Test Bank for Medical-
d d d
Surgical Nursing Critical Thinking in Client Care, 4t
d d d d d d d
h Edition Priscilla LeMon
d d d
Chapter 1 d
1. Thednursedisdcaringdfordfourdclientsdondadmedical–
surgicaldunit.dWhichdclientdshoulddthednursedseedinitially?
1. AdclientdadmitteddwithdhepatitisdAdwhodhasdhaddsevereddiarrheadfordthedlastd2
4dhours
2. Adclientdadmitteddwithdpneumoniadwhodisdhasdsmalldamountsdofdyellowd
productivedsputum
3. Adclientdadmitteddwithdfeverdofdunknowndorigind(FUO)dwhodhasdbeend
withoutdfeverdfordthedlastd48dhours
4. AdclientdadmitteddwithdadwounddinfectiondwhosedWBCdisd8,500dmm3
Answer:d1
Rationale:dThednursedmustddecidedwhichdclientdshoulddbedseendondthedinitialdroundsdofdthedd
ay.dThednursedmustdrememberdthatdthedfirstdclientdtodbedseendshoulddbedthedclientdwh
odneedsdthedattentiondofdthednursedinitially.dAdclientdwithdhepatitisdAddoesdexperienc
eddiarrhea,dbutddiarrheadfordthedlastd24dhoursdcoulddcausedthedclientdtodhavedadproble
mdwithddehydrationdanddexperiencedadstatedofdfluiddvolumeddeficit.
CognitivedLevel:dApplication
ClientdNeeds:dSafe,dEffectivedCaredEnvironmentdNurs
ingdProcess:dPlanning
2. Thednursedisdpreparingdtodadministerdinfluenzadvaccinesdtodadmassddrive-
throughdclinic.dWhichdstatementdbydadclientdwoulddindicatedfurtherdquestioningdpriordtodgiv
ingdthedclientdthedinfluenzadvaccine?
1. “Idamdallergicdtodhorsedhair.”
2. “Idtrydtodgetdmydvaccinedeverydyear.”
3. “Idamdnotdallergicdtodanythingdexceptdeggs.”
4. “Mydhusbanddhaddadseveredallergicdreactiondafterdhedreceiveddhisdinfluenzad
vaccine.”
Answer:d3
Rationale:dInfluenzadvaccinesdaredrecommendeddfordpersondatdhighdriskdfordseriousdsequela
edofdinfluenza.dThednursedshoulddbedawaredthatdclientdwithdadsensitivitydtodeggsdshou
lddnotdreceivedthedvaccine.dVaccinesdprepareddfromdchickendordduckdembryosdaredc
ontraindicateddindclientsdwhodaredallergicdtodeggs.
,Test Bank for Medical-
d d d
Surgical Nursing Critical Thinking in Client Care, 4t
d d d d d d d
h Edition Priscilla LeMon
d d d
CognitivedLevel:dApplication
ClientdNeeds:dSafe,dEffectivedCaredEnvironmentdNurs
ingdProcess:dAssessment
3. Thednursedisdcaringdfordfourdclientsdondadmedical–
surgicaldunit.dThedsecretarydgivesdthednursedthedmorningdlabs.dWhichdofdthedfollowingdlabsd
woulddrequiredthatdthednursedcalldthedphysiciandanddinformdthedhealthcaredproviderdaboutdth
edclient’sdabnormalities?
1. WBCd14,600dmm3
2. Serumdproteind6.9dg/dL
3. Id&dDd(incisiondandddrainage)dshowingdnodgrowthdfordthedlastd24dhours
4. Albumind4.2dg/dL
Answer:d1
Rationale:dWhendthednursedisdcaringdfordseveraldclients,dalldofdthedlabsdshoulddbedcheckeddfreq
uentlydthroughoutdthedshiftdtodassessdfordanydabnormalities.dThedWBCdindoptiond1disdabnorm
al.d(NormaldWBCd4,000–
10,000dmm3.)dAlldofdthedotherdlabdresultsdaredwithindacceptabledrange;dtherefore,dthedresultsds
houlddnotdbedcalleddindtodthedphysician.
