Test Bank for Medical-Surgical Nursing Critical Thinking in
I I I I I I I
Client Care, 4th Edition Priscilla LeMon
I I I I I I
Chapterg1
1. Thegnursegisgcaringgforgfourgclientsgongagmedical–
surgicalgunit.gWhichgclientgshouldgthegnursegseeginitially?
1. AgclientgadmittedgwithghepatitisgAgwhoghasghadgseveregdiarrheagforgthegla
stg24ghours
2. Agclientgadmittedgwithgpneumoniagwhogisghasgsmallgamountsgofgyello
wgproductivegsputum
3. Agclientgadmittedgwithgfevergofgunknowngoriging(FUO)gwhoghasgbee
ngwithoutgfevergforgtheglastg48ghours
4. AgclientgadmittedgwithgagwoundginfectiongwhosegWBCgisg8,500gmm3
Answer:g1
Rationale:gThegnursegmustgdecidegwhichgclientgshouldgbegseengongtheginitialgroundsgofgthe
gday.gThegnursegmustgremembergthatgthegfirstgclientgtogbegseengshouldgbegthegclien
tgwhogneedsgthegattentiongofgthegnurseginitially.gAgclientgwithghepatitisgAgdoesgex
periencegdiarrhea,gbutgdiarrheagforgtheglastg24ghoursgcouldgcausegthegclientgtoghav
egagproblemgwithgdehydrationgandgexperiencegagstategofgfluidgvolumegdeficit.
CognitivegLevel:gApplication
ClientgNeeds:gSafe,gEffectivegCaregEnvironmentgNur
singgProcess:gPlanning
2. Thegnursegisgpreparinggtogadministerginfluenzagvaccinesgtogagmassgdrive-
throughgclinic.gWhichgstatementgbygagclientgwouldgindicategfurthergquestioninggpriorgtog
givinggthegclientgtheginfluenzagvaccine?
1. “Igamgallergicgtoghorseghair.”
2. “Igtrygtoggetgmygvaccinegeverygyear.”
3. “Igamgnotgallergicgtoganythinggexceptgeggs.”
4. “Myghusbandghadgagseveregallergicgreactiongafterghegreceivedghisginfluenz
agvaccine.”
Answer:g3
Rationale:gInfluenzagvaccinesgaregrecommendedgforgpersongatghighgriskgforgseriousgsequ
elaegofginfluenza.gThegnursegshouldgbegawaregthatgclientgwithgagsensitivitygtogeggs
gshouldgnotgreceivegthegvaccine.gVaccinesgpreparedgfromgchickengorgduckgembry
osgaregcontraindicatedgingclientsgwhogaregallergicgtogeggs.
,Test Bank for Medical-
I I I
Surgical Nursing Critical Thinking in Client Care, 4t
I I I I gI I I
hEditionPriscillaLeMon
CognitivegLevel:gApplication
ClientgNeeds:gSafe,gEffectivegCaregEnvironmentgNur
singgProcess:gAssessment
3. Thegnursegisgcaringgforgfourgclientsgongagmedical–
surgicalgunit.gThegsecretaryggivesgthegnursegthegmorningglabs.gWhichgofgthegfollowinggla
bsgwouldgrequiregthatgthegnursegcallgthegphysiciangandginformgtheghealthcaregprovidergab
outgthegclient’sgabnormalities?
1. WBCg14,600gmm3
2. Serumgproteing6.9gg/dL
3. Ig&gDg(incisiongandgdrainage)gshowinggnoggrowthgforgtheglastg24ghours
4. Albuming4.2gg/dL
Answer:g1
Rationale:gWhengthegnursegisgcaringgforgseveralgclients,gallgofgtheglabsgshouldgbegcheckedgfre
quentlygthroughoutgthegshiftgtogassessgforganygabnormalities.gThegWBCgingoptiong1gisgabnor
mal.g(NormalgWBCg4,000–
10,000gmm3.)gAllgofgthegotherglabgresultsgaregwithingacceptablegrange;gtherefore,gthegresults
gshouldgnotgbegcalledgingtogthegphysician.
