1
Test Bank for Medical-Surgical Nursing Critical Thinking
I I I I I I
in Client Care, 4th Edition Priscilla LeMon
I I I I I I I
Chapter 1 I
1. The Inurse Iis Icaring Ifor Ifour Iclients Ion Ia Imedical–surgical Iunit. IWhich Iclient Ishould Ithe
nurseI Isee Iinitially?
1. A Iclient Iadmitted Iwith Ihepatitis IA Iwho Ihas Ihad Isevere Idiarrhea Ifor Ithe Ilast
24I Ihours
2. A Iclient Iadmitted Iwith Ipneumonia Iwho Iis Ihas Ismall Iamounts Iof Iyellow
productiveI Isputum
3. A Iclient Iadmitted Iwith Ifever Iof Iunknown Iorigin I(FUO) Iwho Ihas Ibeen
withoutI Ifever Ifor Ithe Ilast I48 Ihours
4. A Iclient Iadmitted Iwith Ia Iwound Iinfection Iwhose IWBC Iis I8,500 Imm3
Answer: I1
Rationale: IThe Inurse Imust Idecide Iwhich Iclient Ishould Ibe Iseen Ion Ithe Iinitial Irounds Iof Ithe
day.I IThe Inurse Imust Iremember Ithat Ithe Ifirst Iclient Ito Ibe Iseen Ishould Ibe Ithe
Iclient whoI Ineeds Ithe Iattention Iof Ithe Inurse Iinitially. IA Iclient Iwith Ihepatitis
IA Idoes Iexperience Idiarrhea, Ibut Idiarrhea Ifor Ithe Ilast I24 Ihours Icould Icause Ithe
Iclient Ito
Ihave Ia Iproblem Iwith Idehydration Iand Iexperience Ia Istate Iof Ifluid Ivolume Ideficit.
Cognitive ILevel: IApplication
Client INeeds: ISafe, IEffective ICare IEnvironment
NursingI IProcess: IPlanning
2. The Inurse Iis Ipreparing Ito Iadminister Iinfluenza Ivaccines Ito Ia Imass Idrive-through Iclinic.
WhichI Istatement Iby Ia Iclient Iwould Iindicate Ifurther Iquestioning Iprior Ito Igiving Ithe Iclient
Ithe Iinfluenza Ivaccine?
1. “I Iam Iallergic Ito Ihorse Ihair.”
2. “I Itry Ito Iget Imy Ivaccine Ievery Iyear.”
3. “I Iam Inot Iallergic Ito Ianything Iexcept Ieggs.”
4. “My Ihusband Ihad Ia Isevere Iallergic Ireaction Iafter Ihe Ireceived Ihis Iinfluenza
vaccine.”I
Answer: I3
Rationale: IInfluenza Ivaccines Iare Irecommended Ifor Iperson Iat Ihigh Irisk Ifor Iserious
Isequelae Iof Iinfluenza. IThe Inurse Ishould Ibe Iaware Ithat Iclient Iwith Ia Isensitivity Ito
eggsI Ishould Inot Ireceive Ithe Ivaccine. IVaccines Iprepared Ifrom Ichicken Ior Iduck
Iembryos Iare Icontraindicated Iin Iclients Iwho Iare Iallergic Ito Ieggs.
Page 1 of 370
,2
Test Bank for Medical-Surgical Nursing Critical Thinking
I I I I I I
in Client Care, 4th Edition Priscilla LeMon
I I I I I I I
Cognitive ILevel: IApplication
Client INeeds: ISafe, IEffective ICare IEnvironment
NursingI IProcess: IAssessment
3. The Inurse Iis Icaring Ifor Ifour Iclients Ion Ia Imedical–surgical Iunit. IThe Isecretary Igives
Ithe nurseI Ithe Imorning Ilabs. IWhich Iof Ithe Ifollowing Ilabs Iwould Irequire Ithat Ithe Inurse
Icall Ithe physicianI Iand Iinform Ithe Ihealthcare Iprovider Iabout Ithe Iclient’s Iabnormalities?
