BIO 102 Test Bank for Medical-Surgical Nursing Critical
Thinking in Client Care, 4th Edition Priscilla LeMon
Test Bank for Medical-Surgical Nursing Critical Thinking
in Client Care, 4th Edition Priscilla LeMon
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 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.”
Answer: 3
Rationale: Influenza vaccines are recommended for person at high risk for serious
sequelae 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.
,BIO 102 Test Bank for Medical-Surgical Nursing Critical
Thinking in Client Care, 4th Edition Priscilla LeMon
Test Bank for Medical-Surgical Nursing Critical Thinking
in Client Care, 4th Edition Priscilla LeMon
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 the
nurse the morning labs. Which of the following labs would require that the nurse call the
physician and inform the healthcare provider about 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 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
Client Needs: Physiologic Integrity
Nursing Process: Assessment
4. The nurse is orienting a new graduate. The nurse is reinforcing the importance of
standard precautions. Which of the following observations by the nurse would require
further education regarding standard precautions?
1. The graduate nurse understands to wash hands when entering and exiting
the client’s room.
2. The graduate nurse wears gloves when serving breakfast trays to various
clients.
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a
client.
4. The graduate nurse leav
ess1alls1suppliess1ins1thes1rooms1ofs1as1clients1whos1iss1ins1contacts1isolat
ion.
Answer:s12
Rationale:s1Thes1nurses1musts1haves1ans1understandings1ofs1standards1precautions.s1Preve
ntions1iss1thes1mosts1importants1measures1tos1prevents1nosocomials1infections.s1Sta
downloads1fulls1files1ats1http://testbankinstan
t.com
,BIO 102 Test Bank for Medical-Surgical Nursing Critical
Thinking in Client Care, 4th Edition Priscilla LeMon
ndards1precautionss1weres1publisheds1ins11996s1thats1provides1guideliness1fors1thes
1handlings1of
downloads1fulls1files1ats1http://testbankinstan
t.com
, BIO 102 Test Bank for Medical-Surgical Nursing Critical
Thinking in Client Care, 4th Edition Priscilla LeMon
bloods1ands1others1bodys1fluids.s1Theses1guideliness1ares1useds1withs1alls1clients,s1r
egardlesss1ofs1whethers1theys1haves1as1knowns1infectiouss1disease.s1Standards1prec
autionss1ares1useds1bys1alls1healthcares1workerss1whos1haves1directs1contacts1withs
1clientss1ors1withs1theirs1bodys1fluids.s1Its1iss1nots1necessarys1fors1thes1nurses1tos1w
ears1glovess1whiles1deliverings1foods1trayss1tos1thes1client,s1becauses1theres1iss1nots1
contacts1withs1thes1client.
Cognitives1Level:s1Application
Clients1Needs:s1Safe,s1Effectives1Cares1Environ
ments1Nursings1Process:s1Evaluation
5. Thes1admittings1departments1alertss1thes1nurses1ons1as1medical–
surgicals1units1thats1as1clients1withs1actives1tuberculosiss1(TB)s1iss1beings1admitteds1tos1the
s1unit.s1Whichs1types1ofs1isolations1iss1appropriates1baseds1ons1thes1client’ss1diagnosis?
1. Standards1precautions
2. Airbornes1precautions
3. Droplets1precautions
4. Contacts1precautions
Answer:s12
Ins1additions1tos1handwashings1ands1standards1precautions,s1thes1natures1ands1spreads1
ofs1somes1infectiouss1diseasess1requires1thats1specials1techniquess1bes1useds1tos1protect
s1uninfecteds1clientss1ands1workers.s1Thes1clients1withs1pulmonarys1tuberculosiss1wills1b
es1placeds1ins1airbornes1precautions.s1Thes1clients1shoulds1bes1placeds1ins1as1privates1ro
oms1withs1specials1ventilations1thats1doess1nots1allows1airs1tos1circulates1tos1generals1hos
pitals1ventilation;s1as1masks1ors1specials1filters1respiratorss1wills1bes1useds1fors1everyon
es1enterings1thes1room.
Cognitives1Level:s1Application
Clients1Needs:s1Safe,s1Effectives1Cares1Environ
ments1Nursings1Process:s1Assessment
6. As1clients1iss1receivings1IVs1vancomycins1fors1thes1treatments1ofs1Clostridiums1diffi
cile.s1Thes1nurses1understandss1thats1thes1clients1whos1developss1flushing,s1tachycardia
,s1ands1hypotensions1durings1thes1infusions1ofs1vancomycins1indicates:
1. Ototoxicitys1effect.
2. Superinfection.
3. Reds1mans1syndrome.
4. Hives.
Answer:s13
downloads1fulls1files1ats1http://testbankinstan
t.com
Thinking in Client Care, 4th Edition Priscilla LeMon
Test Bank for Medical-Surgical Nursing Critical Thinking
in Client Care, 4th Edition Priscilla LeMon
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 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.”