CognitivedLevel:dApplicationdClien
tdNeeds:dPhysiologicdIntegritydNursi
ngdProcess:dAssessment
4. Thednursedisdorientingdadnewdgraduate.dThednursedisdreinforcingdthedimportancedofdsta
ndarddprecautions.dWhichdofdthedfollowingdobservationsdbydthednursedwoulddrequiredfurt
herdeducationdregardingdstandarddprecautions?
1. Thedgraduatednursedunderstandsdtodwashdhandsdwhendenteringdanddexitingdt
hedclient’sdroom.
2. Thedgraduatednursedwearsdglovesdwhendservingdbreakfastdtraysdtodvariousd
clients.
3. Thedgraduatednursedwearsdadgown,dgloves,danddgogglesdwhendsuctioningdad
client.
4. Thedgraduatednursedleavesdalldsuppliesdindthedroomdofdadclientdwhodisdindc
ontactdisolation.
Answer:d2
Rationale:dThednursedmustdhavedandunderstandingdofdstandarddprecautions.dPreventiondisdth
edmostdimportantdmeasuredtodpreventdnosocomialdinfections.dStandarddprecautionsd
downloaddfulldfiledatdhttp://testbankinstant.com
,weredpublisheddind1996dthatdprovidedguidelinesdfordthedhandlingdof
downloaddfulldfiledatdhttp://testbankinstant.com
, blooddanddotherdbodydfluids.dThesedguidelinesdareduseddwithdalldclients,dregardlessdo
fdwhetherdtheydhavedadknowndinfectiousddisease.dStandarddprecautionsdareduseddbyd
alldhealthcaredworkersdwhodhaveddirectdcontactdwithdclientsdordwithdtheirdbodydfluid
s.dItdisdnotdnecessarydfordthednursedtodweardglovesdwhileddeliveringdfooddtraysdtodthed
client,dbecausedtheredisdnotdcontactdwithdthedclient.
CognitivedLevel:dApplication
ClientdNeeds:dSafe,dEffectivedCaredEnvironmentdNurs
ingdProcess:dEvaluation
5. Thedadmittingddepartmentdalertsdthednursedondadmedical–
surgicaldunitdthatdadclientdwithdactivedtuberculosisd(TB)disdbeingdadmitteddtodthedunit.dWhic
hdtypedofdisolationdisdappropriatedbaseddondthedclient’sddiagnosis?
1. Standarddprecautions
2. Airbornedprecautions
3. Dropletdprecautions
4. Contactdprecautions
Answer:d2
Indadditiondtodhandwashingdanddstandarddprecautions,dthednaturedanddspreaddofdsomedinfect
iousddiseasesdrequiredthatdspecialdtechniquesdbeduseddtodprotectduninfecteddclientsdanddwork
ers.dThedclientdwithdpulmonarydtuberculosisdwilldbedplaceddindairbornedprecautions.dThedcli
entdshoulddbedplaceddindadprivatedroomdwithdspecialdventilationdthatddoesdnotdallowdairdtodcir
culatedtodgeneraldhospitaldventilation;dadmaskdordspecialdfilterdrespiratorsdwilldbeduseddforde
veryonedenteringdthedroom.
CognitivedLevel:dApplication
ClientdNeeds:dSafe,dEffectivedCaredEnvironmentdNurs
ingdProcess:dAssessment
6. AdclientdisdreceivingdIVdvancomycindfordthedtreatmentdofdClostridiumddifficile.dThedn
ursedunderstandsdthatdthedclientdwhoddevelopsdflushing,dtachycardia,danddhypotensiondd
uringdthedinfusiondofdvancomycindindicates:
1. Ototoxicitydeffect.
2. Superinfection.
3. Reddmandsyndrome.
4. Hives.
Answer:d3
downloaddfulldfiledatdhttp://testbankinstant.com
d d d
Surgical Nursing Critical Thinking in Client Care, 4t
d d d d d d d
h Edition Priscilla LeMon
d d d
Chapter 1 d
1. Thednursedisdcaringdfordfourdclientsdondadmedical–
surgicaldunit.dWhichdclientdshoulddthednursedseedinitially?
