FULL TEST BANK
For LeMone and Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient
Care 7th Edition by Paula Gubrud
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,Chapter 1
1. The Nurse Is Caring For Four Patients On A Medical–Surgical Unit, Which Patient
Should The Nurse See First?
1. A Patient Admitted With Hepatitis A Who Has Had Severe Diarrhea
For The Last24 Hours
2. A Patient Admitted With Pneumonia Who Is Has Small
Amounts Of Yellowproductive Sputum
3. A Patient Admitted With Fever Of Unknown Origin (Fuo) Who
Has Beenwithout Fever For The Last 48 Hours
4. A Patient Admitted With A Wound Infection Whose Wbc Is 8,500 Mm3
Answer: 1
Rationale: The Nurse Must Decide Which Patient Ought To Be Seen On The Initial
Rounds Of The Day, The Nurse Must Remember That The First Patient To Be
Seen Ought To Be The Patientwho Needs The Attention Of The Nurse Initially,
A Patient With Hepatitis A Does Experience Diarrhea, But Diarrhea For The
Last 24 Hours Could Cause The Patient To Have A Problem With Dehydration
And Experience A State Of Fluid Volume Deficit,
Cognitive Level: Application
Patient Needs: Safe, Effective Care
Environmentnursing Process: Planning
2. The Nurse Is Getting Ready To Administer Influenza Vaccines To A Mass Drive-
Through Clinic,Which Statement By A Patient Would Indicate Further Questioning
Prior To Giving The Patient 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,”
Answer: 3
Rationale: Influenza Vaccines Are Recommended For Person At High Risk For Serious
Sequelae Of Influenza, The Nurse Ought To Be Aware That Patient With A
Sensitivity Toeggs Ought To Not Receive The Vaccine, Vaccines Get Readyd
From Chicken Or Duck Embryos Are Contraindicated In Patients Who Are
Allergic To Eggs,
,Cognitive Level: Application
, Patient Needs: Safe, Effective Care
Environmentnursing Process: Assessment
3. The Nurse Is Caring For Four Patients On A Medical–Surgical Unit, The Secretary
Gives The Nurse The Morning Labs, Which Of The Following Labs Would Require
That The Nurse Call Thephysician And Inform The Healthcare Provider About The
Patient’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
Answer: 1
Rationale: When The Nurse Is Caring For Several Patients, All Of The Labs Ought To 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 Ought To Not Be Called In To The
Physician,
Cognitive Level: Application
Patient Needs: Physiologic
Integritynursing Process:
Assessment
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 Patient’s Room,
2. The Graduate Nurse Wears Gloves When Serving Breakfast Trays To
Various Patients,
3. The Graduate Nurse Wears A Gown, Gloves, And Goggles When
Suctioning A Patient,
4. The Graduate Nurse Leaves All Supplies In The Room Of A Patient
Who Is Incontact Isolation,
Answer: 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 Patients,