Answer: 3
Rationale: Influenza vaccines are recommended for person at high risk for serious
sequelae 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.
,BIO 102 Test Bank for Medical-Surgical Nursing Critical
Thinking in Client Care, 4th Edition Priscilla LeMon
Test Bank for Medical-Surgical Nursing Critical Thinking
in Client Care, 4th Edition Priscilla LeMon
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 the
nurse the morning labs. Which of the following labs would require that the nurse call the
physician and inform the healthcare provider about 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 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
Client Needs: Physiologic Integrity
Nursing Process: Assessment
4. The nurse is orienting a new graduate. The nurse is reinforcing the importance of
standard precautions. Which of the following observations by the nurse would require
further education regarding standard precautions?
1. The graduate nurse understands to wash hands when entering and exiting
the client’s room.
2. The graduate nurse wears gloves when serving breakfast trays to various
clients.
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a
client.
4. The graduate nurse leav
ess1alls1suppliess1ins1thes1rooms1ofs1as1clients1whos1iss1ins1contacts1isolat
ion.
Answer:s12
Rationale:s1Thes1nurses1musts1haves1ans1understandings1ofs1standards1precautions.s1Preve
ntions1iss1thes1mosts1importants1measures1tos1prevents1nosocomials1infections.s1Sta
downloads1fulls1files1ats1http://testbankinstan
t.com
,BIO 102 Test Bank for Medical-Surgical Nursing Critical
Thinking in Client Care, 4th Edition Priscilla LeMon
ndards1precautionss1weres1publisheds1ins11996s1thats1provides1guideliness1fors1thes
1handlings1of
downloads1fulls1files1ats1http://testbankinstan
t.com
, BIO 102 Test Bank for Medical-Surgical Nursing Critical
Thinking in Client Care, 4th Edition Priscilla LeMon
bloods1ands1others1bodys1fluids.s1Theses1guideliness1ares1useds1withs1alls1clients,s1r
egardlesss1ofs1whethers1theys1haves1as1knowns1infectiouss1disease.s1Standards1prec
autionss1ares1useds1bys1alls1healthcares1workerss1whos1haves1directs1contacts1withs
1clientss1ors1withs1theirs1bodys1fluids.s1Its1iss1nots1necessarys1fors1thes1nurses1tos1w
ears1glovess1whiles1deliverings1foods1trayss1tos1thes1client,s1becauses1theres1iss1nots1
contacts1withs1thes1client.
Cognitives1Level:s1Application
Clients1Needs:s1Safe,s1Effectives1Cares1Environ
ments1Nursings1Process:s1Evaluation
5. Thes1admittings1departments1alertss1thes1nurses1ons1as1medical–
surgicals1units1thats1as1clients1withs1actives1tuberculosiss1(TB)s1iss1beings1admitteds1tos1the
s1unit.s1Whichs1types1ofs1isolations1iss1appropriates1baseds1ons1thes1client’ss1diagnosis?
1. Standards1precautions
2. Airbornes1precautions
3. Droplets1precautions
4. Contacts1precautions
Answer:s12
Ins1additions1tos1handwashings1ands1standards1precautions,s1thes1natures1ands1spreads1
ofs1somes1infectiouss1diseasess1requires1thats1specials1techniquess1bes1useds1tos1protect
s1uninfecteds1clientss1ands1workers.s1Thes1clients1withs1pulmonarys1tuberculosiss1wills1b
es1placeds1ins1airbornes1precautions.s1Thes1clients1shoulds1bes1placeds1ins1as1privates1ro
oms1withs1specials1ventilations1thats1doess1nots1allows1airs1tos1circulates1tos1generals1hos
pitals1ventilation;s1as1masks1ors1specials1filters1respiratorss1wills1bes1useds1fors1everyon
es1enterings1thes1room.
Cognitives1Level:s1Application
Clients1Needs:s1Safe,s1Effectives1Cares1Environ
ments1Nursings1Process:s1Assessment
6. As1clients1iss1receivings1IVs1vancomycins1fors1thes1treatments1ofs1Clostridiums1diffi
cile.s1Thes1nurses1understandss1thats1thes1clients1whos1developss1flushing,s1tachycardia
,s1ands1hypotensions1durings1thes1infusions1ofs1vancomycins1indicates:
1. Ototoxicitys1effect.
2. Superinfection.
3. Reds1mans1syndrome.
4. Hives.
Answer:s13
downloads1fulls1files1ats1http://testbankinstan
t.com
