Test Bank for Understanding
m m m m
Medical-
Surgical Nursing 6th Edition L
m m m m
inda S. Williams Paula D. Hop
m m m m m
per
,Chapter 1 m
1. Themnursemismcaringmformfourmclientsmonmammedical–
surgicalmunit.mWhichmclient mshould mthemnursemseeminitially?
1. Amclient madmitted mwithmhepatitismAmwhomhasmhad mseveremdiarrheamformtheml
ast m24mhours
2. Amclient madmitted mwithmpneumoniamwhomismhasmsmallmamountsmof myello
wmproductivemsputum
3. Amclient madmitted mwithmfevermof munknownmoriginm(FUO)mwhomhasmbe
enmwithout mfevermformthemlast m48mhours
4. Amclient madmitted mwithmamwound minfectionmwhosemWBCmism8,500mmm3
Answer:m1
Rationale:mThemnursemmust mdecidemwhichmclient mshould mbemseenmonmtheminitialmroundsmof mt
hemday.mThemnursemmust mremembermthat mthemfirst mclient mtombemseenmshould mbemthem
client mwhomneedsmthemattentionmof mthemnurseminitially.mAmclient mwithmhepatitismA md
oesmexperiencemdiarrhea,mbut mdiarrheamformthemlast m24mhoursmcould mcausemthemclien
t mtomhavemamproblemmwithmdehydrationmand mexperiencemamstatemof mfluid mvolumemde
ficit.
CognitivemLevel:mApplication
Client mNeeds:mSafe,mEffectivemCaremEnvironment mNu
rsingmProcess:mPlanning
2. Themnursemismpreparingmtomadministerminfluenzamvaccinesmtomammassmdrive-
throughmclinic.mWhichmstatement mbymamclient mwould mindicatemfurthermquestioningmpriormto
mgivingmthemclient mtheminfluenzamvaccine?
1. “I mammallergicmtomhorsemhair.”
2. “I mtrymtomget mmymvaccinemeverymyear.”
3. “I mammnot mallergicmtomanythingmexcept meggs.”
4. “Mymhusband mhad mamseveremallergicmreactionmaftermhemreceived mhisminfluen
zamvaccine.”
Answer:m3
Rationale:mInfluenzamvaccinesmaremrecommended mformpersonmat mhighmriskmformseriousmseq
uelaemof minfluenza.mThemnursemshould mbemawaremthat mclient mwithmamsensitivitymtome
ggsmshould mnot mreceivemthemvaccine.mVaccinesmprepared mfrommchickenmormduckme
mbryosmaremcontraindicated minmclientsmwhomaremallergicmtomeggs.
CognitivemLevel:mApplication
,Client mNeeds:mSafe,mEffectivemCaremEnvironment mNu
rsingmProcess:mAssessment
3. Themnursemismcaringmformfourmclientsmonmammedical–
surgicalmunit.mThem secretarymgivesmthemnursemthemmorningmlabs.mWhichmof mthemfollowingml
absmwould mrequiremthat mthemnursemcallmthemphysicianmand minformmthemhealthcaremproviderm
about mthemclient’smabnormalities?
1. WBCm14,600mmm3
2. Serummproteinm6.9mg/dL
3. I m&mDm(incisionmand mdrainage)mshowingmnomgrowthmformthemlast m24mhours
4. Albuminm4.2mg/dL
Answer:m1
Rationale:mWhenmthemnursemismcaringmformseveralmclients,mallmof mthemlabsmshould mbemchecke
d mfrequentlymthroughout mthemshift mtomassessmformanymabnormalities.mThemWBCminmoptionm
1mismabnormal.m(NormalmWBCm4,000–
10,000mmm3 .)mAllmof mthemothermlabmresultsmaremwithinmacceptablemrange;mtherefore,mthemre
sultsmshould mnot mbemcalled minmtomthemphysician.
CognitivemLevel:mApplicationmClie
nt mNeeds:mPhysiologicmIntegritymNu
rsingmProcess:mAssessment
4. Themnursemismorientingmamnew mgraduate.mThemnursem ismreinforcingmthem importancemo
f mstandard mprecautions.mWhichmof mthemfollowingmobservationsmbymthemnursemwould mreq
uiremfurthermeducationmregardingmstandard mprecautions?
1. Themgraduatemnursemunderstandsmtomwashmhandsmwhenmenteringmand mexiti
ngmthemclient’smroom.
2. Themgraduatemnursemwearsmglovesmwhenmservingmbreakfast mtraysmtomvario
usmclients.
3. Themgraduatemnursemwearsmamgown,mgloves,mand mgogglesmwhenmsuctioning
mamclient.
4. Themgraduatemnursemleavesmallmsuppliesminmthemroommof mamclient mwhomis
minmcontact misolation.
