TESTBANK FOR LEMONE & BURKE’S MEDICAL-
SURGICAL NURSING: CLINICAL REASONING IN
HOSPITAL CLIENT CARE 7TH EDITION/ALL
CHAPTERS 1-52
,Chapter 1
1. The caregiver is caring for four Hospital clients on a medical–surgical unit. Which
Hospital client should the caregiver see initially?
1. A Hospital client admitted with hepatitis A who has had severe
diarrhea for thelast 24 hours
2. A Hospital client admitted with pneumonia who is has small
amounts ofyellow productive sputum
3. A Hospital client admitted with fever of unknown origin (FUO)
who hasbeen without fever for the last 48 hours
4. A Hospital client admitted with a wound infection whose WBC is
8,500 mm3ACCURATE ANSWER:-1
Reasoning:->>>The caregiver must decide which Hospital client should be seen on the
initial rounds of the day. The caregiver must remember that the first
Hospital client to be seen should be the Hospital client who needs the attention
of the caregiver initially. A Hospital client with hepatitis A does experience
diarrhea,but diarrhea for the last 24 hours could cause the Hospital client to
have a problem withdehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
EnvironmentNursing Process: Planning
2. The caregiver is preparing to administer influenza vaccines to a mass drive-through
clinic. Which statement by a Hospital client would indicate further questioning prior to
giving the Hospital 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.”
ACCURATE ANSWER:-3
Reasoning:->>>Influenza vaccines are recommended for person at high risk for serious
sequelae of influenza. The caregiver should be aware that Hospital client with a
sensitivity to eggs should not receive the vaccine. Vaccines prepared from
chicken or duck embryos are contraindicated in Hospital clients who are allergic
to eggs.
,Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
EnvironmentNursing Process: Assessment
3. The caregiver is caring for four Hospital clients on a medical–surgical unit. The
secretary gives the caregiver the morning labs. Which of the following labs would
require that the caregiver call the physician and inform the healthcare provider about the
Hospital 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
ACCURATE ANSWER:-1
Reasoning:->>>When the caregiver is caring for several Hospital clients, all of the
labsshould be checked frequently throughout the shift to assess for any abnormalities.
TheWBC 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
thephysician.
Cognitive Level: Application
Hospital client Needs:
Physiologic Integrity
Nursing Process:
Assessment
4. The caregiver is orienting a new graduate. The caregiver is reinforcing the
importance of standard precautions. Which of the following observations by the
caregiver would require further education regardingstandard precautions?
1. The graduate caregiver understands to wash hands whenentering
and exiting the Hospital client’s room.
2. The graduate caregiver wears gloves when serving breakfasttrays to
various Hospital clients.
3. The graduate caregiver wears a gown, gloves, and goggles when
suctioning a Hospital client.
4. The graduate caregiver leaves all supplies in the room of aHospital
client who is in contact isolation.
ACCURATE ANSWER:-2
Reasoning:->>>The caregiver 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 blood and other body fluids. These guidelines are used with
all Hospital clients, regardless of whether they have a known infectious disease.
Standardprecautions are used
by all healthcare workers who have direct contact with Hospital clients or with
their body fluids. It is not necessary for the caregiver to wear gloves while
delivering food trays to the Hospital client, because there is not contact with the
Hospital client.
Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
EnvironmentNursing Process: Evaluation
5. The admitting department alerts the caregiver on a medical–surgical unit thata
Hospital client with active tuberculosis (TB) is being admitted to the unit. Which type
of isolation is appropriate based on the Hospital client’s diagnosis?
1. Standard precautions
2. Airborne precautions
3. Droplet precautions
4. Contact precautions
ACCURATE ANSWER:-2
Reasoning:->>>In addition to handwashing and standard precautions, the nature and
spread of some infectious diseases require that special techniques be used to protect
uninfected Hospital clients and workers. The Hospital client with pulmonary tuberculosis
will be placed in airborne precautions. The Hospital client should be placed in a private
room with special ventilation that does not allow air to circulate to general health center
ventilation; a maskor special filter respirators will be used for everyone entering the
room.
Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
EnvironmentNursing Process: Assessment
6. A Hospital client is receiving IV vancomycin for the treatment of Clostridium
difficile.The caregiver understands that the Hospital client who develops
flushing, tachycardia, and hypotension during the infusion of vancomycin
indicates:
1. Ototoxicity effect.
2. Superinfection.
3. Red man syndrome.
4. Hives.
SURGICAL NURSING: CLINICAL REASONING IN
HOSPITAL CLIENT CARE 7TH EDITION/ALL
CHAPTERS 1-52
,Chapter 1
1. The caregiver is caring for four Hospital clients on a medical–surgical unit. Which
Hospital client should the caregiver see initially?
1. A Hospital client admitted with hepatitis A who has had severe
diarrhea for thelast 24 hours
2. A Hospital client admitted with pneumonia who is has small
amounts ofyellow productive sputum
3. A Hospital client admitted with fever of unknown origin (FUO)
who hasbeen without fever for the last 48 hours
4. A Hospital client admitted with a wound infection whose WBC is
8,500 mm3ACCURATE ANSWER:-1
Reasoning:->>>The caregiver must decide which Hospital client should be seen on the
initial rounds of the day. The caregiver must remember that the first
Hospital client to be seen should be the Hospital client who needs the attention
of the caregiver initially. A Hospital client with hepatitis A does experience
diarrhea,but diarrhea for the last 24 hours could cause the Hospital client to
have a problem withdehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
EnvironmentNursing Process: Planning
2. The caregiver is preparing to administer influenza vaccines to a mass drive-through
clinic. Which statement by a Hospital client would indicate further questioning prior to
giving the Hospital 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.”
ACCURATE ANSWER:-3
Reasoning:->>>Influenza vaccines are recommended for person at high risk for serious
sequelae of influenza. The caregiver should be aware that Hospital client with a
sensitivity to eggs should not receive the vaccine. Vaccines prepared from
chicken or duck embryos are contraindicated in Hospital clients who are allergic
to eggs.
,Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
EnvironmentNursing Process: Assessment
3. The caregiver is caring for four Hospital clients on a medical–surgical unit. The
secretary gives the caregiver the morning labs. Which of the following labs would
require that the caregiver call the physician and inform the healthcare provider about the
Hospital 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
ACCURATE ANSWER:-1
Reasoning:->>>When the caregiver is caring for several Hospital clients, all of the
labsshould be checked frequently throughout the shift to assess for any abnormalities.
TheWBC 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
thephysician.
Cognitive Level: Application
Hospital client Needs:
Physiologic Integrity
Nursing Process:
Assessment
4. The caregiver is orienting a new graduate. The caregiver is reinforcing the
importance of standard precautions. Which of the following observations by the
caregiver would require further education regardingstandard precautions?
1. The graduate caregiver understands to wash hands whenentering
and exiting the Hospital client’s room.
2. The graduate caregiver wears gloves when serving breakfasttrays to
various Hospital clients.
3. The graduate caregiver wears a gown, gloves, and goggles when
suctioning a Hospital client.
4. The graduate caregiver leaves all supplies in the room of aHospital
client who is in contact isolation.
ACCURATE ANSWER:-2
Reasoning:->>>The caregiver 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 blood and other body fluids. These guidelines are used with
all Hospital clients, regardless of whether they have a known infectious disease.
Standardprecautions are used
by all healthcare workers who have direct contact with Hospital clients or with
their body fluids. It is not necessary for the caregiver to wear gloves while
delivering food trays to the Hospital client, because there is not contact with the
Hospital client.
Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
EnvironmentNursing Process: Evaluation
5. The admitting department alerts the caregiver on a medical–surgical unit thata
Hospital client with active tuberculosis (TB) is being admitted to the unit. Which type
of isolation is appropriate based on the Hospital client’s diagnosis?
1. Standard precautions
2. Airborne precautions
3. Droplet precautions
4. Contact precautions
ACCURATE ANSWER:-2
Reasoning:->>>In addition to handwashing and standard precautions, the nature and
spread of some infectious diseases require that special techniques be used to protect
uninfected Hospital clients and workers. The Hospital client with pulmonary tuberculosis
will be placed in airborne precautions. The Hospital client should be placed in a private
room with special ventilation that does not allow air to circulate to general health center
ventilation; a maskor special filter respirators will be used for everyone entering the
room.
Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
EnvironmentNursing Process: Assessment
6. A Hospital client is receiving IV vancomycin for the treatment of Clostridium
difficile.The caregiver understands that the Hospital client who develops
flushing, tachycardia, and hypotension during the infusion of vancomycin
indicates:
1. Ototoxicity effect.
2. Superinfection.
3. Red man syndrome.
4. Hives.
