TESTBANK FOR LEMONE & BURKE’S MEDICAL-
SURGICAL NURSING: CLINICAL REASONING IN
HOSPITAL CLIENT CARE 7TH EDITION/ALL
CHAPTERS 1-52
,Chapter 1
1. The caregiver is caring for four Hospital clients on a medical–surgical unit. Which
Hospital client should the caregiver see initially?
1. A Hospital client admitted with hepatitis A who has had severe
diarrhea for thelast 24 hours
2. A Hospital client admitted with pneumonia who is has small
amounts ofyellow productive sputum
3. A Hospital client admitted with fever of unknown origin (FUO)
who hasbeen without fever for the last 48 hours
4. A Hospital client admitted with a wound infection whose WBC is
8,500 mm3ACCURATE ANSWER:-1
Reasoning:->>>The caregiver must decide which Hospital client should be seen on the
initial rounds of the day. The caregiver must remember that the first
Hospital client to be seen should be the Hospital client who needs the attention
of the caregiver initially. A Hospital client with hepatitis A does experience
diarrhea,but diarrhea for the last 24 hours could cause the Hospital client to
have a problem withdehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
EnvironmentNursing Process: Planning
2. The caregiver is preparing to administer influenza vaccines to a mass drive-through
clinic. Which statement by a Hospital client would indicate further questioning prior to
giving the Hospital client 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.”
ACCURATE ANSWER:-3
Reasoning:->>>Influenza vaccines are recommended for person at high risk for serious
sequelae of influenza. The caregiver should be aware that Hospital client with a
sensitivity to eggs should not receive the vaccine. Vaccines prepared from
chicken or duck embryos are contraindicated in Hospital clients who are allergic
to eggs.
,Cognitive MLevel: MApplication
Hospital Mclient MNeeds: MSafe, MEffective MCare
MEnvironmentMNursing MProcess: MAssessment
3. The Mcaregiver Mis Mcaring Mfor Mfour MHospital Mclients Mon Ma Mmedical–surgical Munit.
MThe Msecretary Mgives Mthe Mcaregiver Mthe Mmorning Mlabs. MWhich Mof Mthe Mfollowing
Mlabs Mwould Mrequire Mthat Mthe Mcaregiver Mcall Mthe Mphysician Mand Minform Mthe
Mhealthcare Mprovider Mabout Mthe MHospital Mclient’s Mabnormalities?
1. MWBC M14,600 Mmm3
2. Serum Mprotein M6.9 Mg/dL
3. I M& MD M(incision Mand Mdrainage) Mshowing Mno Mgrowth Mfor Mthe Mlast M24 Mhours
4. Albumin M4.2
Mg/dLMACCURATE
MANSWER:-1
Reasoning:->>>When Mthe Mcaregiver Mis Mcaring Mfor Mseveral MHospital Mclients, Mall
Mof Mthe Mlabs Mshould Mbe Mchecked Mfrequently Mthroughout Mthe Mshift Mto Massess Mfor
Many Mabnormalities. MThe MWBC Min Moption M1 Mis Mabnormal. M(Normal MWBC M4,000–
10,000 Mmm3.) MAll Mof Mthe Mother Mlab Mresults Mare Mwithin Macceptable Mrange;
Mtherefore, Mthe Mresults Mshould Mnot Mbe Mcalled Min Mto MtheMphysician.
Cognitive MLevel:
MApplicationMHospital Mclient
MNeeds: MPhysiologic
MIntegrity MNursing MProcess:
Assessment
4. The Mcaregiver Mis Morienting Ma Mnew Mgraduate. MThe Mcaregiver Mis
Mreinforcing Mthe Mimportance Mof Mstandard Mprecautions. MWhich Mof Mthe
Mfollowing Mobservations Mby Mthe Mcaregiver Mwould Mrequire Mfurther Meducation
MregardingMstandard Mprecautions?