1. I WBC I14,600 Imm3
2. Serum Iprotein I6.9 Ig/dL
3. I I& ID I(incision Iand Idrainage) Ishowing Ino Igrowth Ifor Ithe Ilast I24 Ihours
4. Albumin I4.2 Ig/dL
Answer: I1
Rationale: IWhen Ithe Inurse Iis Icaring Ifor Iseveral Iclients, Iall Iof Ithe Ilabs Ishould Ibe Ichecked
frequentlyI Ithroughout Ithe Ishift Ito Iassess Ifor Iany Iabnormalities. IThe IWBC Iin Ioption I1 Iis
3
Iabnormal. I(Normal IWBC I4,000–10,000 Imm .) IAll Iof Ithe Iother Ilab Iresults Iare Iwithin
Iacceptable Irange; Itherefore, Ithe Iresults Ishould Inot Ibe Icalled Iin Ito Ithe Iphysician.
Cognitive ILevel: IApplication
IClient INeeds: IPhysiologic
IIntegrityNursing I IProcess:
IAssessment
4. The Inurse Iis Iorienting Ia Inew Igraduate. IThe Inurse Iis Ireinforcing Ithe Iimportance Iof
Istandard Iprecautions. IWhich Iof Ithe Ifollowing Iobservations Iby Ithe Inurse Iwould Irequire furtherI
Ieducation Iregarding Istandard Iprecautions?
1. The Igraduate Inurse Iunderstands Ito Iwash Ihands Iwhen Ientering Iand Iexiting
theI Iclient’s Iroom.
2. The Igraduate Inurse Iwears Igloves Iwhen Iserving Ibreakfast Itrays Ito Ivarious
clients.I
3. The Igraduate Inurse Iwears Ia Igown, Igloves, Iand Igoggles Iwhen Isuctioning Ia
client.I
4. The Igraduate Inurse Ileaves Iall Isupplies Iin Ithe Iroom Iof Ia Iclient Iwho Iis Iin
contactI Iisolation.
Answer: I2
Rationale: IThe Inurse Imust Ihave Ian Iunderstanding Iof Istandard Iprecautions. IPrevention Iis
theI Imost Iimportant Imeasure Ito Iprevent Inosocomial Iinfections. IStandard
Iprecautions Iwere Ipublished Iin I1996 Ithat Iprovide Iguidelines Ifor Ithe Ihandling Iof
Page 2 of 370
,3
blood Iand Iother Ibody Ifluids. IThese Iguidelines Iare Iused Iwith Iall Iclients, Iregardless
ofI Iwhether Ithey Ihave Ia Iknown Iinfectious Idisease. IStandard Iprecautions Iare Iused
Iby Iall Ihealthcare Iworkers Iwho Ihave Idirect Icontact Iwith Iclients Ior Iwith Itheir Ibody
Ifluids. IIt Iis Inot Inecessary Ifor Ithe Inurse Ito Iwear Igloves Iwhile Idelivering Ifood Itrays
toI Ithe Iclient, Ibecause Ithere Iis Inot Icontact Iwith Ithe Iclient.
Cognitive ILevel: IApplication
Client INeeds: ISafe, IEffective ICare IEnvironment
NursingI IProcess: IEvaluation
5. The Iadmitting Idepartment Ialerts Ithe Inurse Ion Ia Imedical–surgical Iunit Ithat Ia Iclient Iwith
activeI Ituberculosis I(TB) Iis Ibeing Iadmitted Ito Ithe Iunit. IWhich Itype Iof Iisolation Iis
Iappropriate Ibased Ion Ithe Iclient’s Idiagnosis?
1. Standard Iprecautions
2. Airborne Iprecautions
3. Droplet Iprecautions
4. Contact Iprecautions
Answer: I2
In Iaddition Ito Ihandwashing Iand Istandard Iprecautions, Ithe Inature Iand Ispread Iof Isome
Iinfectious Idiseases Irequire Ithat Ispecial Itechniques Ibe Iused Ito Iprotect Iuninfected Iclients
andI Iworkers. IThe Iclient Iwith Ipulmonary Ituberculosis Iwill Ibe Iplaced Iin Iairborne
Iprecautions. IThe Iclient Ishould Ibe Iplaced Iin Ia Iprivate Iroom Iwith Ispecial Iventilation Ithat
doesI Inot Iallow Iair Ito Icirculate Ito Igeneral Ihospital Iventilation; Ia Imask Ior Ispecial Ifilter
Irespirators Iwill Ibe Iused Ifor Ieveryone Ientering Ithe Iroom.
