assessment
4. Promote frequent rest periods to increase energy reserve.
5. Restrict fluids during periods of hyperthermia because of the risk of
electrolyte imbalance. Alternate item format – Select all that apply
Answer: 2; 3; 4 Which of the following manifestations would the nurse expect to see with a client who
has had previous knee surgery who suffered a surgical infection with signs of systemic
Rationale: Hyperthemia is an expected consequence of the infectious disease process. manifestations? Select all that apply.
Fever can produce mild, short-term effects or, when prolonged, can cause life- 1. Erythema
threatening effects. The nurse should administer antipyretic medications as 2. WBC 14,200 mm3
indicated for elevated temperatures. The nurse should use ice packs, cool/tepid 3. Pain at the surgical site
baths, or hypothermia blanket with caution. The nurse should enforce frequent 4. 10% Bands
rest periods because rest increases energy reserve, which is depleted by an 5. Respiratory rate of 16
increased metabolic, heart, and respiratory rate. The nurse should encourage fluids 6. Pulse 114
rather than restrict fluids because of the risk of electrolyte imbalance.
Answer: 2; 3; 6
Cognitive Level: Assessment
Client Needs: Physiological Integrity Rationale: The client is post–surgical repair of the knee. The nurse should be able to
Nursing Process: Implementation distinguish between local reactions and system reactions. An elevated WBC and 10%
bands are indicative of an infection. Vital sign changes typically associated with an
infection include an elevation in temperature and tachycardia. Local manifestations
12. The nurse is assessing a client’s wound for signs and symptoms of inflammation. include erythema, warmth, pain, edema, and functional impairment, whereas systemic
Which of the following would alert the nurse that the client is exhibiting signs of manifestations include elevated temperature above 100.4°F, pulse greater than 90/min.,
inflammation? Select all that apply. respiratory rate greater than 20, and WBC greater than 12,000 mm3 or > 10% bands.
1. Leg edema
2. Leg cool to touch
3. Severe pain from swelling Cognitive Level: Application
4. Decreased peripheral pulses Client Needs: Physiological Integrity
5. Severe erythema of leg Nursing Process: Assessment
Answer: 1; 3; 5
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
Test Bank for Understanding Answer: 1
Rationale: The nurse must decide which client should be seen on the initial rounds of the
Medical-Surgical Nursing 6th 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
Edition Linda S. Williams have a problem with dehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
Paula D. Hopper Client Needs: Safe, Effective Care Environment
Nursing Process: Planning
2. 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.”
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 by all healthcare workers who have direct contact with clients or with their body
Nursing Process: Assessment 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.
3. The nurse is caring for four clients on a medical–surgical unit. The secretary gives the Cognitive Level: Application
nurse the morning labs. Which of the following labs would require that the nurse call the Client Needs: Safe, Effective Care Environment
physician and inform the healthcare provider about the client’s abnormalities? Nursing Process: Evaluation
1. WBC 14,600 mm3
2. Serum protein 6.9 g/dL 5. The admitting department alerts the nurse on a medical–surgical unit that a client with
3. I & D (incision and drainage) showing no growth for the last 24 hours active tuberculosis (TB) is being admitted to the unit. Which type of isolation is
4. Albumin 4.2 g/dL appropriate based on the client’s diagnosis?
Answer: 1 1. Standard precautions
2. Airborne precautions
Rationale: When the nurse is caring for several clients, all of the labs should be checked 3. Droplet precautions
frequently throughout the shift to assess for any abnormalities. The WBC in option 1 is 4. Contact precautions
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. Answer: 2
Cognitive Level: Application In addition to handwashing and standard precautions, the nature and spread of some
Client Needs: Physiologic Integrity infectious diseases require that special techniques be used to protect uninfected clients
Nursing Process: Assessment and workers. The client with pulmonary tuberculosis will be placed in airborne
precautions. The client should be placed in a private room with special ventilation that
does not allow air to circulate to general hospital ventilation; a mask or special filter
4. The nurse is orienting a new graduate. The nurse is reinforcing the importance of respirators will be used for everyone entering the room.
standard precautions. Which of the following observations by the nurse would require
further education regarding standard precautions? Cognitive Level: Application
Client Needs: Safe, Effective Care Environment
1. The graduate nurse understands to wash hands when entering and exiting Nursing Process: Assessment
the client’s room.