1. The Mgraduate Mcaregiver Munderstands Mto Mwash Mhands Mwhen
Mentering Mand Mexiting Mthe MHospital Mclient’s Mroom.
2. The Mgraduate Mcaregiver Mwears Mgloves Mwhen Mserving Mbreakfast
Mtrays Mto Mvarious MHospital Mclients.
3. The Mgraduate Mcaregiver Mwears Ma Mgown, Mgloves, Mand Mgoggles Mwhen
Msuctioning Ma MHospital Mclient.
4. The Mgraduate Mcaregiver Mleaves Mall Msupplies Min Mthe Mroom Mof Ma
MHospital Mclient M who Mis Min Mcontact Misolation.
ACCURATE MANSWER:-2
, Reasoning:->>>The Mcaregiver Mmust Mhave Man Munderstanding Mof Mstandard
Mprecautions. MPrevention Mis Mthe Mmost Mimportant Mmeasure Mto Mprevent
Mnosocomial Minfections. MStandard Mprecautions Mwere Mpublished Min M1996 Mthat
Mprovide Mguidelines
for Mthe Mhandling Mof Mblood Mand Mother Mbody Mfluids. MThese Mguidelines Mare
Mused Mwith Mall MHospital Mclients, Mregardless Mof Mwhether Mthey Mhave Ma Mknown
Minfectious Mdisease. MStandardMprecautions Mare Mused
by Mall Mhealthcare Mworkers Mwho Mhave Mdirect Mcontact Mwith MHospital Mclients
Mor Mwith Mtheir Mbody Mfluids. MIt Mis Mnot Mnecessary Mfor Mthe Mcaregiver Mto Mwear
Mgloves Mwhile Mdelivering M food Mtrays Mto Mthe MHospital Mclient, Mbecause Mthere
Mis Mnot Mcontact Mwith Mthe MHospital Mclient.
Cognitive MLevel: MApplication
Hospital Mclient MNeeds: MSafe, MEffective MCare
MEnvironmentMNursing MProcess: MEvaluation
5. The Madmitting Mdepartment Malerts Mthe Mcaregiver Mon Ma Mmedical–surgical Munit MthatMa
MHospital Mclient Mwith Mactive Mtuberculosis M(TB) Mis Mbeing Madmitted Mto Mthe Munit.
MWhich Mtype Mof Misolation Mis Mappropriate Mbased Mon Mthe MHospital Mclient’s
Mdiagnosis?
1. Standard Mprecautions
2. Airborne Mprecautions
3. Droplet Mprecautions
4. Contact
MprecautionsMACCURATE
MANSWER:-2
Reasoning:->>>In Maddition Mto Mhandwashing Mand Mstandard Mprecautions, Mthe Mnature
Mand Mspread Mof Msome Minfectious Mdiseases Mrequire Mthat Mspecial Mtechniques Mbe Mused
Mto Mprotect Muninfected MHospital Mclients Mand Mworkers. MThe MHospital Mclient Mwith
Mpulmonary Mtuberculosis Mwill Mbe Mplaced Min Mairborne Mprecautions. MThe MHospital
Mclient Mshould Mbe Mplaced Min Ma Mprivate Mroom Mwith Mspecial Mventilation Mthat Mdoes Mnot
Mallow Mair Mto Mcirculate Mto Mgeneral Mhealth Mcenter Mventilation; Ma MmaskMor Mspecial
Mfilter Mrespirators Mwill Mbe Mused M for Meveryone Mentering Mthe Mroom.
Cognitive MLevel: MApplication
Hospital Mclient MNeeds: MSafe, MEffective MCare
MEnvironmentMNursing MProcess: MAssessment
6. A MHospital Mclient Mis Mreceiving MIV Mvancomycin Mfor Mthe Mtreatment Mof
MClostridium Mdifficile.MThe Mcaregiver Munderstands Mthat Mthe MHospital Mclient
Mwho Mdevelops Mflushing, Mtachycardia, Mand Mhypotension Mduring Mthe Minfusion
SURGICAL NURSING: CLINICAL REASONING IN
HOSPITAL CLIENT CARE 7TH EDITION/ALL
CHAPTERS 1-52
,Chapter 1
1. The caregiver is caring for four Hospital clients on a medical–surgical unit. Which
Hospital client should the caregiver see initially?