Cognitive ILevel: IApplication
Client INeeds: ISafe, IEffective ICare IEnvironment
NursingI IProcess: IAssessment
6. A Iclient Iis Ireceiving IIV Ivancomycin Ifor Ithe Itreatment Iof IClostridium Idifficile. IThe
Inurse Iunderstands Ithat Ithe Iclient Iwho Idevelops Iflushing, Itachycardia, Iand Ihypotension
duringI Ithe Iinfusion Iof Ivancomycin Iindicates:
1. Ototoxicity Ieffect.
2. Superinfection.
3. Red Iman Isyndrome.
4. Hives.
Answer: I3
Page 3 of 370
, 4
Rationale: IVancomycin Iinhibits Icell Iwall Isynthesis, Iand Iis Iused Ifor Iserious Iinfections. IIt Iis
onlyI Ieffective Iagainst Igram-positive Ibacteria, Iespecially IStaphylococcus Iaureus Iand
IStaphylococcus Iepidermidis. IThe Inurse Ishould Iinfuse Ithis Imedication Islowly Iover I60
Iminutes Ior Imore Ito Iavoid I“red Iman” Isyndrome. IThe Isyndrome Iis Icharacterized Iby
Ierythematous Irash, Iflushing, Itachycardia, Iand Ihypotension. IClients Ican Ibecome Idizzy Iand
agitated.I
Cognitive ILevel: IApplication
Client INeeds: IPhysiological IIntegrity
NursingI IProcess: IEvaluation
7. The Iphysician Ihas Iordered Ifor Ithe Iclient Ito Ireceive Ia Itrough Iblood Ilevel Ito Ievaluate Ithe
therapeuticI Ieffect Iof Ian Iantibiotic. IThe Inurse Iunderstands Ithat Ithe Itrough Ishould Ibe
Iordered:
1. A Ifew Iminutes Ibefore Ithe Inext Ischeduled Idose Iof Imedication.
2. 1–2 Ihours Iafter Ithe Ioral Iadministration Iof Ithe Imedication.
3. 30 Iminutes Iafter Ithe IIV Iadministration.
4. During Ithe Iinfusion Iof Ithe Iantibiotic.
Answer: I1
Rationale: IAntibiotic Ipeak Iand Itrough Ilevels Imonitor Itherapeutic Iblood Ilevels Iof Ithe
Iprescribed Imedication. IThe Itherapeutic Irange—the Iminimum Iand Imaximum Iblood Ilevels
atI Iwhich Ithe Idrug Iis Ieffective—is Iknown Ifor Ia Igiven Idrug. IBy Imeasuring Iblood Ilevels Iat
Ithe Ipredicted Ipeak I(1–2 Ihours Iafter Ioral Iadministration, I1 Ihour Iafter Iintramuscular
Iadministration, Iand I30 Iminutes Iafter IIV Iadministration) Iand Itrough I(usually Ia Ifew
Iminutes Ibefore Ithe Inext Ischeduled Idose), Iit Iis Ialso Ipossible Ito Idetermine Iwhether Ithe Idrug
iI s Ireaching Ia Itoxic Ior Iharmful Ilevel Iduring Itherapy, Iincreasing Ithe Ilikelihood Iof Iadverse
Ieffects.
Cognitive ILevel: IApplication
Client INeeds: ISafe, IEffective ICare IEnvironment
NursingI IProcess: IAssessment
8. The Inurse Ineeds Ito Ichange Ia Idressing Ion Ithe Iclient’s Iabdomen. IWhich Iof Ithe Ifollowing
techniquesI Ishould Ibe Iimplemented?
1. Contact Iprecautions
2. Standard Iprecautions
3. Droplet Iprecautions
4. Airborne Iprecautions
Answer: I2
Rationale: IStandard Iprecautions Iare Iused Ion Iall Iclients, Iregardless Iof Iwhether Ithey Ihave Ia
knowI Iinfectious Idisease. IStandard Iprecautions Iare Iused Iby Iall Ihealthcare Iworkers
Iwho
Page 4 of 370
Test Bank for Medical-Surgical Nursing Critical Thinking
I I I I I I
in Client Care, 4th Edition Priscilla LeMon
I I I I I I I
Chapter 1 I
1. The Inurse Iis Icaring Ifor Ifour Iclients Ion Ia Imedical–surgical Iunit. IWhich Iclient Ishould Ithe
nurseI Isee Iinitially?
