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THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
Chapter 1 The nurse is caring for four clients on a medical–surgical unit. Which client should the nurse see initially?
- A client admitted with hepatitis A who has had severe diarrhea for the last 24 hours
- A client admitted with pneumonia who is has small amounts of yellow productive sputum
- A client admitted with fever of unknown origin (FUO) who has been without fever for the last 48 hours
- A client admitted with a wound infection whose WBC is 8,500 mm^3 Answer: 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.
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
Cognitive Level: Application Client Needs: Safe, Effective Care Environment Nursing Process: Planning 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?
- “I am allergic to horse hair.”
- “I try to get my vaccine every year.”
- “I am not allergic to anything except eggs.”
- “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 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.
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
Cognitive Level: Application Client Needs: Safe, Effective Care Environment Nursing Process: Assessment 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 about the client’s abnormalities?
- WBC 14,600 mm 3
- Serum protein 6.9 g/dL
- I & D (incision and drainage) showing no growth for the last 24 hours
- Albumin 4.2 g/dL Answer: 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 mm^3 .) All of the other lab results are within acceptable range;
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
therefore, the results should not be called in to the physician. Cognitive Level: Application Client Needs: Physiologic Integrity Nursing Process: Assessment 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? The graduate nurse understands to wash hands when entering and exiting the client’s room. The graduate nurse wears gloves when serving breakfast trays to various clients. The graduate nurse wears a gown, gloves, and goggles when suctioning a client. The graduate nurse leaves all supplies in the room of a client who is in contact isolation. Answer: 2
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
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 all healthcare workers who have direct contact with clients or with their body 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. Cognitive Level: Application Client Needs: Safe, Effective Care Environment Nursing Process: Evaluation 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?
- Standard precautions
- Airborne precautions
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
- Droplet precautions
- Contact precautions Answer: 2 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. Cognitive Level: Application Client Needs: Safe, Effective Care Environment Nursing Process: Assessment 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:
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
- Ototoxicity effect.
- Superinfection.
- Red man syndrome.
- Hives. Answer: 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 erythematous rash, flushing, tachycardia, and hypotension. Clients can become dizzy and agitated. Cognitive Level: Application Client Needs: Physiological Integrity Nursing Process: Evaluation The physician has ordered for the client to receive a trough blood level to evaluate the therapeutic effect of an antibiotic. The nurse
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
understands that the trough should be ordered:
- A few minutes before the next scheduled dose of medication.
- 1–2 hours after the oral administration of the medication.
- 30 minutes after the IV administration.
- During the infusion of the antibiotic. Answer: 1 Rationale: Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The therapeutic range—the minimum and maximum blood levels at which the drug is effective—is known for a given drug. By measuring blood levels at the predicted peak (1–2 hours after oral administration, 1 hour after intramuscular administration, and 30 minutes after IV administration) and trough (usually a few minutes before the next scheduled dose), it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy, increasing the likelihood of adverse effects. Cognitive Level: Application Client Needs: Safe, Effective Care Environment Nursing Process: Assessment
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
The nurse needs to change a dressing on the client’s abdomen. Which of the following techniques should be implemented?
- Contact precautions
- Standard precautions
- Droplet precautions
- Airborne precautions Answer: 2 Rationale: Standard precautions are used on all clients, regardless of whether they have a know infectious disease. Standard precautions are used by all healthcare workers who have direct contact with clients or with their body fluids. Since the client has an abdominal dressing, the nurse will use standard precautions. Cognitive Level: Application Client Needs: Safe, Effective Care Environment Nursing Process: Planning The physician has ordered for the nurse to obtain a sputum specimen. The nurse understands that the sputum specimen
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
should be collected:
- Immediately after the first dose of antibiotic is administered.
- 30 minutes after the first dose of antibiotics is administered.
- During the first dose of antibiotics.
- Before the first dose of antibiotics is administered. Answer: 4 Rationale: When the physician orders a specimen to be collected, the nurse should collect the specimen before the first dose of antibiotics is administered, to ensure adequate organisms for culture. Cognitive Level: Comprehension Client Needs: Safe, Effective Care Environment Nursing Process: Planning Which of the following manifestations indicates a systemic reaction associated with an inflammatory response?
