TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL THINKING IN CLIENT
CARE, 5TH EDITION PRISCILLA LEMON
Test Bank
,TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL THINKING IN CLIENT
CARE, 5TH EDITION PRISCILLA LEMON
Chapter 1
1. The NURSE is caring for four CLIENTs on a medical–surgical unit. Which CLIENT
should the NURSE see initially?
1.
A CLIENT admitted with hepatitis A who has had severe diarrhea for the
last 24 hours
2.
A CLIENT admitted with pneumonia who is has small amounts of
yellow productive sputum
3.
A CLIENT admitted with fever of unknown origin (FUO) who has
been without fever for the last 48 hours
4.
A CLIENT admitted with a wound infection whose WBC is 8,500 mm3
CORRECT:1
Rationale: The NURSE must decide which CLIENT should be seen on the initial rounds
of the day. The NURSE must remember that the first CLIENT to be seen should
be the CLIENT who needs the attention of the NURSE initially. A CLIENT with
hepatitis A does experience diarrhea, but diarrhea for the last 24 hours could
cause the CLIENT to have a problem with dehydration and experience a state of
fluid volume deficit.
2. The NURSE is preparing to administer influenza vaccines to a mass drive-through
clinic. Which statement by a CLIENT would indicate further questioning prior to giving
the 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.”
CORRECT:3
Rationale: Influenza vaccines are recommended for person at high risk for serious
sequelae of influenza. The NURSE should be aware that CLIENT with a
sensitivity to eggs should not receive the vaccine. Vaccines prepared from
chicken or duck embryos are contraindicated in CLIENTs who are allergic to
eggs.
Cognitive Level: Application
CLIENT Needs: Safe, Effective Care Environment
,TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL THINKING IN CLIENT
CARE, 5TH EDITION PRISCILLA LEMON
Nursing Process: Assessment
3. The NURSE is caring for four CLIENTs on a medical–surgical unit. The secretary
gives the NURSE the morning labs. Which of the following labs would require that the
NURSE call the physician and inform theHeaithCareprovider about the CLIENT’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
CORRECT:1
Rationale: When the NURSE is caring for several CLIENTs, all of the labs should 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 should not be called in to the physician.
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 CLIENT’s room.
2. The graduate NURSE wears gloves when serving breakfast trays to
various CLIENTs.
3. The graduate NURSE wears a gown, gloves, and goggles when
suctioning a CLIENT.
4. The graduate NURSE leaves all supplies in the room of a CLIENT
who is in contact isolation.
CORRECT: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 CLIENTs,
regardless of whether they have a known infectious disease. Standard
precautions are used by allHeaithCareworkers who have direct contact with
CLIENTs or with their body
, TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL THINKING IN CLIENT
CARE, 5TH EDITION PRISCILLA LEMON
fluids. It is not necessary for the NURSE to wear gloves while delivering food
trays to the CLIENT, because there is not contact with the CLIENT.
5. The admitting department alerts the NURSE on a medical–surgical unit that a
CLIENT with active tuberculosis (TB) is being admitted to the unit. Which type of
isolation is appropriate based on the CLIENT’s diagnosis?
In addition to handwashing and standard precautions, the nature and spread of some
infectious diseases require that special techniques be used to protect uninfected
CLIENTs and workers. The CLIENT with pulmonary tuberculosis will be placed in
airborne precautions. The CLIENT should be placed in a private room with special
ventilation that does not allow air to circulate to general hospital ventilation; a mask or
special filter respirators will be used for everyone entering the room.
6. A CLIENT is receiving IV vancomycin for the treatment of Clostridium difficile.
The NURSE understands that the CLIENT who develops flushing, tachycardia, and
hypotension during the infusion of vancomycin indicates:
1. Ototoxicity effect.
2. Superinfection.
3. Red man syndrome.
4. Hives.
CORRECT:3
Rationale: Vancomycin inhibits cell wall synthesis, and is used for serious infections. It is
only effective against gram-positive bacteria, especially Staphylococcus aureus and
Staphylococcus epidermidis. The NURSE should infuse this medication slowly over 60
minutes or more to avoid “red man” syndrome. The syndrome is characterized by
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