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
... [Show More] 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
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.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environment
Nursing Process: Planning
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.”
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.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environment
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 the healthcare provider 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
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 mm3.) All of the other lab results are within
acceptable range; therefore, the results should not be called in to the physician.
Cognitive Level: Application Client
Needs: Physiologic Integrity
Nursing 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 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.
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 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
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?
1. Standard precautions
2. Airborne precautions
3. Droplet precautions
4. 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
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.
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
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.
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
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
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
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.
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
10. Which of the following manifestations indicates a systemic reaction associated
with an inflammatory response?
1. Erythema
2. Pain
3. Tachypnea (RR 26)
4. 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
11. 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.
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 lifethreatening
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
12. 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 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
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.
1. Erythema
2. WBC 14,200 mm3
3. Pain at the surgical site
4. 10% Bands
5. Respiratory rate of 16
6. 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 mm3 or > 10%
bands.
Cognitive Level: Application
Client Needs: Physiological Integrity
Nursing Process: Assessment
Chapter 2
1. When collecting data at the immunization clinic, which of the following disclosures by
the client would cause the nurse to hold administration of the varicella vaccine?
a. History of an allergic reaction to yeast bread
b. Itching and swelling on the face and hands after ingesting eggs
c. A low grade temperature within the past two days
d. A blood transfusion after undergoing surgery three months ago
Answer: d
Rationale: Contradictions for the varicella vaccine [Show Less]