- Erythema
- Pain
- Tachypnea (RR 26)
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
- Edema Answer: 3 Rationale: If the nurse observes a systemic reaction, the client will exhibit manifestations including temperature, increased pulse, tachypnea, and leukocytosis. Erythema, warmth, pain, edema, and functional impairment indicate a local reaction. Cognitive Level: Application Client Needs: Physiological Integrity Nursing Process: Assessment 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.
- Increase the temperature of the room environment to prevent shivering.
- Use ice packs and a tepid bath as needed.
- Administer antipyretic medications per physician’s orders.
- Promote frequent rest periods to increase energy reserve.
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
- Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance. Answer: 2; 3; 4 Rationale: Hyperthemia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects or, when prolonged, can cause life- threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures. The nurse should use ice packs, cool/tepid baths, or hypothermia blanket with caution. The nurse should enforce frequent rest periods because rest increases energy reserve, which is depleted by an increased metabolic, heart, and respiratory rate. The nurse should encourage fluids rather than restrict fluids because of the risk of electrolyte imbalance. Cognitive Level: Assessment Client Needs: Physiological Integrity Nursing Process: Implementation The nurse is assessing a client’s wound for signs and symptoms of inflammation. Which of the following would alert the nurse that
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
the client is exhibiting signs of inflammation? Select all that apply.
- Leg edema
- Leg cool to touch
- Severe pain from swelling
- Decreased peripheral pulses
- Severe erythema of leg Answer: 1; 3; 5 Rationale: Regardless of the cause, location, or extent of the injury, the acute inflammatory response follows the sequence of vascular response, cellular and phagocytic response, and healing. Many manifestations of inflammation are produced by inflammatory mediators such as histamines and prostaglandins released when tissue is damaged. The cardinal signs of inflammation include erythema, local heat caused by the increased blood flow to the injured area (hyperemia), swelling due to accumulated fluid at site, pain from tissue swelling and chemical irritation of nerve endings, and loss of function caused by the swelling and pain. Cognitive Level: Application Client Needs: Physiological Integrity Nursing Process: Assessment
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
Alternate item format – Select all that apply Which of the following manifestations would the nurse expect to see with a client who has had previous knee surgery who suffered a surgical infection with signs of systemic manifestations? Select all that apply.
- Erythema
- WBC 14,200 mm^3
- Pain at the surgical site
- 10% Bands
- Respiratory rate of 16
- Pulse 114 Answer: 2; 3; 6 Rationale: The client is post–surgical repair of the knee. The nurse should be able to distinguish between local reactions and system reactions. An elevated WBC and 10% bands are indicative of an infection. Vital sign changes typically associated with an infection include an elevation in temperature and tachycardia. Local manifestations include erythema, warmth, pain, edema, and functional impairment, whereas systemic manifestations include elevated temperature above 100.4°F, pulse greater than 90/min., respiratory rate greater than 20, and WBC greater than 12,000 mm^3 or > 10% bands.
