NEW UPDATE 2022/2023 CRITICAL THINKING BIO 102 TEST
BANK FOR MEDICAL-SURGICAL NURSING IN CLIENT
CARE EXAM QUESTIONS AND ANSWERS BEST RATED A+
ASSURED SUCCESS(chapter 1-52 covered)
Chapter 1
• A client develops hyperthermia related to a diagnosis of Pneumonia.
Which of the following nursing interventions would be effective in the
treatment of hyperthermia? Select all that apply.
1. Increase the temperature of the room environment to prevent
shivering.
2. Use ice packs and a tepid bath as needed.
3. Administer antipyretic medications per physician’s orders.
4. Promote frequent rest periods to increase energy reserve.
5. Restrict fluids during periods of hyperthermia because of
the risk of electrolyte imbalance.
Answer: 2; 3; 4
Rationale: Hyperthemia is an expected consequence of the infectious
disease process. Fever can produce mild, short-term effects or, when
prolonged, can cause life- threatening effects. The nurse should
administer antipyretic medications as indicated for elevated
temperatures. The nurse should use ice packs, cool/tepid baths, or
hypothermia blanket with caution. The nurse should enforce frequent
rest periods because rest increases energy reserve, which is depleted
by an increased metabolic, heart, and respiratory rate. The nurse
should encourage fluids rather than restrict fluids because of the risk
of electrolyte imbalance.
Cognitive Level: Assessment
Client Needs: Physiological
Integrity Nursing Process:
Implementation
• The nurse is assessing a client’s wound for signs and symptoms of
NEW UPDATE 2022/2023 CRITICAL THINKING BIO
102 TEST BANK FOR MEDICAL-SURGICAL NURSING
IN CLIENT CARE EXAM QUESTIONS AND ANSWERS
BEST RATED A+ ASSURED SUCCESS
,NEW UPDATE 2022/2023 CRITICAL THINKING BIO 102 TEST
BANK FOR MEDICAL-SURGICAL NURSING IN CLIENT
CARE EXAM QUESTIONS AND ANSWERS BEST RATED A+
ASSURED SUCCESS(chapter 1-52 covered)
inflammation. Which of the following would alert the nurse that the
client is exhibiting signs of inflammation? Select all that apply.
1. Leg edema
2. Leg cool to touch
3. Severe pain from swelling
4. Decreased peripheral pulses
5. Severe erythema of
leg Answer: 1; 3; 5
Rationale: Regardless of the cause, location, or extent of the injury, the
acute inflammatory response follows the sequence of vascular response,
cellular and phagocytic response, and healing. Many manifestations of
inflammation are produced by inflammatory mediators such as histamines
and prostaglandins released when tissue is damaged. The cardinal signs of
inflammation include erythema, local heat caused by the increased blood
flow to the injured area (hyperemia), swelling due to accumulated fluid at
site, pain from tissue swelling and chemical irritation of nerve endings, and
loss of function caused by the swelling and pain.
Cognitive Level: Application
Client Needs: Physiological
Integrity Nursing Process:
Assessment
Alternate item format – Select all that apply
Which of the following manifestations would the nurse expect to see with
a client who has had previous knee surgery who suffered a surgical
infection with signs of systemic manifestations? Select all that apply.
1.
Erythema
2.
WBC 14,200 mm3
NEW UPDATE 2022/2023 CRITICAL THINKING BIO
102 TEST BANK FOR MEDICAL-SURGICAL NURSING
IN CLIENT CARE EXAM QUESTIONS AND ANSWERS
BEST RATED A+ ASSURED SUCCESS
,NEW UPDATE 2022/2023 CRITICAL THINKING BIO 102 TEST
BANK FOR MEDICAL-SURGICAL NURSING IN CLIENT
CARE EXAM QUESTIONS AND ANSWERS BEST RATED A+
ASSURED SUCCESS(chapter 1-52 covered)
3.
Pain at the surgical site
4.
10% Bands
5.
Respiratory rate of 16
6.
Pulse
114 Answer: 2; 3; 6
Rationale: The client is post–surgical repair of the knee. The nurse should
be able to distinguish between local reactions and system reactions. An
elevated WBC and 10% bands are indicative of an infection. Vital sign
changes typically associated with an infection include an elevation in
temperature and tachycardia. Local manifestations include erythema,
warmth, pain, edema, and functional impairment, whereas systemic
manifestations include elevated temperature above 100.4°F, pulse greater
than 90/min., respiratory rate greater than 20, and WBC greater than 12,000
mm3 or > 10% bands.
• 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
NEW UPDATE 2022/2023 CRITICAL THINKING BIO
102 TEST BANK FOR MEDICAL-SURGICAL NURSING
IN CLIENT CARE EXAM QUESTIONS AND ANSWERS
BEST RATED A+ ASSURED SUCCESS
, NEW UPDATE 2022/2023 CRITICAL THINKING BIO 102 TEST
BANK FOR MEDICAL-SURGICAL NURSING IN CLIENT
CARE EXAM QUESTIONS AND ANSWERS BEST RATED A+
ASSURED SUCCESS(chapter 1-52 covered)
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
• 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?
• “I am allergic to horse hair.”
• “I try to get my vaccine every year.”
• “I am not allergic to anything except eggs.”
