TESTBANK FOR LEMONE & BURKE’S MEDICAL-SURGICAL NURSING: CLINICAL REASONING IN PATIENT CARE 7TH EDITION/ALL CHAPTERS 1-52

TESTBANK FOR LEMONE & BURKE’S MEDICAL-
SURGICAL NURSING: CLINICAL REASONING IN
PATIENT CARE 7TH EDITION/ALL CHAPTERS 1-52

,Chapter 1


1. The professional nurse is caring for four patients on a medical–surgical unit. Which
patient should the professional nurse see initially?

1. A patient admitted with hepatitis A who has had severe diarrhea for the
last 24 hours
2. A patient admitted with pneumonia who is has small amounts of
yellow productive sputum
3. A patient admitted with fever of unknown origin (FUO) who has
been without fever for the last 48 hours
4. A patient admitted with a wound infection whose WBC is 8,500 mm3

CORRECT ANSWER:- 1

Feedback :->> The professional nurse must decide which patient should be seen on the
initial rounds of the day. The professional nurse must remember that the first
patient to be seen should be the patient who needs the attention of the
professional 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 Environment
Nursing Process: Planning


2. The professional nurse is preparing 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.”

CORRECT ANSWER:- 3

Feedback:->>Influenza vaccines are recommended for person at high risk for serious
sequelae of influenza. The professional nurse should be aware that patient with a
sensitivity to eggs should not receive the vaccine. Vaccines prepared from
chicken or duck embryos are contraindicated in patients who are allergic to eggs.

Cognitive Level: Application

,Patient Needs: Safe, Effective Care Environment
Nursing Process: Assessment


3. The professional nurse is caring for four patients on a medical–surgical unit. The
secretary gives the professional nurse the morning labs. Which of the following labs
would require that the professional nurse call the physician 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

CORRECT ANSWER:- 1

Feedback:->>When the professional nurse is caring for several patients, 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.

Cognitive Level: Application
Patient Needs: Physiologic
Integrity Nursing Process:
Assessment


4. The professional nurse is orienting a new graduate. The professional nurse is
reinforcing the importance of standard precautions. Which of the following
observations by the professional nurse would require further education regarding
standard precautions?

1. The graduate professional nurse understands to wash hands when
entering and exiting the patient’s room.
2. The graduate professional nurse wears gloves when serving breakfast
trays to various patients.
3. The graduate professional nurse wears a gown, gloves, and goggles when
suctioning a patient.
4. The graduate professional nurse leaves all supplies in the room of a
patient who is in contact isolation.

CORRECT ANSWER:- 2

Feedback :->> The professional 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, regardless of whether they have a known infectious disease. Standard
precautions are used
by all healthcare workers who have direct contact with patients or with their
body fluids. It is not necessary for the professional nurse to wear gloves while
delivering food trays to the patient, because there is not contact with the patient.

Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
Nursing Process: Evaluation


5. The admitting department alerts the professional nurse on a medical–surgical unit that
a patient with active tuberculosis (TB) is being admitted to the unit. Which type of
isolation is appropriate based on the patient’s diagnosis?

1. Standard precautions
2. Airborne precautions
3. Droplet precautions
4. Contact precautions

CORRECT ANSWER:- 2

Feedback :->> In addition to handwashing and standard precautions, the nature and
spread of some infectious diseases require that special techniques be used to protect
uninfected patients and workers. The patient with pulmonary tuberculosis will be placed
in airborne precautions. The patient should be placed in a private room with special
ventilation that does not allow air to circulate to general health center ventilation; a mask
or special filter respirators will be used for everyone entering the room.

Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
Nursing Process: Assessment


6. A patient is receiving IV vancomycin for the treatment of Clostridium difficile.
The professional nurse understands that the patient who develops flushing,
tachycardia, and hypotension during the infusion of vancomycin indicates:

1. Ototoxicity effect.
2. Superinfection.
3. Red man syndrome.
4. Hives.

CORRECT ANSWER:- 3

Feedback:->>Vancomycin inhibits cell wall synthesis, and is used for serious infections. It