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
Chapter 2
- A review of a client’s medication list is an important part of an assessment prior to any addition of new medications. A client has been advised to take an over-the-counter decongestant. Which other class of medications that the client is currently taking would possibly contraindicate the use of a decongestant? a. Nonsteroidal anti-inflammatory drug (NSAID) b. Anticoagulant c. Antihypertensive d. Antihistamine Answer: C Rationale: If the client has hypertension and is on an antihypertension drug, the use of a decongestant might be contraindicated. Decongestants stimulate the sympathetic nervous system. This increases the peripheral vascular resistance, blood pressure, and pulse. The use of NSAIDs,
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
anticoagulants, or antihistamines is not considered a contraindication. Antihistamines are frequently combined with decongestants. Assessment: Physiological Integrity: Analysis
- An older adult is hospitalized with a respiratory illness. Labs are drawn and a chest x- ray is completed. The white blood cell (WBC) count is elevated. What type of infection does this most likely indicate? a. Bacterial b. Viral c. Fungal d. Atypic al Answer: A Rationale: White blood cells increase in number to fight bacterial infections. When a client has a viral infection, WBCs are usually low. There is not an expected change in WBC count related to fungal or atypical infections. Assessment: Physiological Integrity: Application
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
- The nurse is preparing an educational program for the community prior to the influenza (flu) season. The primary focus will be on: a. Recognition of signs and symptoms of influenza. b. Promotion of yearly flu vaccine. c. Use of antiviral drugs such as Tamiflu if exposed. d. Complimentary therapies that are recommended. Answer: B Rationale: The yearly flu vaccine is the single most important action to prevent or decrease symptoms of the flu. Prevention is better than recognition. Reliance on antiviral drugs should not be the focus. Complimentary therapies might be beneficial, but are not the primary focus. Planning: Health Promotion and Maintenance: Analysis
- During an office visit, the nurse is collecting data regarding a client’s health history and current medication list. The client states “I can’t seem to stop coughing since I have this cold.” The nurse anticipates a
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
cough suppressant will be prescribed with which of the following directions for frequency? a. Take in the morning before beginning activities. b. Take at mealtimes and before bed. c. Take in the evening before bedtime. d. Take in the morning and before bed. Answer: C Rationale: Cough suppressants may be prescribed if a client is unable to get rest due to coughing. They are not recommended for use during the day, since coughing aids in removal of respiratory secretions. Planning: Physiological Integrity: Application
- Following sinus surgery, a client might have a nursing diagnosis of Nutrition, Imbalanced: Less than Body Requirements. Common contributing factors for this diagnosis can include: (Select all that apply.) a. Presence of nasal packing. b. Mouth discomfort. c. Numbness of upper teeth.
TEST BANK FOR MEDICAL-SURGICAL NURSING CRITICAL
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
d. Side effects of antibiotics. Answer: A; B; C Rationale: Following sinus surgery, the nasal packing can cause a decrease in the sense of smell and appetite. Mouth pain can result from an incision. The upper teeth might be numb for several months. The client will have been on antibiotics before surgery to eliminate the infection that led to the surgery. Starting postoperative antibiotics is not one of the primary causes of this nursing diagnosis. Planning: Physiological Integrity: Analysis
- When providing discharge instructions to a client diagnosed with streptococcal pharyngitis, what information should be stressed? a. “Make your follow-up appointment for two weeks from today.” b. “Take all of your antibiotic until gone.” c. “The only medication you need is over-the-counter pain medication.” d. “You will need a repeat CBC (complete blood count) in seven days.” Answer: B Rationale: The full course of prescribed antibiotics must be encouraged. Clients who do not complete the antibiotics are at risk for unresolved bacterial infections. They are also at increased risk of complications that include acute glomerulonephritis and rheumatic fever. No follow-up appointment or lab work is typically needed. Over-the-counter pain medication in addition to the antibiotics might be needed.
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
Implementation: Health Promotion and Maintenance: Application
- A parent asks when his teenager with a diagnosis of bacterial pharyngitis can return to school. The best response by the nurse would be: a. “Once the full course of antibiotics is complete.” b. “Your physician will check her throat at the follow-up appointment and tell you then.” c. “Once she has been on antibiotic therapy for 24 hours.” d. “ After her fever returns to normal.” Answer: C Rationale: A client is no longer contagious once she has had antibiotic therapy for 24 hours, not the full course of therapy. The client might still have a low-grade fever, but is no longer contagious after 24 hours of antibiotics. A follow-up appointment is typically not necessary.