CognitivegLevel:gApplication
gClientgNeeds:gPhysiologicgI
ntegrityNursinggProcess:
Assessment
4. Thegnursegisgorientinggagnewggraduate.gThegnursegisgreinforcinggthegimportancegofg
standardgprecautions.gWhichgofgthegfollowinggobservationsgbygthegnursegwouldgrequir
egfurthergeducationgregardinggstandardgprecautions?
1. Theggraduategnursegunderstandsgtogwashghandsgwhengenteringgandgexitin
ggthegclient’sgroom.
2. Theggraduategnursegwearsgglovesgwhengservinggbreakfastgtraysgtogvariou
sgclients.
3. Theggraduategnursegwearsgaggown,ggloves,gandggogglesgwhengsuctioningg
agclient.
4. Theggraduategnursegleavesgallgsuppliesgingthegroomgofgagclientgwhogisgi
ngcontactgisolation.
Answer:g2
Rationale:gThegnursegmustghavegangunderstandinggofgstandardgprecautions.gPreventiongisg
thegmostgimportantgmeasuregtogpreventgnosocomialginfections.gStandardgprecauti
onsgweregpublishedging1996gthatgprovidegguidelinesgforgtheghandlinggof
, bloodgandgothergbodygfluids.gThesegguidelinesgaregusedgwithgallgclients,gregardles
sgofgwhethergtheyghavegagknownginfectiousgdisease.gStandardgprecautionsgareguse
dgbygallghealthcaregworkersgwhoghavegdirectgcontactgwithgclientsgorgwithgtheirgbo
dygfluids.gItgisgnotgnecessarygforgthegnursegtogweargglovesgwhilegdeliveringgfoodgt
raysgtogthegclient,gbecausegtheregisgnotgcontactgwithgthegclient.
CognitivegLevel:gApplication
ClientgNeeds:gSafe,gEffectivegCaregEnvironmentgNur
singgProcess:gEvaluation
5. Thegadmittinggdepartmentgalertsgthegnursegongagmedical–
surgicalgunitgthatgagclientgwithgactivegtuberculosisg(TB)gisgbeinggadmittedgtogthegunit.gW
hichgtypegofgisolationgisgappropriategbasedgongthegclient’sgdiagnosis?
1. Standardgprecautions
2. Airbornegprecautions
3. Dropletgprecautions
4. Contactgprecautions
Answer:g2
Ingadditiongtoghandwashinggandgstandardgprecautions,gthegnaturegandgspreadgofgsomeginf
ectiousgdiseasesgrequiregthatgspecialgtechniquesgbegusedgtogprotectguninfectedgclientsgand
gworkers.gThegclientgwithgpulmonarygtuberculosisgwillgbegplacedgingairbornegprecautions
.gThegclientgshouldgbegplacedgingagprivategroomgwithgspecialgventilationgthatgdoesgnotgall
owgairgtogcirculategtoggeneralghospitalgventilation;gagmaskgorgspecialgfiltergrespiratorsgwil
lgbegusedgforgeveryonegenteringgthegroom.
CognitivegLevel:gApplication
ClientgNeeds:gSafe,gEffectivegCaregEnvironmentgNur
singgProcess:gAssessment
6. AgclientgisgreceivinggIVgvancomycingforgthegtreatmentgofgClostridiumgdifficile.gTh
egnursegunderstandsgthatgthegclientgwhogdevelopsgflushing,gtachycardia,gandghypotensi
ongduringgtheginfusiongofgvancomycingindicates:
1. Ototoxicitygeffect.
2. Superinfection.
3. Redgmangsyndrome.
4. Hives.
Answer:g3
, Rationale:gVancomycinginhibitsgcellgwallgsynthesis,gandgisgusedgforgseriousginfections.gItgisg
onlygeffectivegagainstggram-
positivegbacteria,gespeciallygStaphylococcusgaureusgandgStaphylococcusgepidermidis.gTheg
nursegshouldginfusegthisgmedicationgslowlygoverg60gminutesgorgmoregtogavoidg“redgman”gs
yndrome.gThegsyndromegisgcharacterizedgbygerythematousgrash,gflushing,gtachycardia,gandg
hypotension.gClientsgcangbecomegdizzygandgagitated.