2. The graduate nurse wears gloves when serving breakfast trays to various
clients. 6. A client is receiving IV vancomycin for the treatment of Clostridium difficile. The
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a nurse understands that the client who develops flushing, tachycardia, and hypotension
client. during the infusion of vancomycin indicates:
4. The graduate nurse leaves all supplies in the room of a client who is in
contact isolation. 1. Ototoxicity effect.
2. Superinfection.
Answer: 2 3. Red man syndrome.
4. Hives.
Rationale: The nurse must have an understanding of standard precautions. Prevention is
the most important measure to prevent nosocomial infections. Standard Answer: 3
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 Rationale: Vancomycin inhibits cell wall synthesis, and is used for serious infections. It is
of whether they have a known infectious disease. Standard precautions are used only effective against gram-positive bacteria, especially Staphylococcus aureus and
, Test Bank for Understanding Medical-Surgical Test Bank for Understanding Medical-Surgical
Nursing 6th Edition Linda S. Williams Paula D. Nursing 6th Edition Linda S. Williams Paula D.
Hopper Hopper
Staphylococcus epidermidis. The nurse should infuse this medication slowly over 60 Rationale: Standard precautions are used on all clients, regardless of whether they have a
minutes or more to avoid “red man” syndrome. The syndrome is characterized by know infectious disease. Standard precautions are used by all healthcare workers who
erythematous rash, flushing, tachycardia, and hypotension. Clients can become dizzy and have direct contact with clients or with their body fluids. Since the client has an
agitated. abdominal dressing, the nurse will use standard precautions.
Cognitive Level: Application Cognitive Level: Application
Client Needs: Physiological Integrity Client Needs: Safe, Effective Care Environment
Nursing Process: Evaluation Nursing Process: Planning
7. The physician has ordered for the client to receive a trough blood level to evaluate the
therapeutic effect of an antibiotic. The nurse understands that the trough should be 9. The physician has ordered for the nurse to obtain a sputum specimen. The nurse
ordered: understands that the sputum specimen should be collected:
1. A few minutes before the next scheduled dose of medication. 1. Immediately after the first dose of antibiotic is administered.
2. 1–2 hours after the oral administration of the medication. 2. 30 minutes after the first dose of antibiotics is administered.
3. 30 minutes after the IV administration. 3. During the first dose of antibiotics.
4. During the infusion of the antibiotic. 4. Before the first dose of antibiotics is administered.
Answer: 1 Answer: 4
Rationale: Antibiotic peak and trough levels monitor therapeutic blood levels of the Rationale: When the physician orders a specimen to be collected, the nurse should collect
prescribed medication. The therapeutic range—the minimum and maximum blood levels the specimen before the first dose of antibiotics is administered, to ensure adequate
at which the drug is effective—is known for a given drug. By measuring blood levels at organisms for culture.
the predicted peak (1–2 hours after oral administration, 1 hour after intramuscular
administration, and 30 minutes after IV administration) and trough (usually a few minutes Cognitive Level: Comprehension
before the next scheduled dose), it is also possible to determine whether the drug is Client Needs: Safe, Effective Care Environment
reaching a toxic or harmful level during therapy, increasing the likelihood of adverse Nursing Process: Planning
effects.
Cognitive Level: Application 10. Which of the following manifestations indicates a systemic reaction associated with
Client Needs: Safe, Effective Care Environment an inflammatory response?
