FULL TEST BANK FOR
MEDICAL-SURGICAL NURSING: CRITICAL THINKING IN CLIENT CARE 4TH EDITION
BY PRISCILLA LEMONE (AUTHOR), KAREN M. BURKE (AUTHOR)
,CHAPTER 1
1. THE NURSE IS CARING FOR FOUR PATIENTS ON A MEDICAL–SURGICAL UNIT, WHICH PATIENT
SHOULD THE NURSE SEE FIRST?
1. A PATIENT ADMITTED WITH HEPATITIS A WHO HAS HAD SEVERE DIARRHEA FOR THE LAST24
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
ANSWER: 1
RATIONALE: THE NURSE MUST DECIDE WHICH PATIENT OUGHT TO BE SEEN ON THE INITIAL ROUNDS OF
THE DAY, THE NURSE MUST REMEMBER THAT THE FIRST PATIENT TO BE SEEN OUGHT TO BE THE
PATIENT WHO NEEDS THE ATTENTION OF THE NURSE 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 NURSE IS GETTING READY 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,”
ANSWER: 3
RATIONALE: INFLUENZA VACCINES ARE RECOMMENDED FOR PERSON AT HIGH RISK FOR SERIOUS
SEQUELAE OF INFLUENZA, THE NURSE OUGHT TO BE AWARE THAT PATIENT WITH A SENSITIVITY TO
EGGS OUGHT TO NOT RECEIVE THE VACCINE, VACCINES GET READY FROM CHICKEN OR DUCK EMBRYOS
ARE CONTRAINDICATED IN PATIENTS WHO ARE ALLERGIC TO EGGS,
COGNITIVE LEVEL: APPLICATION
PATIENT NEEDS: SAFE, EFFECTIVE CARE ENVIRONMENTNURSING PROCESS: ASSESSMENT
3. THE NURSE IS CARING FOR FOUR PATIENTS ON A MEDICAL–SURGICAL UNIT, THE SECRETARY
GIVES THE NURSE THE MORNING LABS, WHICH OF THE FOLLOWING LABS WOULD REQUIRE THAT THE
NURSE CALL THEPHYSICIAN 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
ANSWER: 1
RATIONALE: WHEN THE NURSE IS CARING FOR SEVERAL PATIENTS, ALL OF THE LABS OUGHT TO 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 RESULTS ARE
WITHIN ACCEPTABLE RANGE; THEREFORE, THE RESULTS OUGHT TO NOT BE CALLED IN TO THE
PHYSICIAN,
COGNITIVE LEVEL: APPLICATION PATIENT NEEDS: PHYSIOLOGIC INTEGRITYNURSING PROCESS:
ASSESSMENT
, 4. THE NURSE IS ORIENTING A NEW GRADUATE, THE NURSE IS REINFORCING THE IMPORTANCE OF
STANDARD PRECAUTIONS, WHICH OF THE FOLLOWING OBSERVATIONS BY THE NURSE WOULD REQUIRE
FURTHER EDUCATION REGARDING STANDARD PRECAUTIONS?
1. THE GRADUATE NURSE UNDERSTANDS TO WASH HANDS WHEN ENTERING AND EXITING
THE PATIENT’S ROOM,
2. THE GRADUATE NURSE WEARS GLOVES WHEN SERVING BREAKFAST TRAYS TO VARIOUS
PATIENTS,
3. THE GRADUATE NURSE WEARS A GOWN, GLOVES, AND GOGGLES WHEN SUCTIONING A
PATIENT,
4. THE GRADUATE NURSE LEAVES ALL SUPPLIES IN THE ROOM OF A PATIENT WHO IS INCONTACT
ISOLATION,
ANSWER: 2
RATIONALE: THE NURSE 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 PATIENTS, REGARDLESSOF 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 NURSE TO WEAR GLOVES WHILE DELIVERING FOOD TRAYSTO
THE PATIENT, BECAUSE THERE IS NOT CONTACT WITH THE PATIENT,
COGNITIVE LEVEL: APPLICATION PATIENT NEEDS: SAFE, EFFECTIVE CARE
ENVIRONMENTNURSING PROCESS: EVALUATION
5. THE ADMITTING DEPARTMENT ALERTS THE NURSE ON A MEDICAL–SURGICAL UNIT THAT A
PATIENT WITHACTIVE TUBERCULOSIS (TB) IS BEING ADMITTED TO THE UNIT, WHICH TYPE OF ISOLATION
IS APPROPRIATE BASED ON THE PATIENT’S DIAGNOSIS?
