Test Bank for Medical Surgical Nursing Critical Thinking in C
k k k k k k k k k
lient Care,4th Edition Priscilla LeMon(100% Verified)
k k k k k
Chapter 1 k
1. Theknursekiskcaringkforkfourkclientskonkakmedical–
surgicalkunit.kWhichkclientkshouldktheknursekseekinitially?
1. AkclientkadmittedkwithkhepatitiskAkwhokhaskhadkseverekdiarrheakforktheklastk2
4khours
2. Akclientkadmittedkwithkpneumoniakwhokiskhasksmallkamountskofkyellowk
productiveksputum
3. Akclientkadmittedkwithkfeverkofkunknownkorigink(FUO)kwhokhaskbeenk
withoutkfeverkforktheklastk48khours
4. AkclientkadmittedkwithkakwoundkinfectionkwhosekWBCkisk8,500kmm3
Answer:k1
Rationale:kTheknursekmustkdecidekwhichkclientkshouldkbekseenkonkthekinitialkroundskofkthekd
ay.kTheknursekmustkrememberkthatkthekfirstkclientktokbekseenkshouldkbekthekclientkwh
okneedskthekattentionkofktheknursekinitially.kAkclientkwithkhepatitiskAkdoeskexperienc
ekdiarrhea,kbutkdiarrheakforktheklastk24khourskcouldkcausekthekclientktokhavekakproble
mkwithkdehydrationkandkexperiencekakstatekofkfluidkvolumekdeficit.
CognitivekLevel:kApplication
ClientkNeeds:kSafe,kEffectivekCarekEnvironmentkNurs
ingkProcess:kPlanning
2. Theknursekiskpreparingktokadministerkinfluenzakvaccinesktokakmasskdrive-
throughkclinic.kWhichkstatementkbykakclientkwouldkindicatekfurtherkquestioningkpriorktokgiv
ingkthekclientkthekinfluenzakvaccine?
1. ―Ikamkallergicktokhorsekhair.‖
2. ―Iktryktokgetkmykvaccinekeverykyear.‖
3. ―Ikamknotkallergicktokanythingkexceptkeggs.‖
4. ―Mykhusbandkhadkakseverekallergickreactionkafterkhekreceivedkhiskinfluenzak
vaccine.‖
Answer:k3
Rationale:kInfluenzakvaccineskarekrecommendedkforkpersonkatkhighkriskkforkseriousksequela
ekofkinfluenza.kTheknursekshouldkbekawarekthatkclientkwithkaksensitivityktokeggskshoul
dknotkreceivekthekvaccine.kVaccineskpreparedkfromkchickenkorkduckkembryoskarekco
ntraindicatedkinkclientskwhokarekallergicktokeggs.
CognitivekLevel:kApplication
,Test Bank for Medical Surgical Nursing Critical Thinking in C
k k k k k k k k k
lient Care,4th Edition Priscilla LeMon(100% Verified)
k k k k k
ClientkNeeds:kSafe,kEffectivekCarekEnvironmentkNurs
ingkProcess:kAssessment
3. Theknursekiskcaringkforkfourkclientskonkakmedical–
surgicalkunit.kTheksecretarykgivesktheknursekthekmorningklabs.kWhichkofkthekfollowingklabsk
wouldkrequirekthatktheknursekcallkthekphysiciankandkinformkthekhealthcarekproviderkaboutkth
ekclient‘skabnormalities?
1. WBCk14,600kmm3
2. Serumkproteink6.9kg/dL
3. Ik&kDk(incisionkandkdrainage)kshowingknokgrowthkforktheklastk24khours
4. Albumink4.2kg/dL
Answer:k1
Rationale:kWhenktheknursekiskcaringkforkseveralkclients,kallkofktheklabskshouldkbekcheckedkfreque
ntlykthroughoutkthekshiftktokassesskforkanykabnormalities.kThekWBCkinkoptionk1kiskabnormal.k(N
ormalkWBCk4,000–
10,000kmm3.)kAllkofkthekotherklabkresultskarekwithinkacceptablekrange;ktherefore,kthekresultsksho
uldknotkbekcalledkinktokthekphysician.
