1
Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th
c c c c c c c c c c
Edition Priscilla LeMon
c c
Chapter 1 c
1. Thecnursecisccaringcforcfourcclientsconcacmedical–
surgicalcunit.cWhichcclientcshouldcthecnursecseecinitially?
1. AcclientcadmittedcwithchepatitiscAcwhochaschadcseverecdiarrheacforctheclastc2
4chours
2. Acclientcadmittedcwithcpneumoniacwhocischascsmallcamountscofcyellowcp
roductivecsputum
3. Acclientcadmittedcwithcfevercofcunknowncoriginc(FUO)cwhochascbeencw
ithoutcfevercforctheclastc48chours
4. AcclientcadmittedcwithcacwoundcinfectioncwhosecWBCcisc8,500cmm3
Answer:c1
Rationale:cThecnursecmustcdecidecwhichcclientcshouldcbecseenconcthecinitialcroundscofcthecda
y.cThecnursecmustcremembercthatcthecfirstcclientctocbecseencshouldcbecthecclientcwhoc
needscthecattentioncofcthecnursecinitially.cAcclientcwithchepatitiscAcdoescexperiencec
diarrhea,cbutcdiarrheacforctheclastc24choursccouldccausecthecclientctochavecacproblemc
withcdehydrationcandcexperiencecacstatecofcfluidcvolumecdeficit.
CognitivecLevel:cApplication
ClientcNeeds:cSafe,cEffectivecCarecEnvironmentc
NursingcProcess:cPlanning
2. Thecnurseciscpreparingctocadministercinfluenzacvaccinesctocacmasscdrive-
throughcclinic.cWhichcstatementcbycacclientcwouldcindicatecfurthercquestioningcpriorctocgivi
ngcthecclientcthecinfluenzacvaccine?
1. “Icamcallergicctochorsechair.”
2. “Ictryctocgetcmycvaccineceverycyear.”
3. “Icamcnotcallergicctocanythingcexceptceggs.”
4. “Mychusbandchadcacseverecallergiccreactioncafterchecreceivedchiscinfluenzacv
accine.”
Answer:c3
Rationale:cInfluenzacvaccinescarecrecommendedcforcpersoncatchighcriskcforcseriouscsequel
aecofcinfluenza.cThecnursecshouldcbecawarecthatcclientcwithcacsensitivityctoceggscsho
uldcnotcreceivecthecvaccine.cVaccinescpreparedcfromcchickencorcduckcembryoscare
ccontraindicatedcincclients cwhocarecallergicctoceggs.
Test Bank for Medical-
c c c
Surgical Nursing Critical Thinking in Client Care, 4thEdition Priscilla LeMon
c c c c c c c c c c
Pcacgcec 1c|c342
, 2
Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th
c c c c c c c c c c
Edition Priscilla LeMon
c c
CognitivecLevel:cApplication
Test Bank for Medical-
c c c
Surgical Nursing Critical Thinking in Client Care, 4thEdition Priscilla LeMon
c c c c c c c c c c
Pcacgcec 2c|c342
, 3
Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th
c c c c c c c c c c
Edition Priscilla LeMon
c c
ClientcNeeds:cSafe,cEffectivecCarecEnvironmentc
NursingcProcess:cAssessment
3. Thecnursecisccaringcforcfourcclientsconcacmedical–
surgicalcunit.cThecsecretarycgivescthecnursecthecmorningclabs.cWhichcofcthecfollowingclabsc
wouldcrequirecthatcthecnurseccallcthecphysiciancandcinformcthechealthcarecprovidercaboutcthe
cclient’scabnormalities?
1.c WBCc14,600cmm3
2. Serumcproteinc6.9cg/dL
3. Ic&cDc(incisioncandcdrainage)cshowingcnocgrowthcforctheclastc24chours
4. Albuminc4.2cg/dL
Answer:c1
Rationale:cWhencthecnursecisccaringcforcseveralcclients,callcofctheclabscshouldcbeccheckedcfr
equentlycthroughoutcthecshiftctocassesscforcanycabnormalities.cThecWBCcincoptionc1ciscabn
ormal.c(NormalcWBCc4,000–
10,000cmm3.)cAllcofcthecotherclabcresultscarecwithincacceptablecrange;ctherefore,cthecresult
scshouldcnotcbeccalledcinctocthecphysician.
