Test Bank for Understanding
n n n n
Medical-
Surgical Nursing 6th Edition L
n n n n
inda S. Williams Paula D. Hop
n n n n n
per
,Chapter 1 n
1. Then nursen isn caringn forn fourn clientsn onn an medical–
surgicaln unit.n Whichn client n should n then nursen seen initially?
1. An client n admittednwithnhepatitisn Anwhonhasn hadnseveren diarrhean forn thenlastn2
4n hours
2. An client n admittednwithnpneumonian whon isn hasn smalln amountsn of n yellow n
productiven sputum
3. An client n admittednwithnfevernof nunknownnoriginn (FUO)n whon hasn beenn
without n fevern forn then last n 48n hours
4. An client n admitted n withn an wound n infectionn whosen WBCn isn 8,500n mm3
Answer:n 1
Rationale:n Then nursen must n decidenwhichn client nshould nbenseennonntheninitialn roundsnofnthen d
ay.n Then nursen must n remembern that n then first n client ntonben seennshould n benthen client nwh
on needsn then attentionnof nthen nursen initially.n An client n withn hepatitisn Andoesn experienc
en diarrhea,n but n diarrhean forn then last n24n hoursncould ncausen thenclient n ton haven an proble
mn withn dehydrationn and n experiencen an staten of n fluid n volumen deficit.
Cognitiven Level:n Application
Client nNeeds:nSafe,nEffectivenCarenEnvironment n Nurs
ingn Process:n Planning
2. Then nursen isn preparingn ton administern influenzan vaccinesn ton an massn drive-
throughn clinic.n Whichn statement n byn an client n would n indicaten furthern questioningn priorn ton gi
vingn then client n then influenzan vaccine?
1. “I n amn allergicn ton horsen hair.”
2. “I n tryn ton get n myn vaccinen everyn year.”
3. “I n amn not n allergicn ton anythingn except n eggs.”
4. “Myn husband n had nanseveren allergicn reactionn aftern hen received n hisn influenzan
vaccine.”
Answer:n 3
Rationale:n Influenzan vaccinesn aren recommended n forn personn at nhighn riskn fornseriousn sequela
en of n influenza.n Then nursenshould nbenawaren that nclient nwithnansensitivitynton eggsn shou
ld n not n receiven then vaccine.n Vaccinesn prepared n fromn chickenn orn duckn embryosn aren c
ontraindicated n inn clientsn whon aren allergicn ton eggs.
Cognitiven Level:n Application
,Client nNeeds:nSafe,nEffectivenCarenEnvironment n Nurs
ingn Process:n Assessment
3. Then nursen isn caringn fornfourn clientsn onn an medical–
surgicaln unit.n Then secretaryn givesnthen nursen then morningn labs.n Whichn ofn thenfollowingn labsn
wouldn requiren that nthen nursen calln then physiciann andn informn then healthcaren providern about nt
hen client’sn abnormalities?
1. WBCn 14,600n mm3
2. Serumn proteinn 6.9n g/dL
3. I n &n Dn (incisionn and n drainage)n showingn non growthn forn then last n 24n hours
4. Albuminn 4.2n g/dL
Answer:n 1
Rationale:n Whenn then nursen isn caringn forn severaln clients,n alln ofnthenlabsn shouldnbenchecked nfre
quentlyn throughout n then shiftn tonassessn forn anyn abnormalities.n Then WBCn inn optionn 1n isn abno
rmal.n (Normaln WBCn 4,000–
10,000n mm3 .)n Alln of n then othern labn resultsn aren withinn acceptablen range;n therefore,nthenresults
n should n not n ben called n inn ton then physician.
Cognitiven Level:n Applicationn Clien
t nNeeds:nPhysiologicnIntegrityn Nursi
ngn Process:n Assessment
4. Then nursen isn orientingn an new n graduate.n Then nursen isn reinforcingn then importancen of nsta
ndard n precautions.n Whichn ofnthenfollowingn observationsn bynthennursenwouldnrequiren furt
hern educationn regardingn standard n precautions?
1. Thengraduaten nursen understandsntonwashnhandsnwhennenteringn andnexitingnt
hen client’sn room.
2. Thengraduaten nursen wearsn glovesn whennservingn breakfastn traysn ton variousn
clients.
3. Then graduaten nursen wearsn angown,ngloves,n andngogglesn whennsuctioningn anc
lient.
4. Then graduaten nursen leavesn alln suppliesn inn thenroomn ofnan client nwhonisninn c
ontact n isolation.