1. A Iclient Iadmitted Iwith Ihepatitis IA Iwho Ihas Ihad Isevere Idiarrhea Ifor Ithe Ilast
24I Ihours
2. A Iclient Iadmitted Iwith Ipneumonia Iwho Iis Ihas Ismall Iamounts Iof Iyellow
productiveI Isputum
3. A Iclient Iadmitted Iwith Ifever Iof Iunknown Iorigin I(FUO) Iwho Ihas Ibeen
withoutI Ifever Ifor Ithe Ilast I48 Ihours
4. A Iclient Iadmitted Iwith Ia Iwound Iinfection Iwhose IWBC Iis I8,500 Imm3
Answer: I1
Rationale: IThe Inurse Imust Idecide Iwhich Iclient Ishould Ibe Iseen Ion Ithe Iinitial Irounds Iof Ithe
day.I IThe Inurse Imust Iremember Ithat Ithe Ifirst Iclient Ito Ibe Iseen Ishould Ibe Ithe
Iclient whoI Ineeds Ithe Iattention Iof Ithe Inurse Iinitially. IA Iclient Iwith Ihepatitis
IA Idoes Iexperience Idiarrhea, Ibut Idiarrhea Ifor Ithe Ilast I24 Ihours Icould Icause Ithe
Iclient Ito
Ihave Ia Iproblem Iwith Idehydration Iand Iexperience Ia Istate Iof Ifluid Ivolume Ideficit.
Cognitive ILevel: IApplication
Client INeeds: ISafe, IEffective ICare IEnvironment
NursingI IProcess: IPlanning
2. The Inurse Iis Ipreparing Ito Iadminister Iinfluenza Ivaccines Ito Ia Imass Idrive-through Iclinic.
WhichI Istatement Iby Ia Iclient Iwould Iindicate Ifurther Iquestioning Iprior Ito Igiving Ithe Iclient
Ithe Iinfluenza Ivaccine?
1. “I Iam Iallergic Ito Ihorse Ihair.”
2. “I Itry Ito Iget Imy Ivaccine Ievery Iyear.”
3. “I Iam Inot Iallergic Ito Ianything Iexcept Ieggs.”
4. “My Ihusband Ihad Ia Isevere Iallergic Ireaction Iafter Ihe Ireceived Ihis Iinfluenza
vaccine.”I
Answer: I3
Rationale: IInfluenza Ivaccines Iare Irecommended Ifor Iperson Iat Ihigh Irisk Ifor Iserious
Isequelae Iof Iinfluenza. IThe Inurse Ishould Ibe Iaware Ithat Iclient Iwith Ia Isensitivity Ito
eggsI Ishould Inot Ireceive Ithe Ivaccine. IVaccines Iprepared Ifrom Ichicken Ior Iduck
Iembryos Iare Icontraindicated Iin Iclients Iwho Iare Iallergic Ito Ieggs.
Page 1 of 370
,2
Test Bank for Medical-Surgical Nursing Critical Thinking
I I I I I I
in Client Care, 4th Edition Priscilla LeMon
I I I I I I I
Cognitive ILevel: IApplication
Client INeeds: ISafe, IEffective ICare IEnvironment
NursingI IProcess: IAssessment
3. The Inurse Iis Icaring Ifor Ifour Iclients Ion Ia Imedical–surgical Iunit. IThe Isecretary Igives
Ithe nurseI Ithe Imorning Ilabs. IWhich Iof Ithe Ifollowing Ilabs Iwould Irequire Ithat Ithe Inurse
Icall Ithe physicianI Iand Iinform Ithe Ihealthcare Iprovider Iabout Ithe Iclient’s Iabnormalities?