CognitivecLevel:cApplicationcClien
tcNeeds:cPhysiologiccIntegritycNursi
ngcProcess:cAssessment
4. Thecnurseciscorientingcacnewcgraduate.cThecnurseciscreinforcingcthecimportancecofcsta
ndardcprecautions.cWhichcofcthecfollowingcobservationscbycthecnursecwouldcrequirecfurt
herceducationcregardingcstandardcprecautions?
1. Thecgraduatecnursecunderstandsctocwashchandscwhencenteringcandcexitingct
hecclient’scroom.
2. Thecgraduatecnursecwearscglovescwhencservingcbreakfastctraysctocvariouscc
lients.
3. Thecgraduatecnursecwearscacgown,cgloves,candcgogglescwhencsuctioningcaccl
ient.
4. Thecgraduatecnursecleavescallcsuppliescincthecroomcofcacclientcwhociscincco
ntactcisolation.
Answer:c2
Rationale:cThecnursecmustchavecancunderstandingcofcstandardcprecautions.cPreventionciscth
ecmostcimportantcmeasurectocpreventcnosocomialcinfections.cStandardcprecautionsc
werecpublishedcinc1996cthatcprovidecguidelinescforcthechandlingcofcbloodcandcotherc
Test Bank for Medical-
c c c
Surgical Nursing Critical Thinking in Client Care, 4thEdition Priscilla LeMon
c c c c c c c c c c
Pcacgcec 3c|c342
, bodycfluids.cThesecguidelinescarecusedcwithcallcclients,cregardlesscofcwhetherctheych
avecacknowncinfectiouscdisease.cStandardcprecautionscarecused
Test Bank for Medical-
c c c
Surgical Nursing Critical Thinking in Client Care, 4thEdition Priscilla LeMon
c c c c c c c c c c
Pcacgcec 4c|c342
Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th
c c c c c c c c c c
Edition Priscilla LeMon
c c
Chapter 1 c
1. Thecnursecisccaringcforcfourcclientsconcacmedical–
surgicalcunit.cWhichcclientcshouldcthecnursecseecinitially?
1. AcclientcadmittedcwithchepatitiscAcwhochaschadcseverecdiarrheacforctheclastc2
4chours
2. Acclientcadmittedcwithcpneumoniacwhocischascsmallcamountscofcyellowcp
roductivecsputum
3. Acclientcadmittedcwithcfevercofcunknowncoriginc(FUO)cwhochascbeencw
ithoutcfevercforctheclastc48chours
4. AcclientcadmittedcwithcacwoundcinfectioncwhosecWBCcisc8,500cmm3
Answer:c1
Rationale:cThecnursecmustcdecidecwhichcclientcshouldcbecseenconcthecinitialcroundscofcthecda
y.cThecnursecmustcremembercthatcthecfirstcclientctocbecseencshouldcbecthecclientcwhoc
needscthecattentioncofcthecnursecinitially.cAcclientcwithchepatitiscAcdoescexperiencec
diarrhea,cbutcdiarrheacforctheclastc24choursccouldccausecthecclientctochavecacproblemc
withcdehydrationcandcexperiencecacstatecofcfluidcvolumecdeficit.
CognitivecLevel:cApplication
ClientcNeeds:cSafe,cEffectivecCarecEnvironmentc
NursingcProcess:cPlanning
2. Thecnurseciscpreparingctocadministercinfluenzacvaccinesctocacmasscdrive-
throughcclinic.cWhichcstatementcbycacclientcwouldcindicatecfurthercquestioningcpriorctocgivi
ngcthecclientcthecinfluenzacvaccine?
1. “Icamcallergicctochorsechair.”
2. “Ictryctocgetcmycvaccineceverycyear.”
3. “Icamcnotcallergicctocanythingcexceptceggs.”
4. “Mychusbandchadcacseverecallergiccreactioncafterchecreceivedchiscinfluenzacv
accine.”