Answer:n 2
Rationale:n Then nursen must n haven ann understandingn of n standard n precautions.n Preventionn isn t
hen most n important n measuren ton prevent n nosocomialn infections.n Standard n precaution
sn weren published n inn 1996n that nprovidenguidelinesn fornthenhandlingn of nblood nand n oth
ern bodyn fluids.nThesen guidelinesn arenused nwithnalln clients,n regardlessn of nwhethern the
yn haven an knownn infectiousn disease.n Standard n precautionsn aren used
, byn alln healthcaren workersn whon havendirectn contactnwithn clientsn orn withn theirn bodynf
luids.nItn isn notn necessaryn fornthen nursen tonwearn glovesnwhilendeliveringn foodn traysnto
n then client,n becausen theren isn not n contact n withn then client.
Cognitiven Level:n Application
Client nNeeds:nSafe,nEffectivenCarenEnvironment n Nurs
ingn Process:n Evaluation
5. Then admittingn department n alertsn then nursen onn an medical–
surgicaln unit n that n an client nwithnactiven tuberculosisn (TB)n isn beingn admitted nton then unit.nWhic
hn typen of n isolationn isn appropriaten based n onn then client’sn diagnosis?
1. Standard n precautions
2. Airbornenprecautions
3. Droplet n precautions
4. Contact n precautions
Answer:n 2
Inn additionntonhandwashingn andn standard nprecautions,n thennaturenand nspread nofn somen infect
iousn diseasesn requiren that n specialn techniquesn benusedntonprotectnuninfectednclientsn andnwork
ers.n Then client n withn pulmonaryn tuberculosisn willn ben placed n inn airbornen precautions.n Then cli
ent n should n benplaced ninn anprivatenroomn withnspecialn ventilationn thatn doesnnot nallow n airn ton cir
culaten ton generaln hospitaln ventilation;n an maskn orn specialn filtern respiratorsn willn ben used n forn e
veryonen enteringn then room.
Cognitiven Level:n Application
Client nNeeds:nSafe,nEffectivenCarenEnvironment n Nurs
ingn Process:n Assessment
6. An client n isn receivingn IVn vancomycinn forn thentreatment nofn Clostridiumn difficile.n Then n
ursenunderstandsn that nthenclient n whondevelopsn flushing,n tachycardia,n and n hypotensionn d
uringn then infusionn of n vancomycinn indicates:
1. Ototoxicityn effect.
2. Superinfection.
3. Red n mann syndrome.
4. Hives.
Answer:n 3
Rationale:n Vancomycinn inhibitsn celln walln synthesis,n and n isn usednfornseriousn infections.n Itnisn o
nlyn effectiven against n gram-positiven bacteria,n especiallyn Staphylococcusn aureusn and
n n n n
Medical-
Surgical Nursing 6th Edition L
n n n n
inda S. Williams Paula D. Hop
n n n n n
per
,Chapter 1 n
1. Then nursen isn caringn forn fourn clientsn onn an medical–
surgicaln unit.n Whichn client n should n then nursen seen initially?
1. An client n admittednwithnhepatitisn Anwhonhasn hadnseveren diarrhean forn thenlastn2
4n hours
2. An client n admittednwithnpneumonian whon isn hasn smalln amountsn of n yellow n
productiven sputum
3. An client n admittednwithnfevernof nunknownnoriginn (FUO)n whon hasn beenn
without n fevern forn then last n 48n hours
4. An client n admitted n withn an wound n infectionn whosen WBCn isn 8,500n mm3
Answer:n 1
Rationale:n Then nursen must n decidenwhichn client nshould nbenseennonntheninitialn roundsnofnthen d
ay.n Then nursen must n remembern that n then first n client ntonben seennshould n benthen client nwh
on needsn then attentionnof nthen nursen initially.n An client n withn hepatitisn Andoesn experienc
en diarrhea,n but n diarrhean forn then last n24n hoursncould ncausen thenclient n ton haven an proble
mn withn dehydrationn and n experiencen an staten of n fluid n volumen deficit.
Cognitiven Level:n Application
Client nNeeds:nSafe,nEffectivenCarenEnvironment n Nurs
ingn Process:n Planning
2. Then nursen isn preparingn ton administern influenzan vaccinesn ton an massn drive-
throughn clinic.n Whichn statement n byn an client n would n indicaten furthern questioningn priorn ton gi
vingn then client n then influenzan vaccine?
1. “I n amn allergicn ton horsen hair.”
2. “I n tryn ton get n myn vaccinen everyn year.”
3. “I n amn not n allergicn ton anythingn except n eggs.”
4. “Myn husband n had nanseveren allergicn reactionn aftern hen received n hisn influenzan
vaccine.”
Answer:n 3
Rationale:n Influenzan vaccinesn aren recommended n forn personn at nhighn riskn fornseriousn sequela
en of n influenza.n Then nursenshould nbenawaren that nclient nwithnansensitivitynton eggsn shou
ld n not n receiven then vaccine.n Vaccinesn prepared n fromn chickenn orn duckn embryosn aren c
ontraindicated n inn clientsn whon aren allergicn ton eggs.