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
Implementation: Physiological Integrity: Application
- A client presents with a two-day history of sore throat, painful swallowing, drooling, and stridor. A diagnosis of epiglottitis is suspected. What would it be important for the nurse to communicate to the nurses on the next shift? a. The throat should not be visualized using a tongue blade. b. Oxygen should be applied only by nasal cannula. c. The client will most likely go to surgery after the diagnosis is confirmed. d. Any visitors need to wear a mask when entering the room. Answer: A Rationale: Visualization of the oropharynx should be done using a flexible fiber optic laryngoscope by a physician, not a tongue blade by the nurse. Using a tongue blade could trigger laryngospasm and airway obstruction. Oxygen might be needed, but can be delivered by nasal cannula or by mask. No surgery is recommended for epiglottitis, although intubation might be necessary. No infection control precautions are implemented with this diagnosis.
Test Bank for Medical-Surgical Nursing Critical Thinking
in Client Care, 4th Edition Priscilla LeMon Q&A
LATEST UPDATE 2022/2023 GRADED A+
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
Implementation: Safe, Effective Care Environment: Application
- The nurse caring for a client notes a grayish membrane covering the pharynx. A diagnosis of diphtheria is made by the physician. Infection control measures are implemented after the diagnosis. The nurse will need which of the following due to the exposure to diphtheria? a. Antitoxin b. Booster immunization shot c. Epinephrine d. Antibiotics Answer: B Rationale: The nurse would have been required to be up-to-date on immunizations if providing client care. Booster immunization shots are given to people who have not been immunized within the past five years, and to those exposed to the infection. People who are not immunized would need the immunization and antibiotics. Diphtheria antitoxin is given to clients with a diagnosis of diphtheria. Epinephrine is readily available if the client experiences an anaphylactic reaction to the antitoxin.
Test Bank for Medical-Surgical Nursing Critical Thinking
in Client Care, 4th Edition Priscilla LeMon Q&A
LATEST UPDATE 2022/2023 GRADED A+
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
Assessment: Health Promotion and Maintenance: Analysis
Test Bank for Medical-Surgical Nursing Critical Thinking
in Client Care, 4th Edition Priscilla LeMon Q&A
LATEST UPDATE 2022/2023 GRADED A+
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
- During a sporting event, a client gets hit with a ball in the nose. The injury is severe enough to require medical attention. After the bleeding is stopped, the nurse notes a clear, watery fluid dripping from the nose. What should the nurse do first? a. Lower the head of the bed. b. Apply some of the fluid to a glucose test strip. c. Call the physician. d. Have the client blow his nose. Answer: B Rationale: Cerebrospinal fluid (CSF) might be leaking through the nose due to the injury. By applying some of the drainage to a glucose test strip, the nurse can determine if glucose is present in the fluid. A positive result indicates the presence of CSF. If would be best to check this before calling the physician. The head of the bed should remain up to decrease the risk of aspiration. Having the client blow his nose would be contraindicated until it is determined whether the fluid is CSF. Evaluation: Physiological Integrity: Analysis
Test Bank for Medical-Surgical Nursing Critical Thinking
in Client Care, 4th Edition Priscilla LeMon Q&A
LATEST UPDATE 2022/2023 GRADED A+
THINKING IN CLIENT CARE, 4TH EDITION PRISCILLA
LEMON Q&A LATEST UPDATE 2023/2024 GRADED A+
Chapter 3
- A nursing student is reading about the concept of parish nursing. Which of the following statements indicates understanding of the key concepts of parish nursing?
- “You must practice a certain faith to be involved in parish nursing.”
- “Parish nurses are independent practitioners providing care to members of a selected church.”
- “Parish nursing is reserved for nurse practitioners.”
- “Parish nurses may be employed by a hospital.” Answer: 4 Rationale: Parish nursing seeks to provide health care to traditionally underserved populations. Involvement in parish nursing is not limited to select faiths. The parish nurse may work directly for the church involved or be contracted by the church to provide nursing services and perform referrals. Parish nursing is not limited to nurse practitioners. Nursing Process Step: Evaluation Client Needs Category: Health Promotion and Maintenance Client Needs Subcategory: Prevention and/or Early Detection of Health
Test Bank for Medical-Surgical Nursing Critical Thinking
in Client Care, 4th Edition Priscilla LeMon Q&A
LATEST UPDATE 2022/2023 GRADED A+