1. A Hospital client admitted with hepatitis A who has had severe
diarrhea for thelast 24 hours
2. A Hospital client admitted with pneumonia who is has small
amounts ofyellow productive sputum
3. A Hospital client admitted with fever of unknown origin (FUO)
who hasbeen without fever for the last 48 hours
4. A Hospital client admitted with a wound infection whose WBC is
8,500 mm3ACCURATE ANSWER:-1
Reasoning:->>>The caregiver must decide which Hospital client should be seen on the
initial rounds of the day. The caregiver must remember that the first
Hospital client to be seen should be the Hospital client who needs the attention
of the caregiver initially. A Hospital client with hepatitis A does experience
diarrhea,but diarrhea for the last 24 hours could cause the Hospital client to
have a problem withdehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
Hospital client Needs: Safe, Effective Care
EnvironmentNursing Process: Planning
2. The caregiver is preparing to administer influenza vaccines to a mass drive-through
clinic. Which statement by a Hospital client would indicate further questioning prior to
giving the Hospital client 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.”
ACCURATE ANSWER:-3
Reasoning:->>>Influenza vaccines are recommended for person at high risk for serious
sequelae of influenza. The caregiver should be aware that Hospital client with a
sensitivity to eggs should not receive the vaccine. Vaccines prepared from
chicken or duck embryos are contraindicated in Hospital clients who are allergic
to eggs.
,Cognitive MLevel: MApplication
Hospital Mclient MNeeds: MSafe, MEffective MCare
MEnvironmentMNursing MProcess: MAssessment
3. The Mcaregiver Mis Mcaring Mfor Mfour MHospital Mclients Mon Ma Mmedical–surgical Munit.
MThe Msecretary Mgives Mthe Mcaregiver Mthe Mmorning Mlabs. MWhich Mof Mthe Mfollowing
Mlabs Mwould Mrequire Mthat Mthe Mcaregiver Mcall Mthe Mphysician Mand Minform Mthe
Mhealthcare Mprovider Mabout Mthe MHospital Mclient’s Mabnormalities?
1. MWBC M14,600 Mmm3
2. Serum Mprotein M6.9 Mg/dL
3. I M& MD M(incision Mand Mdrainage) Mshowing Mno Mgrowth Mfor Mthe Mlast M24 Mhours
4. Albumin M4.2
Mg/dLMACCURATE
MANSWER:-1
Reasoning:->>>When Mthe Mcaregiver Mis Mcaring Mfor Mseveral MHospital Mclients, Mall
Mof Mthe Mlabs Mshould Mbe Mchecked Mfrequently Mthroughout Mthe Mshift Mto Massess Mfor
Many Mabnormalities. MThe MWBC Min Moption M1 Mis Mabnormal. M(Normal MWBC M4,000–
10,000 Mmm3.) MAll Mof Mthe Mother Mlab Mresults Mare Mwithin Macceptable Mrange;
Mtherefore, Mthe Mresults Mshould Mnot Mbe Mcalled Min Mto MtheMphysician.
Cognitive MLevel:
MApplicationMHospital Mclient
MNeeds: MPhysiologic
MIntegrity MNursing MProcess:
Assessment
4. The Mcaregiver Mis Morienting Ma Mnew Mgraduate. MThe Mcaregiver Mis
Mreinforcing Mthe Mimportance Mof Mstandard Mprecautions. MWhich Mof Mthe
Mfollowing Mobservations Mby Mthe Mcaregiver Mwould Mrequire Mfurther Meducation
MregardingMstandard Mprecautions?