Cognitiven Level:n Application
,Client nNeeds:nSafe,nEffectivenCarenEnvironment n Nurs
ingn Process:n Assessment
3. Then nursen isn caringn fornfourn clientsn onn an medical–
surgicaln unit.n Then secretaryn givesnthen nursen then morningn labs.n Whichn ofn thenfollowingn labsn
wouldn requiren that nthen nursen calln then physiciann andn informn then healthcaren providern about nt
hen client’sn abnormalities?
1. WBCn 14,600n mm3
2. Serumn proteinn 6.9n g/dL
3. I n &n Dn (incisionn and n drainage)n showingn non growthn forn then last n 24n hours
4. Albuminn 4.2n g/dL
Answer:n 1
Rationale:n Whenn then nursen isn caringn forn severaln clients,n alln ofnthenlabsn shouldnbenchecked nfre
quentlyn throughout n then shiftn tonassessn forn anyn abnormalities.n Then WBCn inn optionn 1n isn abno
rmal.n (Normaln WBCn 4,000–
10,000n mm3 .)n Alln of n then othern labn resultsn aren withinn acceptablen range;n therefore,nthenresults
n should n not n ben called n inn ton then physician.
Cognitiven Level:n Applicationn Clien
t nNeeds:nPhysiologicnIntegrityn Nursi
ngn Process:n Assessment
4. Then nursen isn orientingn an new n graduate.n Then nursen isn reinforcingn then importancen of nsta
ndard n precautions.n Whichn ofnthenfollowingn observationsn bynthennursenwouldnrequiren furt
hern educationn regardingn standard n precautions?
1. Thengraduaten nursen understandsntonwashnhandsnwhennenteringn andnexitingnt
hen client’sn room.
2. Thengraduaten nursen wearsn glovesn whennservingn breakfastn traysn ton variousn
clients.
3. Then graduaten nursen wearsn angown,ngloves,n andngogglesn whennsuctioningn anc
lient.
4. Then graduaten nursen leavesn alln suppliesn inn thenroomn ofnan client nwhonisninn c
ontact n isolation.
Answer:n 2
Rationale:n Then nursen must n haven ann understandingn of n standard n precautions.n Preventionn isn t
hen most n important n measuren ton prevent n nosocomialn infections.n Standard n precaution
sn weren published n inn 1996n that nprovidenguidelinesn fornthenhandlingn of nblood nand n oth
ern bodyn fluids.nThesen guidelinesn arenused nwithnalln clients,n regardlessn of nwhethern the
yn haven an knownn infectiousn disease.n Standard n precautionsn aren used
, byn alln healthcaren workersn whon havendirectn contactnwithn clientsn orn withn theirn bodynf
luids.nItn isn notn necessaryn fornthen nursen tonwearn glovesnwhilendeliveringn foodn traysnto
n then client,n becausen theren isn not n contact n withn then client.
Cognitiven Level:n Application
Client nNeeds:nSafe,nEffectivenCarenEnvironment n Nurs
ingn Process:n Evaluation
5. Then admittingn department n alertsn then nursen onn an medical–
surgicaln unit n that n an client nwithnactiven tuberculosisn (TB)n isn beingn admitted nton then unit.nWhic
hn typen of n isolationn isn appropriaten based n onn then client’sn diagnosis?
1. Standard n precautions
2. Airbornenprecautions
3. Droplet n precautions
4. Contact n precautions
Answer:n 2
Inn additionntonhandwashingn andn standard nprecautions,n thennaturenand nspread nofn somen infect
iousn diseasesn requiren that n specialn techniquesn benusedntonprotectnuninfectednclientsn andnwork
ers.n Then client n withn pulmonaryn tuberculosisn willn ben placed n inn airbornen precautions.n Then cli
ent n should n benplaced ninn anprivatenroomn withnspecialn ventilationn thatn doesnnot nallow n airn ton cir
culaten ton generaln hospitaln ventilation;n an maskn orn specialn filtern respiratorsn willn ben used n forn e
veryonen enteringn then room.
Cognitiven Level:n Application
Client nNeeds:nSafe,nEffectivenCarenEnvironment n Nurs
ingn Process:n Assessment
6. An client n isn receivingn IVn vancomycinn forn thentreatment nofn Clostridiumn difficile.n Then n
ursenunderstandsn that nthenclient n whondevelopsn flushing,n tachycardia,n and n hypotensionn d
uringn then infusionn of n vancomycinn indicates:
1. Ototoxicityn effect.
2. Superinfection.
3. Red n mann syndrome.
4. Hives.
Answer:n 3
Rationale:n Vancomycinn inhibitsn celln walln synthesis,n and n isn usednfornseriousn infections.n Itnisn o
nlyn effectiven against n gram-positiven bacteria,n especiallyn Staphylococcusn aureusn and