CognitivekLevel:kApplicationkClien
tkNeeds:kPhysiologickIntegritykNursi
ngkProcess:kAssessment
4. Theknursekiskorientingkaknewkgraduate.kTheknursekiskreinforcingkthekimportancekofksta
ndardkprecautions.kWhichkofkthekfollowingkobservationskbyktheknursekwouldkrequirekfurt
herkeducationkregardingkstandardkprecautions?
1. Thekgraduateknursekunderstandsktokwashkhandskwhenkenteringkandkexitingkt
hekclient‘skroom.
2. Thekgraduateknursekwearskgloveskwhenkservingkbreakfastktraysktokvariousk
clients.
3. Thekgraduateknursekwearskakgown,kgloves,kandkgoggleskwhenksuctioningkak
client.
4. Thekgraduateknursekleaveskallksupplieskinkthekroomkofkakclientkwhokiskinkc
ontactkisolation.
Answer:k2
Rationale:kTheknursekmustkhavekankunderstandingkofkstandardkprecautions.kPreventionkiskth
ekmostkimportantkmeasurektokpreventknosocomialkinfections.kStandardkprecautionsk
werekpublishedkink1996kthatkprovidekguidelineskforkthekhandlingkofkbloodkandkotherk
bodykfluids.kThesekguidelineskarekusedkwithkallkclients,kregardlesskofkwhetherktheykh
avekakknownkinfectiouskdisease.kStandardkprecautionskarekused
,Test Bank for Medical Surgical Nursing Critical Thinking in C
k k k k k k k k k
lient Care,4th Edition Priscilla LeMon(100% Verified)
k k k k k
bykallkhealthcarekworkerskwhokhavekdirectkcontactkwithkclientskorkwithktheirkbodykf
luids.kItkisknotknecessarykforktheknursektokwearkgloveskwhilekdeliveringkfoodktrayskto
kthekclient,kbecausektherekisknotkcontactkwithkthekclient.
CognitivekLevel:kApplication
ClientkNeeds:kSafe,kEffectivekCarekEnvironmentkNurs
ingkProcess:kEvaluation
5. Thekadmittingkdepartmentkalertsktheknursekonkakmedical–
surgicalkunitkthatkakclientkwithkactivektuberculosisk(TB)kiskbeingkadmittedktokthekunit.kWhic
hktypekofkisolationkiskappropriatekbasedkonkthekclient‘skdiagnosis?
1. Standardkprecautions
2. Airbornekprecautions
3. Dropletkprecautions
4. Contactkprecautions
Answer:k2
Inkadditionktokhandwashingkandkstandardkprecautions,ktheknaturekandkspreadkofksomekinfect
iouskdiseaseskrequirekthatkspecialktechniqueskbekusedktokprotectkuninfectedkclientskandkwork
ers.kThekclientkwithkpulmonaryktuberculosiskwillkbekplacedkinkairbornekprecautions.kThekcli
entkshouldkbekplacedkinkakprivatekroomkwithkspecialkventilationkthatkdoesknotkallowkairktokcir
culatektokgeneralkhospitalkventilation;kakmaskkorkspecialkfilterkrespiratorskwillkbekusedkforke
veryonekenteringkthekroom.
CognitivekLevel:kApplication
ClientkNeeds:kSafe,kEffectivekCarekEnvironmentkNurs
ingkProcess:kAssessment
6. AkclientkiskreceivingkIVkvancomycinkforkthektreatmentkofkClostridiumkdifficile.kThekn
ursekunderstandskthatkthekclientkwhokdevelopskflushing,ktachycardia,kandkhypotensionkd
uringkthekinfusionkofkvancomycinkindicates:
1. Ototoxicitykeffect.
2. Superinfection.
3. Redkmanksyndrome.
4. Hives.
Answer:k3
Rationale:kVancomycinkinhibitskcellkwallksynthesis,kandkiskusedkforkseriouskinfections.kItkisko
nlykeffectivekagainstkgram-positivekbacteria,kespeciallykStaphylococcuskaureuskand
, Test Bank for Medical Surgical Nursing Critical Thinking in C
k k k k k k k k k
lient Care,4th Edition Priscilla LeMon(100% Verified)
k k k k k
Staphylococcuskepidermidis.kTheknursekshouldkinfusekthiskmedicationkslowlykoverk60kmin
uteskorkmorektokavoidk―redkman‖ksyndrome.kTheksyndromekiskcharacterizedkbykerythemato
uskrash,kflushing,ktachycardia,kandkhypotension.kClientskcankbecomekdizzykandkagitated.