1. The Mgraduate Mcaregiver Munderstands Mto Mwash Mhands Mwhen
Mentering Mand Mexiting Mthe MHospital Mclient’s Mroom.
2. The Mgraduate Mcaregiver Mwears Mgloves Mwhen Mserving Mbreakfast
Mtrays Mto Mvarious MHospital Mclients.
3. The Mgraduate Mcaregiver Mwears Ma Mgown, Mgloves, Mand Mgoggles Mwhen
Msuctioning Ma MHospital Mclient.
4. The Mgraduate Mcaregiver Mleaves Mall Msupplies Min Mthe Mroom Mof Ma
MHospital Mclient M who Mis Min Mcontact Misolation.
ACCURATE MANSWER:-2
, Reasoning:->>>The Mcaregiver Mmust Mhave Man Munderstanding Mof Mstandard
Mprecautions. MPrevention Mis Mthe Mmost Mimportant Mmeasure Mto Mprevent
Mnosocomial Minfections. MStandard Mprecautions Mwere Mpublished Min M1996 Mthat
Mprovide Mguidelines
for Mthe Mhandling Mof Mblood Mand Mother Mbody Mfluids. MThese Mguidelines Mare
Mused Mwith Mall MHospital Mclients, Mregardless Mof Mwhether Mthey Mhave Ma Mknown
Minfectious Mdisease. MStandardMprecautions Mare Mused
by Mall Mhealthcare Mworkers Mwho Mhave Mdirect Mcontact Mwith MHospital Mclients
Mor Mwith Mtheir Mbody Mfluids. MIt Mis Mnot Mnecessary Mfor Mthe Mcaregiver Mto Mwear
Mgloves Mwhile Mdelivering M food Mtrays Mto Mthe MHospital Mclient, Mbecause Mthere
Mis Mnot Mcontact Mwith Mthe MHospital Mclient.
Cognitive MLevel: MApplication
Hospital Mclient MNeeds: MSafe, MEffective MCare
MEnvironmentMNursing MProcess: MEvaluation
5. The Madmitting Mdepartment Malerts Mthe Mcaregiver Mon Ma Mmedical–surgical Munit MthatMa
MHospital Mclient Mwith Mactive Mtuberculosis M(TB) Mis Mbeing Madmitted Mto Mthe Munit.
MWhich Mtype Mof Misolation Mis Mappropriate Mbased Mon Mthe MHospital Mclient’s
Mdiagnosis?
1. Standard Mprecautions
2. Airborne Mprecautions
3. Droplet Mprecautions
4. Contact
MprecautionsMACCURATE
MANSWER:-2
Reasoning:->>>In Maddition Mto Mhandwashing Mand Mstandard Mprecautions, Mthe Mnature
Mand Mspread Mof Msome Minfectious Mdiseases Mrequire Mthat Mspecial Mtechniques Mbe Mused
Mto Mprotect Muninfected MHospital Mclients Mand Mworkers. MThe MHospital Mclient Mwith
Mpulmonary Mtuberculosis Mwill Mbe Mplaced Min Mairborne Mprecautions. MThe MHospital
Mclient Mshould Mbe Mplaced Min Ma Mprivate Mroom Mwith Mspecial Mventilation Mthat Mdoes Mnot
Mallow Mair Mto Mcirculate Mto Mgeneral Mhealth Mcenter Mventilation; Ma MmaskMor Mspecial
Mfilter Mrespirators Mwill Mbe Mused M for Meveryone Mentering Mthe Mroom.
Cognitive MLevel: MApplication
Hospital Mclient MNeeds: MSafe, MEffective MCare
MEnvironmentMNursing MProcess: MAssessment
6. A MHospital Mclient Mis Mreceiving MIV Mvancomycin Mfor Mthe Mtreatment Mof
MClostridium Mdifficile.MThe Mcaregiver Munderstands Mthat Mthe MHospital Mclient
Mwho Mdevelops Mflushing, Mtachycardia, Mand Mhypotension Mduring Mthe Minfusion