Answer:c3
Rationale:cInfluenzacvaccinescarecrecommendedcforcpersoncatchighcriskcforcseriouscsequel
aecofcinfluenza.cThecnursecshouldcbecawarecthatcclientcwithcacsensitivityctoceggscsho
uldcnotcreceivecthecvaccine.cVaccinescpreparedcfromcchickencorcduckcembryoscare
ccontraindicatedcincclients cwhocarecallergicctoceggs.
Test Bank for Medical-
c c c
Surgical Nursing Critical Thinking in Client Care, 4thEdition Priscilla LeMon
c c c c c c c c c c
Pcacgcec 1c|c342
, 2
Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th
c c c c c c c c c c
Edition Priscilla LeMon
c c
CognitivecLevel:cApplication
Test Bank for Medical-
c c c
Surgical Nursing Critical Thinking in Client Care, 4thEdition Priscilla LeMon
c c c c c c c c c c
Pcacgcec 2c|c342
, 3
Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th
c c c c c c c c c c
Edition Priscilla LeMon
c c
ClientcNeeds:cSafe,cEffectivecCarecEnvironmentc
NursingcProcess:cAssessment
3. Thecnursecisccaringcforcfourcclientsconcacmedical–
surgicalcunit.cThecsecretarycgivescthecnursecthecmorningclabs.cWhichcofcthecfollowingclabsc
wouldcrequirecthatcthecnurseccallcthecphysiciancandcinformcthechealthcarecprovidercaboutcthe
cclient’scabnormalities?
1.c WBCc14,600cmm3
2. Serumcproteinc6.9cg/dL
3. Ic&cDc(incisioncandcdrainage)cshowingcnocgrowthcforctheclastc24chours
4. Albuminc4.2cg/dL
Answer:c1
Rationale:cWhencthecnursecisccaringcforcseveralcclients,callcofctheclabscshouldcbeccheckedcfr
equentlycthroughoutcthecshiftctocassesscforcanycabnormalities.cThecWBCcincoptionc1ciscabn
ormal.c(NormalcWBCc4,000–
10,000cmm3.)cAllcofcthecotherclabcresultscarecwithincacceptablecrange;ctherefore,cthecresult
scshouldcnotcbeccalledcinctocthecphysician.
CognitivecLevel:cApplicationcClien
tcNeeds:cPhysiologiccIntegritycNursi
ngcProcess:cAssessment
4. Thecnurseciscorientingcacnewcgraduate.cThecnurseciscreinforcingcthecimportancecofcsta
ndardcprecautions.cWhichcofcthecfollowingcobservationscbycthecnursecwouldcrequirecfurt
herceducationcregardingcstandardcprecautions?
1. Thecgraduatecnursecunderstandsctocwashchandscwhencenteringcandcexitingct
hecclient’scroom.
2. Thecgraduatecnursecwearscglovescwhencservingcbreakfastctraysctocvariouscc
lients.
3. Thecgraduatecnursecwearscacgown,cgloves,candcgogglescwhencsuctioningcaccl
ient.
4. Thecgraduatecnursecleavescallcsuppliescincthecroomcofcacclientcwhociscincco
ntactcisolation.
Answer:c2
Rationale:cThecnursecmustchavecancunderstandingcofcstandardcprecautions.cPreventionciscth
ecmostcimportantcmeasurectocpreventcnosocomialcinfections.cStandardcprecautionsc
werecpublishedcinc1996cthatcprovidecguidelinescforcthechandlingcofcbloodcandcotherc
Test Bank for Medical-
c c c
Surgical Nursing Critical Thinking in Client Care, 4thEdition Priscilla LeMon
c c c c c c c c c c
Pcacgcec 3c|c342
, bodycfluids.cThesecguidelinescarecusedcwithcallcclients,cregardlesscofcwhetherctheych
avecacknowncinfectiouscdisease.cStandardcprecautionscarecused
Test Bank for Medical-
c c c
Surgical Nursing Critical Thinking in Client Care, 4thEdition Priscilla LeMon
c c c c c c c c c c
Pcacgcec 4c|c342