Nursing Process: Assessment
1. Erythema
2. Pain
8. The nurse needs to change a dressing on the client’s abdomen. Which of the following 3. Tachypnea (RR 26)
techniques should be implemented? 4. Edema
1. Contact precautions Answer: 3
2. Standard precautions
3. Droplet precautions Rationale: If the nurse observes a systemic reaction, the client will exhibit manifestations
4. Airborne precautions including temperature, increased pulse, tachypnea, and leukocytosis. Erythema, warmth,
pain, edema, and functional impairment indicate a local reaction.
Answer: 2
Cognitive Level: Application
, Test Bank for Understanding Medical-Surgical Test Bank for Understanding Medical-Surgical
Nursing 6th Edition Linda S. Williams Paula D. Nursing 6th Edition Linda S. Williams Paula D.
Hopper Hopper
Client Needs: Physiological Integrity Rationale: Regardless of the cause, location, or extent of the injury, the acute
Nursing Process: Assessment inflammatory response follows the sequence of vascular response, cellular and
phagocytic response, and healing. Many manifestations of inflammation are produced by
inflammatory mediators such as histamines and prostaglandins released when tissue is
damaged. The cardinal signs of inflammation include erythema, local heat caused by the
11. A client develops hyperthermia related to a diagnosis of Pneumonia. Which of the increased blood flow to the injured area (hyperemia), swelling due to accumulated fluid
following nursing interventions would be effective in the treatment of hyperthermia? at site, pain from tissue swelling and chemical irritation of nerve endings, and loss of
Select all that apply. function caused by the swelling and pain.
1. Increase the temperature of the room environment to prevent shivering. Cognitive Level: Application
2. Use ice packs and a tepid bath as needed. Client Needs: Physiological Integrity
3. Administer antipyretic medications per physician’s orders. Nursing Process: Assessment
4. Promote frequent rest periods to increase energy reserve.
5. Restrict fluids during periods of hyperthermia because of the risk of
electrolyte imbalance. Alternate item format – Select all that apply
Answer: 2; 3; 4 Which of the following manifestations would the nurse expect to see with a client who
has had previous knee surgery who suffered a surgical infection with signs of systemic
Rationale: Hyperthemia is an expected consequence of the infectious disease process. manifestations? Select all that apply.
Fever can produce mild, short-term effects or, when prolonged, can cause life- 1. Erythema
threatening effects. The nurse should administer antipyretic medications as 2. WBC 14,200 mm3
indicated for elevated temperatures. The nurse should use ice packs, cool/tepid 3. Pain at the surgical site
baths, or hypothermia blanket with caution. The nurse should enforce frequent 4. 10% Bands
rest periods because rest increases energy reserve, which is depleted by an 5. Respiratory rate of 16
increased metabolic, heart, and respiratory rate. The nurse should encourage fluids 6. Pulse 114
rather than restrict fluids because of the risk of electrolyte imbalance.
Answer: 2; 3; 6
Cognitive Level: Assessment
Client Needs: Physiological Integrity Rationale: The client is post–surgical repair of the knee. The nurse should be able to
Nursing Process: Implementation distinguish between local reactions and system reactions. An elevated WBC and 10%
bands are indicative of an infection. Vital sign changes typically associated with an
infection include an elevation in temperature and tachycardia. Local manifestations
12. The nurse is assessing a client’s wound for signs and symptoms of inflammation. include erythema, warmth, pain, edema, and functional impairment, whereas systemic
Which of the following would alert the nurse that the client is exhibiting signs of manifestations include elevated temperature above 100.4°F, pulse greater than 90/min.,
inflammation? Select all that apply. respiratory rate greater than 20, and WBC greater than 12,000 mm3 or > 10% bands.
1. Leg edema
2. Leg cool to touch
3. Severe pain from swelling Cognitive Level: Application
4. Decreased peripheral pulses Client Needs: Physiological Integrity
5. Severe erythema of leg Nursing Process: Assessment
Answer: 1; 3; 5