1. I WBC I14,600 Imm3
2. Serum Iprotein I6.9 Ig/dL
3. I I& ID I(incision Iand Idrainage) Ishowing Ino Igrowth Ifor Ithe Ilast I24 Ihours
4. Albumin I4.2 Ig/dL
Answer: I1
Rationale: IWhen Ithe Inurse Iis Icaring Ifor Iseveral Iclients, Iall Iof Ithe Ilabs Ishould Ibe Ichecked
frequentlyI Ithroughout Ithe Ishift Ito Iassess Ifor Iany Iabnormalities. IThe IWBC Iin Ioption I1 Iis
3
Iabnormal. I(Normal IWBC I4,000–10,000 Imm .) IAll Iof Ithe Iother Ilab Iresults Iare Iwithin
Iacceptable Irange; Itherefore, Ithe Iresults Ishould Inot Ibe Icalled Iin Ito Ithe Iphysician.
Cognitive ILevel: IApplication
IClient INeeds: IPhysiologic
IIntegrityNursing I IProcess:
IAssessment
4. The Inurse Iis Iorienting Ia Inew Igraduate. IThe Inurse Iis Ireinforcing Ithe Iimportance Iof
Istandard Iprecautions. IWhich Iof Ithe Ifollowing Iobservations Iby Ithe Inurse Iwould Irequire furtherI
Ieducation Iregarding Istandard Iprecautions?
1. The Igraduate Inurse Iunderstands Ito Iwash Ihands Iwhen Ientering Iand Iexiting
theI Iclient’s Iroom.
2. The Igraduate Inurse Iwears Igloves Iwhen Iserving Ibreakfast Itrays Ito Ivarious
clients.I
3. The Igraduate Inurse Iwears Ia Igown, Igloves, Iand Igoggles Iwhen Isuctioning Ia
client.I
4. The Igraduate Inurse Ileaves Iall Isupplies Iin Ithe Iroom Iof Ia Iclient Iwho Iis Iin
contactI Iisolation.
Answer: I2
Rationale: IThe Inurse Imust Ihave Ian Iunderstanding Iof Istandard Iprecautions. IPrevention Iis
theI Imost Iimportant Imeasure Ito Iprevent Inosocomial Iinfections. IStandard
Iprecautions Iwere Ipublished Iin I1996 Ithat Iprovide Iguidelines Ifor Ithe Ihandling Iof
Page 2 of 370
,3
blood Iand Iother Ibody Ifluids. IThese Iguidelines Iare Iused Iwith Iall Iclients, Iregardless
ofI Iwhether Ithey Ihave Ia Iknown Iinfectious Idisease. IStandard Iprecautions Iare Iused
Iby Iall Ihealthcare Iworkers Iwho Ihave Idirect Icontact Iwith Iclients Ior Iwith Itheir Ibody
Ifluids. IIt Iis Inot Inecessary Ifor Ithe Inurse Ito Iwear Igloves Iwhile Idelivering Ifood Itrays
toI Ithe Iclient, Ibecause Ithere Iis Inot Icontact Iwith Ithe Iclient.
Cognitive ILevel: IApplication
Client INeeds: ISafe, IEffective ICare IEnvironment
NursingI IProcess: IEvaluation
5. The Iadmitting Idepartment Ialerts Ithe Inurse Ion Ia Imedical–surgical Iunit Ithat Ia Iclient Iwith
activeI Ituberculosis I(TB) Iis Ibeing Iadmitted Ito Ithe Iunit. IWhich Itype Iof Iisolation Iis
Iappropriate Ibased Ion Ithe Iclient’s Idiagnosis?
1. Standard Iprecautions
2. Airborne Iprecautions
3. Droplet Iprecautions
4. Contact Iprecautions
Answer: I2
In Iaddition Ito Ihandwashing Iand Istandard Iprecautions, Ithe Inature Iand Ispread Iof Isome
Iinfectious Idiseases Irequire Ithat Ispecial Itechniques Ibe Iused Ito Iprotect Iuninfected Iclients
andI Iworkers. IThe Iclient Iwith Ipulmonary Ituberculosis Iwill Ibe Iplaced Iin Iairborne
Iprecautions. IThe Iclient Ishould Ibe Iplaced Iin Ia Iprivate Iroom Iwith Ispecial Iventilation Ithat
doesI Inot Iallow Iair Ito Icirculate Ito Igeneral Ihospital Iventilation; Ia Imask Ior Ispecial Ifilter
Irespirators Iwill Ibe Iused Ifor Ieveryone Ientering Ithe Iroom.