CognitivekLevel:kApplication
ClientkNeeds:kPhysiologicalkIntegritykNursin
gkProcess:kEvaluation
7. Thekphysiciankhaskorderedkforkthekclientktokreceivekaktroughkbloodklevelktokevaluatekthekt
herapeutickeffectkofkankantibiotic.kTheknursekunderstandskthatkthektroughkshouldkbekordere
d:
1. Akfewkminuteskbeforektheknextkscheduledkdosekofkmedication.
2. 1–2khourskafterkthekoralkadministrationkofkthekmedication.
3. 30kminuteskafterkthekIVkadministration.
4. Duringkthekinfusionkofkthekantibiotic.
Answer:k1
Rationale:kAntibiotickpeakkandktroughklevelskmonitorktherapeutickbloodklevelskofkthekprescr
ibedkmedication.kThektherapeutickrange—
thekminimumkandkmaximumkbloodklevelskatkwhichkthekdrugkiskeffective—
iskknownkforkakgivenkdrug.kBykmeasuringkbloodklevelskatkthekpredictedkpeakk(1–
2khourskafterkoralkadministration,k1khourkafterkintramuscularkadministration,kandk30kminutes
kafterkIVkadministration)kandktroughk(usuallykakfewkminuteskbeforektheknextkscheduledkdose)
,kitkiskalsokpossiblektokdeterminekwhetherkthekdrugkiskreachingkaktoxickorkharmfulklevelkdurin
gktherapy,kincreasingktheklikelihoodkofkadversekeffects.
CognitivekLevel:kApplication
ClientkNeeds:kSafe,kEffectivekCarekEnvironmentkNurs
ingkProcess:kAssessment
8. Theknursekneedsktokchangekakdressingkonkthekclient‘skabdomen.kWhichkofkthekfollowingkt
echniqueskshouldkbekimplemented?
1. Contactkprecautions
2. Standardkprecautions
3. Dropletkprecautions
4. Airbornekprecautions
Answer:k2
k k k k k k k k k
lient Care,4th Edition Priscilla LeMon(100% Verified)
k k k k k
Chapter 1 k
1. Theknursekiskcaringkforkfourkclientskonkakmedical–
surgicalkunit.kWhichkclientkshouldktheknursekseekinitially?
1. AkclientkadmittedkwithkhepatitiskAkwhokhaskhadkseverekdiarrheakforktheklastk2
4khours
2. Akclientkadmittedkwithkpneumoniakwhokiskhasksmallkamountskofkyellowk
productiveksputum
3. Akclientkadmittedkwithkfeverkofkunknownkorigink(FUO)kwhokhaskbeenk
withoutkfeverkforktheklastk48khours
4. AkclientkadmittedkwithkakwoundkinfectionkwhosekWBCkisk8,500kmm3
Answer:k1
Rationale:kTheknursekmustkdecidekwhichkclientkshouldkbekseenkonkthekinitialkroundskofkthekd
ay.kTheknursekmustkrememberkthatkthekfirstkclientktokbekseenkshouldkbekthekclientkwh
okneedskthekattentionkofktheknursekinitially.kAkclientkwithkhepatitiskAkdoeskexperienc
ekdiarrhea,kbutkdiarrheakforktheklastk24khourskcouldkcausekthekclientktokhavekakproble
mkwithkdehydrationkandkexperiencekakstatekofkfluidkvolumekdeficit.
CognitivekLevel:kApplication
ClientkNeeds:kSafe,kEffectivekCarekEnvironmentkNurs
ingkProcess:kPlanning
2. Theknursekiskpreparingktokadministerkinfluenzakvaccinesktokakmasskdrive-
throughkclinic.kWhichkstatementkbykakclientkwouldkindicatekfurtherkquestioningkpriorktokgiv
ingkthekclientkthekinfluenzakvaccine?