CognitivegLevel:gApplication
ClientgNeeds:gPhysiologicalgIntegrit
ygNursinggProcess:gEvaluation
7. Thegphysicianghasgorderedgforgthegclientgtogreceivegagtroughgbloodglevelgtogevaluategth
egtherapeuticgeffectgofgangantibiotic.gThegnursegunderstandsgthatgthegtroughgshouldgbegor
dered:
1. Agfewgminutesgbeforegthegnextgscheduledgdosegofgmedication.
2. 1–2ghoursgaftergthegoralgadministrationgofgthegmedication.
3. 30gminutesgaftergthegIVgadministration.
4. Duringgtheginfusiongofgthegantibiotic.
Answer:g1
Rationale:gAntibioticgpeakgandgtroughglevelsgmonitorgtherapeuticgbloodglevelsgofgthegpre
scribedgmedication.gThegtherapeuticgrange—
thegminimumgandgmaximumgbloodglevelsgatgwhichgthegdruggisgeffective—
isgknowngforgaggivengdrug.gBygmeasuringgbloodglevelsgatgthegpredictedgpeakg(1–
2ghoursgaftergoralgadministration,g1ghourgaftergintramusculargadministration,gandg30gmin
utesgaftergIVgadministration)gandgtroughg(usuallygagfewgminutesgbeforegthegnextgschedul
edgdose),gitgisgalsogpossiblegtogdeterminegwhethergthegdruggisgreachinggagtoxicgorgharmful
glevelgduringgtherapy,gincreasinggtheglikelihoodgofgadversegeffects.
CognitivegLevel:gApplication
ClientgNeeds:gSafe,gEffectivegCaregEnvironmentgNur
singgProcess:gAssessment
8. Thegnursegneedsgtogchangegagdressinggongthegclient’sgabdomen.gWhichgofgthegfollowin
ggtechniquesgshouldgbegimplemented?
1. Contactgprecautions
2. Standardgprecautions
3. Dropletgprecautions
I I I I I I I
Client Care, 4th Edition Priscilla LeMon
I I I I I I
Chapterg1
1. Thegnursegisgcaringgforgfourgclientsgongagmedical–
surgicalgunit.gWhichgclientgshouldgthegnursegseeginitially?
1. AgclientgadmittedgwithghepatitisgAgwhoghasghadgseveregdiarrheagforgthegla
stg24ghours
2. Agclientgadmittedgwithgpneumoniagwhogisghasgsmallgamountsgofgyello
wgproductivegsputum
3. Agclientgadmittedgwithgfevergofgunknowngoriging(FUO)gwhoghasgbee
ngwithoutgfevergforgtheglastg48ghours
4. AgclientgadmittedgwithgagwoundginfectiongwhosegWBCgisg8,500gmm3
Answer:g1
Rationale:gThegnursegmustgdecidegwhichgclientgshouldgbegseengongtheginitialgroundsgofgthe
gday.gThegnursegmustgremembergthatgthegfirstgclientgtogbegseengshouldgbegthegclien
tgwhogneedsgthegattentiongofgthegnurseginitially.gAgclientgwithghepatitisgAgdoesgex
periencegdiarrhea,gbutgdiarrheagforgtheglastg24ghoursgcouldgcausegthegclientgtoghav
egagproblemgwithgdehydrationgandgexperiencegagstategofgfluidgvolumegdeficit.
CognitivegLevel:gApplication
ClientgNeeds:gSafe,gEffectivegCaregEnvironmentgNur
singgProcess:gPlanning
2. Thegnursegisgpreparinggtogadministerginfluenzagvaccinesgtogagmassgdrive-
throughgclinic.gWhichgstatementgbygagclientgwouldgindicategfurthergquestioninggpriorgtog
givinggthegclientgtheginfluenzagvaccine?
1. “Igamgallergicgtoghorseghair.”
2. “Igtrygtoggetgmygvaccinegeverygyear.”
3. “Igamgnotgallergicgtoganythinggexceptgeggs.”