• “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.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environment
Nursing Process: Assessment
NEW UPDATE 2022/2023 CRITICAL THINKING BIO
102 TEST BANK FOR MEDICAL-SURGICAL NURSING
IN CLIENT CARE EXAM QUESTIONS AND ANSWERS
BEST RATED A+ ASSURED SUCCESS
BANK FOR MEDICAL-SURGICAL NURSING IN CLIENT
CARE EXAM QUESTIONS AND ANSWERS BEST RATED A+
ASSURED SUCCESS(chapter 1-52 covered)
Chapter 1
• A client develops hyperthermia related to a diagnosis of Pneumonia.
Which of the following nursing interventions would be effective in the
treatment of hyperthermia? Select all that apply.
1. Increase the temperature of the room environment to prevent
shivering.
2. Use ice packs and a tepid bath as needed.
3. Administer antipyretic medications per physician’s orders.
4. Promote frequent rest periods to increase energy reserve.
5. Restrict fluids during periods of hyperthermia because of
the risk of electrolyte imbalance.
Answer: 2; 3; 4
Rationale: Hyperthemia is an expected consequence of the infectious
disease process. Fever can produce mild, short-term effects or, when
prolonged, can cause life- threatening effects. The nurse should
administer antipyretic medications as indicated for elevated
temperatures. The nurse should use ice packs, cool/tepid baths, or
hypothermia blanket with caution. The nurse should enforce frequent
rest periods because rest increases energy reserve, which is depleted
by an increased metabolic, heart, and respiratory rate. The nurse
should encourage fluids rather than restrict fluids because of the risk
of electrolyte imbalance.
Cognitive Level: Assessment
Client Needs: Physiological
Integrity Nursing Process:
Implementation
• The nurse is assessing a client’s wound for signs and symptoms of
NEW UPDATE 2022/2023 CRITICAL THINKING BIO
102 TEST BANK FOR MEDICAL-SURGICAL NURSING
IN CLIENT CARE EXAM QUESTIONS AND ANSWERS
BEST RATED A+ ASSURED SUCCESS
,NEW UPDATE 2022/2023 CRITICAL THINKING BIO 102 TEST
BANK FOR MEDICAL-SURGICAL NURSING IN CLIENT
CARE EXAM QUESTIONS AND ANSWERS BEST RATED A+
ASSURED SUCCESS(chapter 1-52 covered)
inflammation. Which of the following would alert the nurse that the
client is exhibiting signs of inflammation? Select all that apply.
1. Leg edema
2. Leg cool to touch
3. Severe pain from swelling
4. Decreased peripheral pulses
5. Severe erythema of
leg Answer: 1; 3; 5
Rationale: Regardless of the cause, location, or extent of the injury, the
acute inflammatory response follows the sequence of vascular response,
cellular and phagocytic response, and healing. Many manifestations of
inflammation are produced by inflammatory mediators such as histamines
and prostaglandins released when tissue is damaged. The cardinal signs of
inflammation include erythema, local heat caused by the increased blood
flow to the injured area (hyperemia), swelling due to accumulated fluid at
site, pain from tissue swelling and chemical irritation of nerve endings, and
loss of function caused by the swelling and pain.
Cognitive Level: Application
Client Needs: Physiological
Integrity Nursing Process:
Assessment
Alternate item format – Select all that apply
Which of the following manifestations would the nurse expect to see with
a client who has had previous knee surgery who suffered a surgical
infection with signs of systemic manifestations? Select all that apply.
1.
Erythema
2.
WBC 14,200 mm3
NEW UPDATE 2022/2023 CRITICAL THINKING BIO
102 TEST BANK FOR MEDICAL-SURGICAL NURSING
IN CLIENT CARE EXAM QUESTIONS AND ANSWERS
BEST RATED A+ ASSURED SUCCESS
,NEW UPDATE 2022/2023 CRITICAL THINKING BIO 102 TEST
BANK FOR MEDICAL-SURGICAL NURSING IN CLIENT
CARE EXAM QUESTIONS AND ANSWERS BEST RATED A+
ASSURED SUCCESS(chapter 1-52 covered)
3.
Pain at the surgical site
4.
10% Bands
5.
Respiratory rate of 16
6.
Pulse
114 Answer: 2; 3; 6
Rationale: The client is post–surgical repair of the knee. The nurse should
be able to distinguish between local reactions and system reactions. An
elevated WBC and 10% bands are indicative of an infection. Vital sign
changes typically associated with an infection include an elevation in
temperature and tachycardia. Local manifestations include erythema,
warmth, pain, edema, and functional impairment, whereas systemic
manifestations include elevated temperature above 100.4°F, pulse greater
than 90/min., respiratory rate greater than 20, and WBC greater than 12,000
mm3 or > 10% bands.
• 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
NEW UPDATE 2022/2023 CRITICAL THINKING BIO
102 TEST BANK FOR MEDICAL-SURGICAL NURSING
IN CLIENT CARE EXAM QUESTIONS AND ANSWERS
BEST RATED A+ ASSURED SUCCESS
, NEW UPDATE 2022/2023 CRITICAL THINKING BIO 102 TEST
BANK FOR MEDICAL-SURGICAL NURSING IN CLIENT
CARE EXAM QUESTIONS AND ANSWERS BEST RATED A+
ASSURED SUCCESS(chapter 1-52 covered)
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
• 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?
• “I am allergic to horse hair.”
• “I try to get my vaccine every year.”
• “I am not allergic to anything except eggs.”
• “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.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environment
Nursing Process: Assessment
NEW UPDATE 2022/2023 CRITICAL THINKING BIO
102 TEST BANK FOR MEDICAL-SURGICAL NURSING
IN CLIENT CARE EXAM QUESTIONS AND ANSWERS
BEST RATED A+ ASSURED SUCCESS