1. ―Ikamkallergicktokhorsekhair.‖
2. ―Iktryktokgetkmykvaccinekeverykyear.‖
3. ―Ikamknotkallergicktokanythingkexceptkeggs.‖
4. ―Mykhusbandkhadkakseverekallergickreactionkafterkhekreceivedkhiskinfluenzak
vaccine.‖
Answer:k3
Rationale:kInfluenzakvaccineskarekrecommendedkforkpersonkatkhighkriskkforkseriousksequela
ekofkinfluenza.kTheknursekshouldkbekawarekthatkclientkwithkaksensitivityktokeggskshoul
dknotkreceivekthekvaccine.kVaccineskpreparedkfromkchickenkorkduckkembryoskarekco
ntraindicatedkinkclientskwhokarekallergicktokeggs.
CognitivekLevel:kApplication
,Test Bank for Medical Surgical Nursing Critical Thinking in C
k k k k k k k k k
lient Care,4th Edition Priscilla LeMon(100% Verified)
k k k k k
ClientkNeeds:kSafe,kEffectivekCarekEnvironmentkNurs
ingkProcess:kAssessment
3. Theknursekiskcaringkforkfourkclientskonkakmedical–
surgicalkunit.kTheksecretarykgivesktheknursekthekmorningklabs.kWhichkofkthekfollowingklabsk
wouldkrequirekthatktheknursekcallkthekphysiciankandkinformkthekhealthcarekproviderkaboutkth
ekclient‘skabnormalities?
1. WBCk14,600kmm3
2. Serumkproteink6.9kg/dL
3. Ik&kDk(incisionkandkdrainage)kshowingknokgrowthkforktheklastk24khours
4. Albumink4.2kg/dL
Answer:k1
Rationale:kWhenktheknursekiskcaringkforkseveralkclients,kallkofktheklabskshouldkbekcheckedkfreque
ntlykthroughoutkthekshiftktokassesskforkanykabnormalities.kThekWBCkinkoptionk1kiskabnormal.k(N
ormalkWBCk4,000–
10,000kmm3.)kAllkofkthekotherklabkresultskarekwithinkacceptablekrange;ktherefore,kthekresultsksho
uldknotkbekcalledkinktokthekphysician.
CognitivekLevel:kApplicationkClien
tkNeeds:kPhysiologickIntegritykNursi
ngkProcess:kAssessment
4. Theknursekiskorientingkaknewkgraduate.kTheknursekiskreinforcingkthekimportancekofksta
ndardkprecautions.kWhichkofkthekfollowingkobservationskbyktheknursekwouldkrequirekfurt
herkeducationkregardingkstandardkprecautions?
1. Thekgraduateknursekunderstandsktokwashkhandskwhenkenteringkandkexitingkt
hekclient‘skroom.
2. Thekgraduateknursekwearskgloveskwhenkservingkbreakfastktraysktokvariousk
clients.
3. Thekgraduateknursekwearskakgown,kgloves,kandkgoggleskwhenksuctioningkak
client.
4. Thekgraduateknursekleaveskallksupplieskinkthekroomkofkakclientkwhokiskinkc
ontactkisolation.
Answer:k2
Rationale:kTheknursekmustkhavekankunderstandingkofkstandardkprecautions.kPreventionkiskth
ekmostkimportantkmeasurektokpreventknosocomialkinfections.kStandardkprecautionsk
werekpublishedkink1996kthatkprovidekguidelineskforkthekhandlingkofkbloodkandkotherk
bodykfluids.kThesekguidelineskarekusedkwithkallkclients,kregardlesskofkwhetherktheykh
avekakknownkinfectiouskdisease.kStandardkprecautionskarekused
,Test Bank for Medical Surgical Nursing Critical Thinking in C
k k k k k k k k k
lient Care,4th Edition Priscilla LeMon(100% Verified)
k k k k k
bykallkhealthcarekworkerskwhokhavekdirectkcontactkwithkclientskorkwithktheirkbodykf
luids.kItkisknotknecessarykforktheknursektokwearkgloveskwhilekdeliveringkfoodktrayskto
kthekclient,kbecausektherekisknotkcontactkwithkthekclient.
CognitivekLevel:kApplication
ClientkNeeds:kSafe,kEffectivekCarekEnvironmentkNurs
ingkProcess:kEvaluation
5. Thekadmittingkdepartmentkalertsktheknursekonkakmedical–
surgicalkunitkthatkakclientkwithkactivektuberculosisk(TB)kiskbeingkadmittedktokthekunit.kWhic
hktypekofkisolationkiskappropriatekbasedkonkthekclient‘skdiagnosis?