Answer:m2
Rationale:mThemnursemmust mhavemanmunderstandingmof mstandard mprecautions.mPreventionmi
smthemmost mimportant mmeasuremtomprevent mnosocomialminfections.mStandard mpreca
utionsmwerempublished minm1996mthat mprovidemguidelinesmformthemhandlingmof mbloo
d mand mothermbodymfluids.mThesemguidelinesmaremused mwithmallmclients,mregardlessmof
mwhethermtheymhavemamknownminfectiousmdisease.mStandard mprecautionsmaremused
, bymallmhealthcaremworkersmwhomhavemdirect mcontact mwithmclientsmormwithmtheirmbo
dymfluids.mIt mismnot mnecessarymformthemnursemtomwearmglovesmwhilemdeliveringmfood
mtraysmtomthemclient,mbecausemtheremismnot mcontact mwithmthemclient.
CognitivemLevel:mApplication
Client mNeeds:mSafe,mEffectivemCaremEnvironment mNu
rsingmProcess:mEvaluation
5. Themadmittingmdepartment malertsmthemnursemonmammedical–
surgicalmunit mthat mamclient mwithmactivemtuberculosism(TB)mismbeingmadmitted mtomthemunit.m
Whichmtypemof misolationmismappropriatembased monmthemclient’smdiagnosis?
1. Standard mprecautions
2. Airbornemprecautions
3. Droplet mprecautions
4. Contact mprecautions
Answer:m2
Inmadditionmtomhandwashingmand mstandardmprecautions,mthemnaturemand mspread mof msomemin
fectiousmdiseasesmrequiremthat mspecialmtechniquesmbemused mtomprotect muninfected mclientsman
d mworkers.mThemclient mwithmpulmonarymtuberculosismwill mbemplaced minmairbornemprecautio
ns.mThemclient mshould mbemplaced minmamprivatemroommwithmspecialmventilationmthat mdoesmnot m
allow mairmtomcirculatemtomgeneralmhospitalmventilation; mammaskmorm specialmfilterm respirators
mwillmbemused mformeveryonementeringmthemroom.
CognitivemLevel:mApplication
Client mNeeds:mSafe,mEffectivemCaremEnvironment mNu
rsingmProcess:mAssessment
6. Amclient mismreceivingmIVmvancomycinmformthemtreatment mof mClostridiummdifficile.mT
hemnursemunderstandsmthat mthemclient mwhomdevelopsmflushing,mtachycardia,mand mhypote
nsionmduringmtheminfusionmof mvancomycinmindicates:
1. Ototoxicitymeffect.
2. Superinfection.
3. Red mmanmsyndrome.
4. Hives.
Answer:m3
Rationale:mVancomycinminhibitsmcellmwallmsynthesis,mand mismused mformseriousminfections.mIt m
ismonlymeffectivemagainst mgram-positivembacteria,mespeciallymStaphylococcusmaureusmand
m m m m
Medical-
Surgical Nursing 6th Edition L
m m m m
inda S. Williams Paula D. Hop
m m m m m
per
,Chapter 1 m
1. Themnursemismcaringmformfourmclientsmonmammedical–
surgicalmunit.mWhichmclient mshould mthemnursemseeminitially?
1. Amclient madmitted mwithmhepatitismAmwhomhasmhad mseveremdiarrheamformtheml
ast m24mhours
2. Amclient madmitted mwithmpneumoniamwhomismhasmsmallmamountsmof myello
wmproductivemsputum
3. Amclient madmitted mwithmfevermof munknownmoriginm(FUO)mwhomhasmbe
enmwithout mfevermformthemlast m48mhours
4. Amclient madmitted mwithmamwound minfectionmwhosemWBCmism8,500mmm3
Answer:m1
Rationale:mThemnursemmust mdecidemwhichmclient mshould mbemseenmonmtheminitialmroundsmof mt
hemday.mThemnursemmust mremembermthat mthemfirst mclient mtombemseenmshould mbemthem
client mwhomneedsmthemattentionmof mthemnurseminitially.mAmclient mwithmhepatitismA md
oesmexperiencemdiarrhea,mbut mdiarrheamformthemlast m24mhoursmcould mcausemthemclien
t mtomhavemamproblemmwithmdehydrationmand mexperiencemamstatemof mfluid mvolumemde
ficit.
CognitivemLevel:mApplication
Client mNeeds:mSafe,mEffectivemCaremEnvironment mNu
rsingmProcess:mPlanning
2. Themnursemismpreparingmtomadministerminfluenzamvaccinesmtomammassmdrive-
throughmclinic.mWhichmstatement mbymamclient mwould mindicatemfurthermquestioningmpriormto
mgivingmthemclient mtheminfluenzamvaccine?
1. “I mammallergicmtomhorsemhair.”
2. “I mtrymtomget mmymvaccinemeverymyear.”
3. “I mammnot mallergicmtomanythingmexcept meggs.”
4. “Mymhusband mhad mamseveremallergicmreactionmaftermhemreceived mhisminfluen
zamvaccine.”
Answer:m3
Rationale:mInfluenzamvaccinesmaremrecommended mformpersonmat mhighmriskmformseriousmseq
uelaemof minfluenza.mThemnursemshould mbemawaremthat mclient mwithmamsensitivitymtome
ggsmshould mnot mreceivemthemvaccine.mVaccinesmprepared mfrommchickenmormduckme
mbryosmaremcontraindicated minmclientsmwhomaremallergicmtomeggs.