1. AdclientdadmitteddwithdhepatitisdAdwhodhasdhaddsevereddiarrheadfordthedlastd2
4dhours
2. Adclientdadmitteddwithdpneumoniadwhodisdhasdsmalldamountsdofdyellowd
productivedsputum
3. Adclientdadmitteddwithdfeverdofdunknowndorigind(FUO)dwhodhasdbeend
withoutdfeverdfordthedlastd48dhours
4. AdclientdadmitteddwithdadwounddinfectiondwhosedWBCdisd8,500dmm3
Answer:d1
Rationale:dThednursedmustddecidedwhichdclientdshoulddbedseendondthedinitialdroundsdofdthedd
ay.dThednursedmustdrememberdthatdthedfirstdclientdtodbedseendshoulddbedthedclientdwh
odneedsdthedattentiondofdthednursedinitially.dAdclientdwithdhepatitisdAddoesdexperienc
eddiarrhea,dbutddiarrheadfordthedlastd24dhoursdcoulddcausedthedclientdtodhavedadproble
mdwithddehydrationdanddexperiencedadstatedofdfluiddvolumeddeficit.
CognitivedLevel:dApplication
ClientdNeeds:dSafe,dEffectivedCaredEnvironmentdNurs
ingdProcess:dPlanning
2. Thednursedisdpreparingdtodadministerdinfluenzadvaccinesdtodadmassddrive-
throughdclinic.dWhichdstatementdbydadclientdwoulddindicatedfurtherdquestioningdpriordtodgiv
ingdthedclientdthedinfluenzadvaccine?
1. “Idamdallergicdtodhorsedhair.”
2. “Idtrydtodgetdmydvaccinedeverydyear.”
3. “Idamdnotdallergicdtodanythingdexceptdeggs.”
4. “Mydhusbanddhaddadseveredallergicdreactiondafterdhedreceiveddhisdinfluenzad
vaccine.”
Answer:d3
Rationale:dInfluenzadvaccinesdaredrecommendeddfordpersondatdhighdriskdfordseriousdsequela
edofdinfluenza.dThednursedshoulddbedawaredthatdclientdwithdadsensitivitydtodeggsdshou
lddnotdreceivedthedvaccine.dVaccinesdprepareddfromdchickendordduckdembryosdaredc
ontraindicateddindclientsdwhodaredallergicdtodeggs.
,Test Bank for Medical-
d d d
Surgical Nursing Critical Thinking in Client Care, 4t
d d d d d d d
h Edition Priscilla LeMon
d d d
CognitivedLevel:dApplication
ClientdNeeds:dSafe,dEffectivedCaredEnvironmentdNurs
ingdProcess:dAssessment
3. Thednursedisdcaringdfordfourdclientsdondadmedical–
surgicaldunit.dThedsecretarydgivesdthednursedthedmorningdlabs.dWhichdofdthedfollowingdlabsd
woulddrequiredthatdthednursedcalldthedphysiciandanddinformdthedhealthcaredproviderdaboutdth
edclient’sdabnormalities?
1. WBCd14,600dmm3
2. Serumdproteind6.9dg/dL
3. Id&dDd(incisiondandddrainage)dshowingdnodgrowthdfordthedlastd24dhours
4. Albumind4.2dg/dL
Answer:d1
Rationale:dWhendthednursedisdcaringdfordseveraldclients,dalldofdthedlabsdshoulddbedcheckeddfreq
uentlydthroughoutdthedshiftdtodassessdfordanydabnormalities.dThedWBCdindoptiond1disdabnorm
al.d(NormaldWBCd4,000–
10,000dmm3.)dAlldofdthedotherdlabdresultsdaredwithindacceptabledrange;dtherefore,dthedresultsds
houlddnotdbedcalleddindtodthedphysician.