1. Standardkprecautions
2. Airbornekprecautions
3. Dropletkprecautions
4. Contactkprecautions
Answer:k2
Inkadditionktokhandwashingkandkstandardkprecautions,ktheknaturekandkspreadkofksomekinfect
iouskdiseaseskrequirekthatkspecialktechniqueskbekusedktokprotectkuninfectedkclientskandkwork
ers.kThekclientkwithkpulmonaryktuberculosiskwillkbekplacedkinkairbornekprecautions.kThekcli
entkshouldkbekplacedkinkakprivatekroomkwithkspecialkventilationkthatkdoesknotkallowkairktokcir
culatektokgeneralkhospitalkventilation;kakmaskkorkspecialkfilterkrespiratorskwillkbekusedkforke
veryonekenteringkthekroom.
CognitivekLevel:kApplication
ClientkNeeds:kSafe,kEffectivekCarekEnvironmentkNurs
ingkProcess:kAssessment
6. AkclientkiskreceivingkIVkvancomycinkforkthektreatmentkofkClostridiumkdifficile.kThekn
ursekunderstandskthatkthekclientkwhokdevelopskflushing,ktachycardia,kandkhypotensionkd
uringkthekinfusionkofkvancomycinkindicates:
1. Ototoxicitykeffect.
2. Superinfection.
3. Redkmanksyndrome.
4. Hives.
Answer:k3
Rationale:kVancomycinkinhibitskcellkwallksynthesis,kandkiskusedkforkseriouskinfections.kItkisko
nlykeffectivekagainstkgram-positivekbacteria,kespeciallykStaphylococcuskaureuskand
, Test Bank for Medical Surgical Nursing Critical Thinking in C
k k k k k k k k k
lient Care,4th Edition Priscilla LeMon(100% Verified)
k k k k k
Staphylococcuskepidermidis.kTheknursekshouldkinfusekthiskmedicationkslowlykoverk60kmin
uteskorkmorektokavoidk―redkman‖ksyndrome.kTheksyndromekiskcharacterizedkbykerythemato
uskrash,kflushing,ktachycardia,kandkhypotension.kClientskcankbecomekdizzykandkagitated.
CognitivekLevel:kApplication
ClientkNeeds:kPhysiologicalkIntegritykNursin
gkProcess:kEvaluation
7. Thekphysiciankhaskorderedkforkthekclientktokreceivekaktroughkbloodklevelktokevaluatekthekt
herapeutickeffectkofkankantibiotic.kTheknursekunderstandskthatkthektroughkshouldkbekordere
d:
1. Akfewkminuteskbeforektheknextkscheduledkdosekofkmedication.
2. 1–2khourskafterkthekoralkadministrationkofkthekmedication.
3. 30kminuteskafterkthekIVkadministration.
4. Duringkthekinfusionkofkthekantibiotic.
Answer:k1
Rationale:kAntibiotickpeakkandktroughklevelskmonitorktherapeutickbloodklevelskofkthekprescr
ibedkmedication.kThektherapeutickrange—
thekminimumkandkmaximumkbloodklevelskatkwhichkthekdrugkiskeffective—
iskknownkforkakgivenkdrug.kBykmeasuringkbloodklevelskatkthekpredictedkpeakk(1–
2khourskafterkoralkadministration,k1khourkafterkintramuscularkadministration,kandk30kminutes
kafterkIVkadministration)kandktroughk(usuallykakfewkminuteskbeforektheknextkscheduledkdose)
,kitkiskalsokpossiblektokdeterminekwhetherkthekdrugkiskreachingkaktoxickorkharmfulklevelkdurin
gktherapy,kincreasingktheklikelihoodkofkadversekeffects.
CognitivekLevel:kApplication
ClientkNeeds:kSafe,kEffectivekCarekEnvironmentkNurs
ingkProcess:kAssessment
8. Theknursekneedsktokchangekakdressingkonkthekclient‘skabdomen.kWhichkofkthekfollowingkt
echniqueskshouldkbekimplemented?
1. Contactkprecautions
2. Standardkprecautions
3. Dropletkprecautions
4. Airbornekprecautions
Answer:k2