4. “Myghusbandghadgagseveregallergicgreactiongafterghegreceivedghisginfluenz
agvaccine.”
Answer:g3
Rationale:gInfluenzagvaccinesgaregrecommendedgforgpersongatghighgriskgforgseriousgsequ
elaegofginfluenza.gThegnursegshouldgbegawaregthatgclientgwithgagsensitivitygtogeggs
gshouldgnotgreceivegthegvaccine.gVaccinesgpreparedgfromgchickengorgduckgembry
osgaregcontraindicatedgingclientsgwhogaregallergicgtogeggs.
,Test Bank for Medical-
I I I
Surgical Nursing Critical Thinking in Client Care, 4t
I I I I gI I I
hEditionPriscillaLeMon
CognitivegLevel:gApplication
ClientgNeeds:gSafe,gEffectivegCaregEnvironmentgNur
singgProcess:gAssessment
3. Thegnursegisgcaringgforgfourgclientsgongagmedical–
surgicalgunit.gThegsecretaryggivesgthegnursegthegmorningglabs.gWhichgofgthegfollowinggla
bsgwouldgrequiregthatgthegnursegcallgthegphysiciangandginformgtheghealthcaregprovidergab
outgthegclient’sgabnormalities?
1. WBCg14,600gmm3
2. Serumgproteing6.9gg/dL
3. Ig&gDg(incisiongandgdrainage)gshowinggnoggrowthgforgtheglastg24ghours
4. Albuming4.2gg/dL
Answer:g1
Rationale:gWhengthegnursegisgcaringgforgseveralgclients,gallgofgtheglabsgshouldgbegcheckedgfre
quentlygthroughoutgthegshiftgtogassessgforganygabnormalities.gThegWBCgingoptiong1gisgabnor
mal.g(NormalgWBCg4,000–
10,000gmm3.)gAllgofgthegotherglabgresultsgaregwithingacceptablegrange;gtherefore,gthegresults
gshouldgnotgbegcalledgingtogthegphysician.
CognitivegLevel:gApplication
gClientgNeeds:gPhysiologicgI
ntegrityNursinggProcess:
Assessment
4. Thegnursegisgorientinggagnewggraduate.gThegnursegisgreinforcinggthegimportancegofg
standardgprecautions.gWhichgofgthegfollowinggobservationsgbygthegnursegwouldgrequir
egfurthergeducationgregardinggstandardgprecautions?
1. Theggraduategnursegunderstandsgtogwashghandsgwhengenteringgandgexitin
ggthegclient’sgroom.
2. Theggraduategnursegwearsgglovesgwhengservinggbreakfastgtraysgtogvariou
sgclients.
3. Theggraduategnursegwearsgaggown,ggloves,gandggogglesgwhengsuctioningg
agclient.
4. Theggraduategnursegleavesgallgsuppliesgingthegroomgofgagclientgwhogisgi
ngcontactgisolation.
Answer:g2
Rationale:gThegnursegmustghavegangunderstandinggofgstandardgprecautions.gPreventiongisg
thegmostgimportantgmeasuregtogpreventgnosocomialginfections.gStandardgprecauti
onsgweregpublishedging1996gthatgprovidegguidelinesgforgtheghandlinggof
, bloodgandgothergbodygfluids.gThesegguidelinesgaregusedgwithgallgclients,gregardles
sgofgwhethergtheyghavegagknownginfectiousgdisease.gStandardgprecautionsgareguse
dgbygallghealthcaregworkersgwhoghavegdirectgcontactgwithgclientsgorgwithgtheirgbo
dygfluids.gItgisgnotgnecessarygforgthegnursegtogweargglovesgwhilegdeliveringgfoodgt
raysgtogthegclient,gbecausegtheregisgnotgcontactgwithgthegclient.
CognitivegLevel:gApplication
ClientgNeeds:gSafe,gEffectivegCaregEnvironmentgNur
singgProcess:gEvaluation
5. Thegadmittinggdepartmentgalertsgthegnursegongagmedical–
surgicalgunitgthatgagclientgwithgactivegtuberculosisg(TB)gisgbeinggadmittedgtogthegunit.gW
hichgtypegofgisolationgisgappropriategbasedgongthegclient’sgdiagnosis?