CognitivemLevel:mApplication
,Client mNeeds:mSafe,mEffectivemCaremEnvironment mNu
rsingmProcess:mAssessment
3. Themnursemismcaringmformfourmclientsmonmammedical–
surgicalmunit.mThem secretarymgivesmthemnursemthemmorningmlabs.mWhichmof mthemfollowingml
absmwould mrequiremthat mthemnursemcallmthemphysicianmand minformmthemhealthcaremproviderm
about mthemclient’smabnormalities?
1. WBCm14,600mmm3
2. Serummproteinm6.9mg/dL
3. I m&mDm(incisionmand mdrainage)mshowingmnomgrowthmformthemlast m24mhours
4. Albuminm4.2mg/dL
Answer:m1
Rationale:mWhenmthemnursemismcaringmformseveralmclients,mallmof mthemlabsmshould mbemchecke
d mfrequentlymthroughout mthemshift mtomassessmformanymabnormalities.mThemWBCminmoptionm
1mismabnormal.m(NormalmWBCm4,000–
10,000mmm3 .)mAllmof mthemothermlabmresultsmaremwithinmacceptablemrange;mtherefore,mthemre
sultsmshould mnot mbemcalled minmtomthemphysician.
CognitivemLevel:mApplicationmClie
nt mNeeds:mPhysiologicmIntegritymNu
rsingmProcess:mAssessment
4. Themnursemismorientingmamnew mgraduate.mThemnursem ismreinforcingmthem importancemo
f mstandard mprecautions.mWhichmof mthemfollowingmobservationsmbymthemnursemwould mreq
uiremfurthermeducationmregardingmstandard mprecautions?
1. Themgraduatemnursemunderstandsmtomwashmhandsmwhenmenteringmand mexiti
ngmthemclient’smroom.
2. Themgraduatemnursemwearsmglovesmwhenmservingmbreakfast mtraysmtomvario
usmclients.
3. Themgraduatemnursemwearsmamgown,mgloves,mand mgogglesmwhenmsuctioning
mamclient.
4. Themgraduatemnursemleavesmallmsuppliesminmthemroommof mamclient mwhomis
minmcontact misolation.
Answer:m2
Rationale:mThemnursemmust mhavemanmunderstandingmof mstandard mprecautions.mPreventionmi
smthemmost mimportant mmeasuremtomprevent mnosocomialminfections.mStandard mpreca
utionsmwerempublished minm1996mthat mprovidemguidelinesmformthemhandlingmof mbloo
d mand mothermbodymfluids.mThesemguidelinesmaremused mwithmallmclients,mregardlessmof
mwhethermtheymhavemamknownminfectiousmdisease.mStandard mprecautionsmaremused
, bymallmhealthcaremworkersmwhomhavemdirect mcontact mwithmclientsmormwithmtheirmbo
dymfluids.mIt mismnot mnecessarymformthemnursemtomwearmglovesmwhilemdeliveringmfood
mtraysmtomthemclient,mbecausemtheremismnot mcontact mwithmthemclient.
CognitivemLevel:mApplication
Client mNeeds:mSafe,mEffectivemCaremEnvironment mNu
rsingmProcess:mEvaluation
5. Themadmittingmdepartment malertsmthemnursemonmammedical–
surgicalmunit mthat mamclient mwithmactivemtuberculosism(TB)mismbeingmadmitted mtomthemunit.m
Whichmtypemof misolationmismappropriatembased monmthemclient’smdiagnosis?
1. Standard mprecautions
2. Airbornemprecautions
3. Droplet mprecautions
4. Contact mprecautions
Answer:m2
Inmadditionmtomhandwashingmand mstandardmprecautions,mthemnaturemand mspread mof msomemin
fectiousmdiseasesmrequiremthat mspecialmtechniquesmbemused mtomprotect muninfected mclientsman
d mworkers.mThemclient mwithmpulmonarymtuberculosismwill mbemplaced minmairbornemprecautio
ns.mThemclient mshould mbemplaced minmamprivatemroommwithmspecialmventilationmthat mdoesmnot m
allow mairmtomcirculatemtomgeneralmhospitalmventilation; mammaskmorm specialmfilterm respirators
mwillmbemused mformeveryonementeringmthemroom.
CognitivemLevel:mApplication
Client mNeeds:mSafe,mEffectivemCaremEnvironment mNu
rsingmProcess:mAssessment
6. Amclient mismreceivingmIVmvancomycinmformthemtreatment mof mClostridiummdifficile.mT
hemnursemunderstandsmthat mthemclient mwhomdevelopsmflushing,mtachycardia,mand mhypote
nsionmduringmtheminfusionmof mvancomycinmindicates:
1. Ototoxicitymeffect.
2. Superinfection.
3. Red mmanmsyndrome.
4. Hives.
Answer:m3
Rationale:mVancomycinminhibitsmcellmwallmsynthesis,mand mismused mformseriousminfections.mIt m
ismonlymeffectivemagainst mgram-positivembacteria,mespeciallymStaphylococcusmaureusmand
