Full Test Bank
Medical-Surgical Nursing Critical Thinking in Client Care, 4th
Edition Priscilla LeMone, Karen M. Burke
,Chapter 1
1. The RN is caring for four patients on a medical–surgical unit. Which patient should
the RN see initially?
1. A patient admitted with hepatitis A who has had severe diarrhea for the
last 24 hours
2. A patient admitted with pneumonia who is has small amounts of
yellow productive sputum
3. A patient admitted with fever of unknown origin (FUO) who has
been without fever for the last 48 hours
4. A patient admitted with a wound infection whose WBC is 8,500 mm3
CORRECT ANS: 1
Feedback: The RN must decide which patient should be seen on the initial rounds of the
day. The RN must remember that the first patient to be seen should be the patient
who needs the attention of the RN initially. A patient with hepatitis A does
experience diarrhea, but diarrhea for the last 24 hours could cause the patient to
have a problem with dehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
Nursing Process: Planning
2. The RN is preparing to administer influenza vaccines to a mass drive-through clinic.
Which statement by a patient would indicate further questioning prior to giving the
patient 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.”
CORRECT ANS: 3
Feedback: Influenza vaccines are recommended for person at high risk for serious
sequelae of influenza. The RN should be aware that patient with a sensitivity to
eggs should not receive the vaccine. Vaccines prepared from chicken or duck
embryos are contraindicated in patients who are allergic to eggs.
,Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMone
Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
Nursing Process: Assessment
3. The RN is caring for four patients on a medical–surgical unit. The secretary gives the
RN the morning labs. Which of the following labs would require that the RN call the
physician and inform the healthcare provider about the patient’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
CORRECT ANS: 1
Feedback: When the RN is caring for several patients, 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 findings are within
acceptable range; therefore, the findings should not be called in to the physician.
Cognitive Level: Application
Patient Needs: Physiologic
Integrity Nursing Process:
Assessment
4. The RN is orienting a new graduate. The RN is reinforcing the importance of
standard precautions. Which of the following observations by the RN would require
further education regarding standard precautions?
1. The graduate RN understands to wash hands when entering and exiting
the patient’s room.
2. The graduate RN wears gloves when serving breakfast trays to various
patients.
3. The graduate RN wears a gown, gloves, and goggles when suctioning a
patient.
4. The graduate RN leaves all supplies in the room of a patient who is in
contact isolation.
CORRECT ANS: 2
Feedback: The RN must have an understanding of standard precautions. Prevention is
the most critical 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 patients,
regardless of whether they have a known infectious disease. Standard precautions
are used by all healthcare workers who have direct contact with patients or with
their body fluids. It is not necessary for the RN to wear gloves while delivering
food trays to the patient, because there is not contact with the patient.
Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
Nursing Process: Evaluation
5. The admitting department alerts the RN on a medical–surgical unit that a patient with
active tuberculosis (TB) is being admitted to the unit. Which type of isolation is
appropriate based on the patient’s diagnosis?
1. Standard precautions
2. Airborne precautions
3. Droplet precautions
4. Contact precautions
CORRECT ANS: 2
Feedback: In addition to handwashing and standard precautions, the nature and spread
of some infectious diseases require that special techniques be used to protect uninfected
patients and workers. The patient with pulmonary tuberculosis will be placed in airborne
precautions. The patient should be placed in a private room with special ventilation that
does not allow air to circulate to general hospital ventilation; a mask or special filter
respirators will be used for everyone entering the room.
Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
Nursing Process: Assessment
6. A patient is receiving IV vancomycin for the treatment of Clostridium difficile.
The RN understands that the patient who develops flushing, tachycardia, and
hypotension during the infusion of vancomycin indicates:
1. Ototoxicity effect.
2. Superinfection.
3. Red man syndrome.
4. Hives.
CORRECT ANS: 3
Medical-Surgical Nursing Critical Thinking in Client Care, 4th
Edition Priscilla LeMone, Karen M. Burke
,Chapter 1
1. The RN is caring for four patients on a medical–surgical unit. Which patient should
the RN see initially?
1. A patient admitted with hepatitis A who has had severe diarrhea for the
last 24 hours
2. A patient admitted with pneumonia who is has small amounts of
yellow productive sputum
3. A patient admitted with fever of unknown origin (FUO) who has
been without fever for the last 48 hours
4. A patient admitted with a wound infection whose WBC is 8,500 mm3
CORRECT ANS: 1
Feedback: The RN must decide which patient should be seen on the initial rounds of the
day. The RN must remember that the first patient to be seen should be the patient
who needs the attention of the RN initially. A patient with hepatitis A does
experience diarrhea, but diarrhea for the last 24 hours could cause the patient to
have a problem with dehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
Nursing Process: Planning
2. The RN is preparing to administer influenza vaccines to a mass drive-through clinic.
Which statement by a patient would indicate further questioning prior to giving the
patient 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.”
CORRECT ANS: 3
Feedback: Influenza vaccines are recommended for person at high risk for serious
sequelae of influenza. The RN should be aware that patient with a sensitivity to
eggs should not receive the vaccine. Vaccines prepared from chicken or duck
embryos are contraindicated in patients who are allergic to eggs.
,Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMone
Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
Nursing Process: Assessment
3. The RN is caring for four patients on a medical–surgical unit. The secretary gives the
RN the morning labs. Which of the following labs would require that the RN call the
physician and inform the healthcare provider about the patient’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
CORRECT ANS: 1
Feedback: When the RN is caring for several patients, 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 findings are within
acceptable range; therefore, the findings should not be called in to the physician.
Cognitive Level: Application
Patient Needs: Physiologic
Integrity Nursing Process:
Assessment
4. The RN is orienting a new graduate. The RN is reinforcing the importance of
standard precautions. Which of the following observations by the RN would require
further education regarding standard precautions?
1. The graduate RN understands to wash hands when entering and exiting
the patient’s room.
2. The graduate RN wears gloves when serving breakfast trays to various
patients.
3. The graduate RN wears a gown, gloves, and goggles when suctioning a
patient.
4. The graduate RN leaves all supplies in the room of a patient who is in
contact isolation.
CORRECT ANS: 2
Feedback: The RN must have an understanding of standard precautions. Prevention is
the most critical 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 patients,
regardless of whether they have a known infectious disease. Standard precautions
are used by all healthcare workers who have direct contact with patients or with
their body fluids. It is not necessary for the RN to wear gloves while delivering
food trays to the patient, because there is not contact with the patient.
Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
Nursing Process: Evaluation
5. The admitting department alerts the RN on a medical–surgical unit that a patient with
active tuberculosis (TB) is being admitted to the unit. Which type of isolation is
appropriate based on the patient’s diagnosis?
1. Standard precautions
2. Airborne precautions
3. Droplet precautions
4. Contact precautions
CORRECT ANS: 2
Feedback: In addition to handwashing and standard precautions, the nature and spread
of some infectious diseases require that special techniques be used to protect uninfected
patients and workers. The patient with pulmonary tuberculosis will be placed in airborne
precautions. The patient should be placed in a private room with special ventilation that
does not allow air to circulate to general hospital ventilation; a mask or special filter
respirators will be used for everyone entering the room.
Cognitive Level: Application
Patient Needs: Safe, Effective Care Environment
Nursing Process: Assessment
6. A patient is receiving IV vancomycin for the treatment of Clostridium difficile.
The RN understands that the patient who develops flushing, tachycardia, and
hypotension during the infusion of vancomycin indicates:
1. Ototoxicity effect.
2. Superinfection.
3. Red man syndrome.
4. Hives.
CORRECT ANS: 3
