Test Bank for Understanding
Medical-Surgical Nursing 6th
Edition Linda S. Williams
Paula D. Hopper
,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
Answer: 1
Rationale: The nurse must decide which client should be seen on the initial rounds of the
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
have a problem with dehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
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 amt 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 influen
zavaccine.”
Answer: 3
Rationale: Influenza vaccines are recommended for person at high risk for serious se
quelae 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
Nursing Process: Assessment
3. The nurse is caring for four clients on a medical–
surgical unit. The secretary gives thenurse the morning labs. Which of the following l
abs would require that the nurse call t h e tpy hysician and inform the healthcare provider a
bout the client’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
Answer: 1
Rationale: When the nurse is caring for several clients, all of the labs should be checke
dfrequently 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 res
ults should not be called in to the physician.
Cognitive Level: Application Clie
nt Needs: Physiologic IntegrityNur
sing Process: Assessment
4. The nurse is orienting a new graduate. The nurse is reinforcing the importance o
f standard precautions. Which of the following observations by the nurse would req
uiretfy urther education regarding standard precautions?
1. The graduate nurse understands to wash hands when entering and exiti
ngthe client’s room.
2. The graduate nurse wears gloves when serving breakfast trays to vario
usclients.
3. The graduate nurse wears a gown, gloves, and goggles when suctioning
a t cy lient.
4. The graduate nurse leaves all supplies in the room of a client who ist
inycontact isolation.
Answer: 2
Rationale: The nurse must have an understanding of standard precautions. Prevention is
the most important measure to prevent nosocomial infections. Standard precaut
ions were published in 1996 that provide guidelines for the handling of blood a
nd other body fluids. These guidelines are used with all clients, regardlessof whe
ther they have a known infectious disease. Standard precautions are used
, by all healthcare workers who have direct contact with clients or with their body
fluids. It is not necessary for the nurse to wear gloves while delivering food tray
stty o the client, because there is not contact with the client.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environmen
tNursing Process: Evaluation
5. The admitting department alerts the nurse on a medical–
surgical unit that a client withactive tuberculosis (TB) is being admitted to the unit.
Which type of isolation is appropriate based on the client’s diagnosis?
1. Standard precautions
2. Airborne precautions
3. Droplet precautions
4. Contact precautions
Answer:a1 2
Ina1additiona1toa1handwashinga1anda1standarda1precautions,a1thea1naturea1anda1spreada
1ofa1somea1infectiousa1diseasesa1requirea1thata1speciala1techniquesa1bea1useda1toa1prote
cta1uninfecteda1cliea1ntsanda1workers.a1Thea1clienta1witha1pulmonarya1tuberculosisa1w
illa1bea1placeda1ina1airbornea1pa1recautions.a1Thea1clienta1shoulda1bea1placeda1ina1aa1pr
ivatea1rooma1witha1speciala1ventilationa1thaa1tdoesa1nota 1 allowa 1 aira1toa 1 circulatea1toa
1 generala 1 hospitala1ventilation;a 1 aa1maska1ora1speciala 1 filta1era1respiratorsa1willa1bea1u
seda1fora1everyonea1enteringa1thea1room.
Cognitivea1 Level:a1 Application
Clienta1Needs:a1Safe,a1Effectivea1Carea1Environmen
a1tNursinga1Process:a1Assessment
6. Aa1clienta1isa1receivinga1IVa1vancomycina1fora1thea1treatmenta1ofa1Clostridiuma1di
fficile.a1Ta1hea1nursea1understandsa1thata1thea1clienta1whoa1developsa1flushing,a1tachy
cardia,a1anda1hypotea1nsionduringa1thea1infusiona1ofa1vancomycina1indicates:
1. Ototoxicitya1 effect.
2. Superinfection.
3. Reda1 mana1 syndrome.
4. Hives.
Medical-Surgical Nursing 6th
Edition Linda S. Williams
Paula D. Hopper
,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
Answer: 1
Rationale: The nurse must decide which client should be seen on the initial rounds of the
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
have a problem with dehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
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 amt 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 influen
zavaccine.”
Answer: 3
Rationale: Influenza vaccines are recommended for person at high risk for serious se
quelae 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
Nursing Process: Assessment
3. The nurse is caring for four clients on a medical–
surgical unit. The secretary gives thenurse the morning labs. Which of the following l
abs would require that the nurse call t h e tpy hysician and inform the healthcare provider a
bout the client’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
Answer: 1
Rationale: When the nurse is caring for several clients, all of the labs should be checke
dfrequently 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 res
ults should not be called in to the physician.
Cognitive Level: Application Clie
nt Needs: Physiologic IntegrityNur
sing Process: Assessment
4. The nurse is orienting a new graduate. The nurse is reinforcing the importance o
f standard precautions. Which of the following observations by the nurse would req
uiretfy urther education regarding standard precautions?
1. The graduate nurse understands to wash hands when entering and exiti
ngthe client’s room.
2. The graduate nurse wears gloves when serving breakfast trays to vario
usclients.
3. The graduate nurse wears a gown, gloves, and goggles when suctioning
a t cy lient.
4. The graduate nurse leaves all supplies in the room of a client who ist
inycontact isolation.
Answer: 2
Rationale: The nurse must have an understanding of standard precautions. Prevention is
the most important measure to prevent nosocomial infections. Standard precaut
ions were published in 1996 that provide guidelines for the handling of blood a
nd other body fluids. These guidelines are used with all clients, regardlessof whe
ther they have a known infectious disease. Standard precautions are used
, by all healthcare workers who have direct contact with clients or with their body
fluids. It is not necessary for the nurse to wear gloves while delivering food tray
stty o the client, because there is not contact with the client.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environmen
tNursing Process: Evaluation
5. The admitting department alerts the nurse on a medical–
surgical unit that a client withactive tuberculosis (TB) is being admitted to the unit.
Which type of isolation is appropriate based on the client’s diagnosis?
1. Standard precautions
2. Airborne precautions
3. Droplet precautions
4. Contact precautions
Answer:a1 2
Ina1additiona1toa1handwashinga1anda1standarda1precautions,a1thea1naturea1anda1spreada
1ofa1somea1infectiousa1diseasesa1requirea1thata1speciala1techniquesa1bea1useda1toa1prote
cta1uninfecteda1cliea1ntsanda1workers.a1Thea1clienta1witha1pulmonarya1tuberculosisa1w
illa1bea1placeda1ina1airbornea1pa1recautions.a1Thea1clienta1shoulda1bea1placeda1ina1aa1pr
ivatea1rooma1witha1speciala1ventilationa1thaa1tdoesa1nota 1 allowa 1 aira1toa 1 circulatea1toa
1 generala 1 hospitala1ventilation;a 1 aa1maska1ora1speciala 1 filta1era1respiratorsa1willa1bea1u
seda1fora1everyonea1enteringa1thea1room.
Cognitivea1 Level:a1 Application
Clienta1Needs:a1Safe,a1Effectivea1Carea1Environmen
a1tNursinga1Process:a1Assessment
6. Aa1clienta1isa1receivinga1IVa1vancomycina1fora1thea1treatmenta1ofa1Clostridiuma1di
fficile.a1Ta1hea1nursea1understandsa1thata1thea1clienta1whoa1developsa1flushing,a1tachy
cardia,a1anda1hypotea1nsionduringa1thea1infusiona1ofa1vancomycina1indicates:
1. Ototoxicitya1 effect.
2. Superinfection.
3. Reda1 mana1 syndrome.
4. Hives.