Cognitive ILevel: IApplication
Client INeeds: ISafe, IEffective ICare IEnvironment
NursingI IProcess: IAssessment
6. A Iclient Iis Ireceiving IIV Ivancomycin Ifor Ithe Itreatment Iof IClostridium Idifficile. IThe
Inurse Iunderstands Ithat Ithe Iclient Iwho Idevelops Iflushing, Itachycardia, Iand Ihypotension
duringI Ithe Iinfusion Iof Ivancomycin Iindicates:
1. Ototoxicity Ieffect.
2. Superinfection.
3. Red Iman Isyndrome.
4. Hives.
Answer: I3
Page 3 of 370
, 4
Rationale: IVancomycin Iinhibits Icell Iwall Isynthesis, Iand Iis Iused Ifor Iserious Iinfections. IIt Iis
onlyI Ieffective Iagainst Igram-positive Ibacteria, Iespecially IStaphylococcus Iaureus Iand
IStaphylococcus Iepidermidis. IThe Inurse Ishould Iinfuse Ithis Imedication Islowly Iover I60
Iminutes Ior Imore Ito Iavoid I“red Iman” Isyndrome. IThe Isyndrome Iis Icharacterized Iby
Ierythematous Irash, Iflushing, Itachycardia, Iand Ihypotension. IClients Ican Ibecome Idizzy Iand
agitated.I
Cognitive ILevel: IApplication
Client INeeds: IPhysiological IIntegrity
NursingI IProcess: IEvaluation
7. The Iphysician Ihas Iordered Ifor Ithe Iclient Ito Ireceive Ia Itrough Iblood Ilevel Ito Ievaluate Ithe
therapeuticI Ieffect Iof Ian Iantibiotic. IThe Inurse Iunderstands Ithat Ithe Itrough Ishould Ibe
Iordered:
1. A Ifew Iminutes Ibefore Ithe Inext Ischeduled Idose Iof Imedication.
2. 1–2 Ihours Iafter Ithe Ioral Iadministration Iof Ithe Imedication.
3. 30 Iminutes Iafter Ithe IIV Iadministration.
4. During Ithe Iinfusion Iof Ithe Iantibiotic.
Answer: I1
Rationale: IAntibiotic Ipeak Iand Itrough Ilevels Imonitor Itherapeutic Iblood Ilevels Iof Ithe
Iprescribed Imedication. IThe Itherapeutic Irange—the Iminimum Iand Imaximum Iblood Ilevels
atI Iwhich Ithe Idrug Iis Ieffective—is Iknown Ifor Ia Igiven Idrug. IBy Imeasuring Iblood Ilevels Iat
Ithe Ipredicted Ipeak I(1–2 Ihours Iafter Ioral Iadministration, I1 Ihour Iafter Iintramuscular
Iadministration, Iand I30 Iminutes Iafter IIV Iadministration) Iand Itrough I(usually Ia Ifew
Iminutes Ibefore Ithe Inext Ischeduled Idose), Iit Iis Ialso Ipossible Ito Idetermine Iwhether Ithe Idrug
iI s Ireaching Ia Itoxic Ior Iharmful Ilevel Iduring Itherapy, Iincreasing Ithe Ilikelihood Iof Iadverse
Ieffects.
Cognitive ILevel: IApplication
Client INeeds: ISafe, IEffective ICare IEnvironment
NursingI IProcess: IAssessment
8. The Inurse Ineeds Ito Ichange Ia Idressing Ion Ithe Iclient’s Iabdomen. IWhich Iof Ithe Ifollowing
techniquesI Ishould Ibe Iimplemented?
1. Contact Iprecautions
2. Standard Iprecautions
3. Droplet Iprecautions
4. Airborne Iprecautions
Answer: I2
Rationale: IStandard Iprecautions Iare Iused Ion Iall Iclients, Iregardless Iof Iwhether Ithey Ihave Ia
knowI Iinfectious Idisease. IStandard Iprecautions Iare Iused Iby Iall Ihealthcare Iworkers
Iwho
Page 4 of 370