1. Standardgprecautions
2. Airbornegprecautions
3. Dropletgprecautions
4. Contactgprecautions
Answer:g2
Ingadditiongtoghandwashinggandgstandardgprecautions,gthegnaturegandgspreadgofgsomeginf
ectiousgdiseasesgrequiregthatgspecialgtechniquesgbegusedgtogprotectguninfectedgclientsgand
gworkers.gThegclientgwithgpulmonarygtuberculosisgwillgbegplacedgingairbornegprecautions
.gThegclientgshouldgbegplacedgingagprivategroomgwithgspecialgventilationgthatgdoesgnotgall
owgairgtogcirculategtoggeneralghospitalgventilation;gagmaskgorgspecialgfiltergrespiratorsgwil
lgbegusedgforgeveryonegenteringgthegroom.
CognitivegLevel:gApplication
ClientgNeeds:gSafe,gEffectivegCaregEnvironmentgNur
singgProcess:gAssessment
6. AgclientgisgreceivinggIVgvancomycingforgthegtreatmentgofgClostridiumgdifficile.gTh
egnursegunderstandsgthatgthegclientgwhogdevelopsgflushing,gtachycardia,gandghypotensi
ongduringgtheginfusiongofgvancomycingindicates:
1. Ototoxicitygeffect.
2. Superinfection.
3. Redgmangsyndrome.
4. Hives.
Answer:g3
, Rationale:gVancomycinginhibitsgcellgwallgsynthesis,gandgisgusedgforgseriousginfections.gItgisg
onlygeffectivegagainstggram-
positivegbacteria,gespeciallygStaphylococcusgaureusgandgStaphylococcusgepidermidis.gTheg
nursegshouldginfusegthisgmedicationgslowlygoverg60gminutesgorgmoregtogavoidg“redgman”gs
yndrome.gThegsyndromegisgcharacterizedgbygerythematousgrash,gflushing,gtachycardia,gandg
hypotension.gClientsgcangbecomegdizzygandgagitated.
CognitivegLevel:gApplication
ClientgNeeds:gPhysiologicalgIntegrit
ygNursinggProcess:gEvaluation
7. Thegphysicianghasgorderedgforgthegclientgtogreceivegagtroughgbloodglevelgtogevaluategth
egtherapeuticgeffectgofgangantibiotic.gThegnursegunderstandsgthatgthegtroughgshouldgbegor
dered:
1. Agfewgminutesgbeforegthegnextgscheduledgdosegofgmedication.
2. 1–2ghoursgaftergthegoralgadministrationgofgthegmedication.
3. 30gminutesgaftergthegIVgadministration.
4. Duringgtheginfusiongofgthegantibiotic.
Answer:g1
Rationale:gAntibioticgpeakgandgtroughglevelsgmonitorgtherapeuticgbloodglevelsgofgthegpre
scribedgmedication.gThegtherapeuticgrange—
thegminimumgandgmaximumgbloodglevelsgatgwhichgthegdruggisgeffective—
isgknowngforgaggivengdrug.gBygmeasuringgbloodglevelsgatgthegpredictedgpeakg(1–
2ghoursgaftergoralgadministration,g1ghourgaftergintramusculargadministration,gandg30gmin
utesgaftergIVgadministration)gandgtroughg(usuallygagfewgminutesgbeforegthegnextgschedul
edgdose),gitgisgalsogpossiblegtogdeterminegwhethergthegdruggisgreachinggagtoxicgorgharmful
glevelgduringgtherapy,gincreasinggtheglikelihoodgofgadversegeffects.
CognitivegLevel:gApplication
ClientgNeeds:gSafe,gEffectivegCaregEnvironmentgNur
singgProcess:gAssessment
8. Thegnursegneedsgtogchangegagdressinggongthegclient’sgabdomen.gWhichgofgthegfollowin
ggtechniquesgshouldgbegimplemented?
1. Contactgprecautions
2. Standardgprecautions
3. Dropletgprecautions
