Fresno City College BIO 102. Medical-Surgical Nursing Critical Thinking in Client Care, CHAPTER 12

Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon

CHAPTER 12

Chapter 12

Question #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

Question #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.”

Question #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 the healthcare provider regarding 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

Question #4

The nurse is orienting a new graduate. The nurse is reinforcing the importance of standard precautions. Which of the following observations made 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.

Questions #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 should be informed based on the client’s diagnosis?

1.            Standard precautions

2.            Airborne precautions

3.            Droplet precautions

4.            Contact precautions

Question #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.

Question #7

The physician has ordered for the client to receive a trough blood level to evaluate the therapeutic effect of an antibiotic. The nurse understands that the trough should be ordered:

1.            A few minutes before the next scheduled dose of medication.

2.            1–2 hours after the oral administration of the medication.

3.            30 minutes after the IV administration.

4.            During the infusion of the antibiotic.

Question #8

The nurse needs to change a dressing on the client’s abdomen. Which of the following techniques should be implemented?

1.            Contact precautions

2.            Standard precautions

3.            Droplet precautions

4.            Airborne precautions

Question #9

The physician has ordered for the nurse to obtain a sputum specimen. The nurse understands that the sputum specimen should be collected:

1.            Immediately after the first dose of antibiotic is administered.

2.            30 minutes after the first dose of antibiotics is administered.

3.            During the first dose of antibiotics.

4.            Before the first dose of antibiotics is administered.

Question # 10

Which of the following manifestations indicate a systemic reaction associated with an inflammatory response?

1.            Erythema

2.            Pain

3.            Tachypnea (RR 26)

4.            Edema

Question #11 – Alternate Question

A client develops hyperthermia related to a diagnosis of pneumonia. Which of the following nursing interventions would be effective in the treatment of hyperthermia?

Select all that apply.

1.            Increase the temperature of the room environment to prevent shivering.

2.            Use ice packs and a tepid bath as needed.

3.            Administer antipyretic medications per physician’s orders.

4.            Promote frequent rest periods to increase energy reserve.

5.            Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance.

Question #12 – Alternate Question

The nurse is assessing a client’s wound for signs and symptoms of inflammation. Which of the following would alert the nurse that the client is exhibiting signs of inflammation?

Select all that apply.

1.            Leg edema

2.            Leg cool to touch

3.            Severe pain from swelling

4.            Decreased peripheral pulses

5.            Severe erythema of leg

Which of the following manifestations would the nurse expect to see with a client who has had knee surgery and who suffered a surgical infection with signs of systemic manifestations? Select all that apply.

1.            Erythema

2.            WBC 14,200 mm³

3.            Pain at the surgical site

4.            10% bands

5.            Respiratory rate of 16

6.            Pulse 114