CognitivedLevel:dApplicationdClien
tdNeeds:dPhysiologicdIntegritydNursi
ngdProcess:dAssessment
4. Thednursedisdorientingdadnewdgraduate.dThednursedisdreinforcingdthedimportancedofdsta
ndarddprecautions.dWhichdofdthedfollowingdobservationsdbydthednursedwoulddrequiredfurt
herdeducationdregardingdstandarddprecautions?
1. Thedgraduatednursedunderstandsdtodwashdhandsdwhendenteringdanddexitingdt
hedclient’sdroom.
2. Thedgraduatednursedwearsdglovesdwhendservingdbreakfastdtraysdtodvariousd
clients.
3. Thedgraduatednursedwearsdadgown,dgloves,danddgogglesdwhendsuctioningdad
client.
4. Thedgraduatednursedleavesdalldsuppliesdindthedroomdofdadclientdwhodisdindc
ontactdisolation.
Answer:d2
Rationale:dThednursedmustdhavedandunderstandingdofdstandarddprecautions.dPreventiondisdth
edmostdimportantdmeasuredtodpreventdnosocomialdinfections.dStandarddprecautionsd
downloaddfulldfiledatdhttp://testbankinstant.com
,weredpublisheddind1996dthatdprovidedguidelinesdfordthedhandlingdof
downloaddfulldfiledatdhttp://testbankinstant.com
, blooddanddotherdbodydfluids.dThesedguidelinesdareduseddwithdalldclients,dregardlessdo
fdwhetherdtheydhavedadknowndinfectiousddisease.dStandarddprecautionsdareduseddbyd
alldhealthcaredworkersdwhodhaveddirectdcontactdwithdclientsdordwithdtheirdbodydfluid
s.dItdisdnotdnecessarydfordthednursedtodweardglovesdwhileddeliveringdfooddtraysdtodthed
client,dbecausedtheredisdnotdcontactdwithdthedclient.
CognitivedLevel:dApplication
ClientdNeeds:dSafe,dEffectivedCaredEnvironmentdNurs
ingdProcess:dEvaluation
5. Thedadmittingddepartmentdalertsdthednursedondadmedical–
surgicaldunitdthatdadclientdwithdactivedtuberculosisd(TB)disdbeingdadmitteddtodthedunit.dWhic
hdtypedofdisolationdisdappropriatedbaseddondthedclient’sddiagnosis?
1. Standarddprecautions
2. Airbornedprecautions
3. Dropletdprecautions
4. Contactdprecautions
Answer:d2
Indadditiondtodhandwashingdanddstandarddprecautions,dthednaturedanddspreaddofdsomedinfect
iousddiseasesdrequiredthatdspecialdtechniquesdbeduseddtodprotectduninfecteddclientsdanddwork
ers.dThedclientdwithdpulmonarydtuberculosisdwilldbedplaceddindairbornedprecautions.dThedcli
entdshoulddbedplaceddindadprivatedroomdwithdspecialdventilationdthatddoesdnotdallowdairdtodcir
culatedtodgeneraldhospitaldventilation;dadmaskdordspecialdfilterdrespiratorsdwilldbeduseddforde
veryonedenteringdthedroom.
CognitivedLevel:dApplication
ClientdNeeds:dSafe,dEffectivedCaredEnvironmentdNurs
ingdProcess:dAssessment
6. AdclientdisdreceivingdIVdvancomycindfordthedtreatmentdofdClostridiumddifficile.dThedn
ursedunderstandsdthatdthedclientdwhoddevelopsdflushing,dtachycardia,danddhypotensiondd
uringdthedinfusiondofdvancomycindindicates:
1. Ototoxicitydeffect.
2. Superinfection.
3. Reddmandsyndrome.
4. Hives.
Answer:d3
downloaddfulldfiledatdhttp://testbankinstant.com
