Updated/Latest Medical-Surgical Nursing Critical Thinking in Client Care 4th Edition Test Bank Comprehensive Examination Questions and Answers Study Guide for Adult Health Nursing Clinical Reasoning Prioritization Patient Assessment Pathophysiology Nursin

Tes Bank for Medical Surgical Nursing Critical Thinking in
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Clien Care,4th Edition Priscilla LeMon(100% Verified)
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Chapter 1


1. The nurse is caring for four clients on a medical–surgical unit. Which client should the nurse
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see initially?
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1. A client admitted withhepatitis Awho has had severediarrhea forthe last 24
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hours
2. Aclient admitted with pneumonia who is has small amounts of yellow
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productive sputum J




3. A client admitted with fever ofunknown origin (FUO) who has been
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without fever for the last 48 hours J J J J J J




4. Aclient admitted with a wound infection whose WBC is 8,500 mm3
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Answer: 1 J




Rationale: The nurse must decide which client should be seen on the initial rounds ofthe day.
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The nurse must remember that the first client to be seen should be the client who needs
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the attention of the nurse initially. A client with hepatitis A does experience diarrhea,
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but diarrhea for the last 24 hours could cause the client to have a problem with
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dehydration and experience a state of fluid volume deficit. J J J J J J J J




CognitiveLevel:Application J J




Client Needs:Safe,EffectiveCareEnvironment
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Nursing Process: Planning
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2. The nurse is preparing to administer influenza vaccines to a mass drive-through clinic.
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Which statement by a client would indicate further questioning prior to giving the client the
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influenza vaccine? J




1. “I am allergic to horse hair.”
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2. “I tryto get myvaccine every year.”
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3. “I am not allergic to anything except eggs.”
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4. “Myhusband had a severe allergic reaction after he received his influenza
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vaccine.”

Answer: 3 J




Rationale: Influenza vaccines are recommended for person at high risk for serious sequelae of
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influenza. The nurse should be aware that client with a sensitivityto eggs should not
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receive the vaccine. Vaccines prepared from chicken or duck embryos are
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contraindicated in clients who are allergic to eggs. J J J J J J J




CognitiveLevel:Application J J

,Tes Bank for Medical Surgical Nursing Critical Thinking in
J




Clien Care,4th Edition Priscilla LeMon(100% Verified)
J




Client Needs:Safe,EffectiveCareEnvironment
J J J J J J




Nursing Process: Assessment J J




3. The nurse is caring for four clients on a medical–surgical unit. The secretary gives the nurse
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the morning labs. Which of the following labs would require that the nurse call the physician
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and inform the healthcare provider about the client’s abnormalities?
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1. WBC 14,600 mm3 J J




2. Serum protein 6.9 g/dL J J J




3. I & D (incision and drainage) showing no growth for the last 24 hours
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4. Albumin 4.2 g/dL J J




Answer: 1 J




Rationale: When the nurse is caring for several clients, all ofthe labs should bechecked frequently
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throughout the shift to assess for any abnormalities. The WBC in option 1 is abnormal. (Normal
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WBC 4,000–10,000 mm3.) All of the other lab results are within acceptable range; therefore, the
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results should not be called in to the physician.
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Cognitive Level: Application Client J J J J




Needs:PhysiologicIntegrity J J J




Nursing Process: Assessment J J




4. The nurse is orienting a new graduate. The nurse is reinforcing the importance of
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standard precautions. Which ofthe following observations bythe nurse would require
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further education regarding standard precautions?
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1. The graduate nurse understands to wash hands when entering and exiting the
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client’s room. J




2. The graduate nurse wears gloves when serving breakfast trays to various
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clients.
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a
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client.
4. The graduate nurse leaves all supplies in the roomofa client who is in
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contact isolation. J




Answer: 2 J




Rationale: The nurse must have an understanding of standard precautions. Prevention is the
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most important measure to prevent nosocomial infections. Standard precautions
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were published in 1996 that provide guidelines for the handling of blood and other
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bodyfluids. These guidelines are used with all clients, regardless of whether they have
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a known infectious disease. Standard precautions are used
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,Tes Bank for Medical Surgical Nursing Critical Thinking in
J




Clien Care,4th Edition Priscilla LeMon(100% Verified)
J




by all healthcare workers who have direct contact with clients or with their body
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fluids. It is not necessary for the nurse to wear gloves while delivering food trays to the
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client, because there is not contact with the client.
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CognitiveLevel:Application J J




Client Needs:Safe,EffectiveCareEnvironment
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Nursing Process: Evaluation J J




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




2. Airborne precautions J




3. Droplet precautions J




4. Contactprecautions J




Answer: 2 J




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




CognitiveLevel:Application J J




Client Needs:Safe,EffectiveCareEnvironment
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Nursing Process: Assessment J J




6. Aclient is receiving IV vancomycin for the treatment of Clostridium difficile. The
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nurseunderstands that the client who develops flushing, tachycardia, and hypotension
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during the infusion of vancomycin indicates:
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1. Ototoxicityeffect. J




2. Superinfection.
3. Red man syndrome. J J




4. Hives.

Answer: 3 J




Rationale:Vancomycin inhibits cellwallsynthesis, and isused forserious infections. It is only
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effective against gram-positive bacteria, especially Staphylococcus aureus and
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, Tes Bank for Medical Surgical Nursing Critical Thinking in
J




Clien Care,4th Edition Priscilla LeMon(100% Verified)
J




Staphylococcus epidermidis. The nurse should infuse this medication slowly over 60
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minutes or more to avoid “red man” syndrome. The syndrome is characterized by
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erythematous rash, flushing, tachycardia, and hypotension. Clients canbecome dizzyand
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agitated.

CognitiveLevel:Application J J




ClientNeeds:PhysiologicalIntegrity Nursing
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Process: Evaluation J




7. The physician has ordered for the client to receive a trough blood level to evaluate the
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therapeutic effect of an antibiotic. The nurse understands that the trough should be ordered:
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1. Afew minutes before the next scheduled dose of medication.
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2. 1–2 hours after the oral administration ofthe medication.
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3. 30 minutes after the IVadministration.
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4. During the infusion of the antibiotic. J J J J J




Answer: 1 J




Rationale: Antibiotic peak and trough levels monitor therapeutic blood levels of the
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prescribed medication. The therapeutic range—the minimum and maximum blood levels at
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which the drug is effective—is known for a given drug. By measuring blood levels at the
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predicted peak (1–2 hours after oral administration, 1 hour after intramuscular
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administration, and 30 minutes after IVadministration) and trough (usually a few minutes
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before the next scheduled dose), it is also possible to determine whether the drug is reaching a
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toxic or harmful level during therapy, increasing the likelihood of adverse effects.
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CognitiveLevel:Application J J




Client Needs:Safe,EffectiveCareEnvironment
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Nursing Process: Assessment
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8. The nurse needs to change a dressing on the client’s abdomen. Which ofthe following
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techniques should be implemented? J J J




1. Contact precautions J




2. Standard precautions J




3. Droplet precautions J




4. Airborne precautions J




Answer: 2 J