MEDICAL-SURGICAL NURSING: CRITICAL THINKING IN CLIENT CARE 4TH EDITION
BY PRISCILLA LEMONE (AUTHOR), KAREN M. BURKE (AUTHOR)
,CHAPTER 1
1. THE NURSE IS CARING FOR FOUR PATIENTS ON A MEDICAL–SURGICAL UNIT, WHICH PATIENT
SHOULD THE NURSE SEE FIRST?
1. A PATIENT ADMITTED WITH HEPATITIS A WHO HAS HAD SEVERE DIARRHEA FOR THE LAST24
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
ANSWER: 1
RATIONALE: THE NURSE MUST DECIDE WHICH PATIENT OUGHT TO BE SEEN ON THE INITIAL ROUNDS OF
THE DAY, THE NURSE MUST REMEMBER THAT THE FIRST PATIENT TO BE SEEN OUGHT TO BE THE
PATIENT WHO NEEDS THE ATTENTION OF THE NURSE 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 NURSE IS GETTING READY 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,”
ANSWER: 3
RATIONALE: INFLUENZA VACCINES ARE RECOMMENDED FOR PERSON AT HIGH RISK FOR SERIOUS
SEQUELAE OF INFLUENZA, THE NURSE OUGHT TO BE AWARE THAT PATIENT WITH A SENSITIVITY TO
EGGS OUGHT TO NOT RECEIVE THE VACCINE, VACCINES GET READY FROM CHICKEN OR DUCK EMBRYOS
ARE CONTRAINDICATED IN PATIENTS WHO ARE ALLERGIC TO EGGS,
COGNITIVE LEVEL: APPLICATION
PATIENT NEEDS: SAFE, EFFECTIVE CARE ENVIRONMENTNURSING PROCESS: ASSESSMENT
3. THE NURSE IS CARING FOR FOUR PATIENTS ON A MEDICAL–SURGICAL UNIT, THE SECRETARY
GIVES THE NURSE THE MORNING LABS, WHICH OF THE FOLLOWING LABS WOULD REQUIRE THAT THE
NURSE CALL THEPHYSICIAN 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
ANSWER: 1
RATIONALE: WHEN THE NURSE IS CARING FOR SEVERAL PATIENTS, ALL OF THE LABS OUGHT TO 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 RESULTS ARE
WITHIN ACCEPTABLE RANGE; THEREFORE, THE RESULTS OUGHT TO NOT BE CALLED IN TO THE
PHYSICIAN,
COGNITIVE LEVEL: APPLICATION PATIENT NEEDS: PHYSIOLOGIC INTEGRITYNURSING PROCESS:
ASSESSMENT
, 4. THE NURSE IS ORIENTING A NEW GRADUATE, THE NURSE IS REINFORCING THE IMPORTANCE OF
STANDARD PRECAUTIONS, WHICH OF THE FOLLOWING OBSERVATIONS BY THE NURSE WOULD REQUIRE
FURTHER EDUCATION REGARDING STANDARD PRECAUTIONS?
1. THE GRADUATE NURSE UNDERSTANDS TO WASH HANDS WHEN ENTERING AND EXITING
THE PATIENT’S ROOM,
2. THE GRADUATE NURSE WEARS GLOVES WHEN SERVING BREAKFAST TRAYS TO VARIOUS
PATIENTS,
3. THE GRADUATE NURSE WEARS A GOWN, GLOVES, AND GOGGLES WHEN SUCTIONING A
PATIENT,
4. THE GRADUATE NURSE LEAVES ALL SUPPLIES IN THE ROOM OF A PATIENT WHO IS INCONTACT
ISOLATION,
ANSWER: 2
RATIONALE: THE NURSE 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 PATIENTS, REGARDLESSOF 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 NURSE TO WEAR GLOVES WHILE DELIVERING FOOD TRAYSTO
THE PATIENT, BECAUSE THERE IS NOT CONTACT WITH THE PATIENT,
COGNITIVE LEVEL: APPLICATION PATIENT NEEDS: SAFE, EFFECTIVE CARE
ENVIRONMENTNURSING PROCESS: EVALUATION
5. THE ADMITTING DEPARTMENT ALERTS THE NURSE ON A MEDICAL–SURGICAL UNIT THAT A
PATIENT WITHACTIVE TUBERCULOSIS (TB) IS BEING ADMITTED TO THE UNIT, WHICH TYPE OF ISOLATION
IS APPROPRIATE BASED ON THE PATIENT’S DIAGNOSIS?
