FULL TEST BANK!!!
Test Bank For Medical-Surgical Nursing Critical Thinking
In Client Care 4th Edition Author:Priscilla Lemone All
Chapters Covered 100% Complete A+ Study Guide Latest
Version
1|Page
,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 mm
3
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.
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,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 mm
3
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 leaves all supplies in the room of a client
who is in contact isolation.
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, Answer: 2
Rationale: The nurse must have an understanding of standard precautions.
Prevention is the most important measure to prevent nosocomial
infections. Standard precautions were published in 1996 that provide
guidelines for the handling of
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Test Bank For Medical-Surgical Nursing Critical Thinking
In Client Care 4th Edition Author:Priscilla Lemone All
Chapters Covered 100% Complete A+ Study Guide Latest
Version
1|Page
,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 mm
3
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.
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Distribution of this document is illegal
,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 mm
3
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 leaves all supplies in the room of a client
who is in contact isolation.
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, Answer: 2
Rationale: The nurse must have an understanding of standard precautions.
Prevention is the most important measure to prevent nosocomial
infections. Standard precautions were published in 1996 that provide
guidelines for the handling of
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