Chapter 14 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 14

Question 1

Type: MCSA

While reviewing the white blood cell count differential for a patient, the nurse notes that the basophil count is elevated. What does this laboratory value indicate to the nurse?

1. The patient may be experiencing an acute hypersensitivity reaction.

2. The patient has a viral gastrointestinal infection.

3. The patient is fighting a bacterial skin infection.

4. The patient is not responding to a parasitic infection.

Correct Answer: 1

Rationale 1: Basophils are not phagocytic and contain proteins and chemicals such as heparin, histamine, bradykinin, serotonin, and leukotrienes that are released into the bloodstream during an acute hypersensitivity reaction or stress response.

Rationale 2: Basophils do not respond to viral infections.

Rationale 3: Basophils do not respond to bacterial infections.

Rationale 4: Basophils increase with parasitic infections, so an increase would indicate a response by the patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-6

Question 2

Type: MCMA

The nurse would be concerned that a patient is exhibiting signs and symptoms of inflammation after assessing which findings in a leg wound?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Edema

2. Pain

3. Erythema

4. Coolness of tissues

5. Decreased distal pulses

Correct Answer: 1,2,3

Rationale 1: Edema results from vasodilation and leaking of fluid into the surrounding tissues.

Rationale 2: Pain results from swelling and prostaglandin release.

Rationale 3: Erythema is related to vasodilation and is a cardinal sign of inflammation.

Rationale 4: Warmth at the site is a sign of inflammation.

Rationale 5: Decreased distal pulses are not a typical sign of inflammation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-6

Question 3

Type: MCSA

Which finding would indicate that a patient is experiencing a systemic reaction associated with an inflammatory response?

1. Fever

2. Erythema

3. Edema

4. Pain

Correct Answer: 1

Rationale 1: Fever is a sign that the inflammatory response has become systemic.

Rationale 2: Erythema indicates a local reaction.

Rationale 3: Edema indicates a local reaction.

Rationale 4: Pain indicates a local reaction.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-6

Question 4

Type: MCSA

The nurse is planning care for a patient at risk for developing an infection. Which intervention is the most important for the nurse to include in this patients plan of care?

1. Wash hands prior to providing care to the patient.

2. Provide prophylactic antibiotic therapy as prescribed.

3. Wear a mask when caring for the patient.

4. Wear a gown and gloves when changing the patients linen.

Correct Answer: 1

Rationale 1: Prevention is the most important control measure for nosocomial infections. The pathogens causing these infections are transmitted primarily by contact with hospital personnel and contaminated inanimate objects. Effective hand hygiene is the single most important measure in infection control.

Rationale 2: Prophylactic antibiotic therapy could lead to the development of bacteria-resistant microorganisms and should not be performed.

Rationale 3: The use of a mask is not needed to prevent the onset of infection in the patient.

Rationale 4: The use of a gown and gloves is not needed to prevent the onset of infection in the patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 14-3

Question 5

Type: MCSA

A patient is diagnosed with an antibiotic-resistant infection. What can the nurse do to reduce the spread of this infection?

1. Isolate the supplies used when caring for this patient.

2. Transfer the patient to a semiprivate room.

3. Limit exposure to this patient.

4. Restrict visitors and plan activities to coincide with meal delivery times.

Correct Answer: 1

Rationale 1: Standard precautions, hand hygiene, and use of carefully selected antibiotics are critical actions for stopping the spread of

these diseases. Equipment such as stethoscopes, blood pressure cuffs, and thermometers should be restricted to use by each patient identified with one of these diseases.

Rationale 2: Transferring the patient to a semiprivate room would not reduce the spread of infection.

Rationale 3: Limiting exposure to this patient could compromise the patients care.

Rationale 4: Restricting visitors and planning activities to coincide with meal delivery times would compromise this patients care.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-3

Question 6

Type: MCSA

The nurse is instructing a patient on ways to prevent the onset of infection. What should be included in these instructions?

1. Wash hands after using disposable tissues for nasal secretions.

2. Reduce animal protein in the diet.

3. Take prescribed antibiotics until symptoms subside.

4. There is no need to limit interactions with people or crowds.

Correct Answer: 1

Rationale 1: One way to reduce the spread of infection is to use disposable tissues for nasal secretions. The nurse should instruct the patient to wash the hands after using a disposable tissue.

Rationale 2: Protein is needed for the production of antibodies. There is no evidence that animal protein intake increases the risk of infection.

Rationale 3: Antibiotics should be taken as prescribed, not until symptoms subside.

Rationale 4: Limiting interactions with people and crowds is one way to reduce the spread of infection.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-3

Question 7

Type: MCSA

A patient diagnosed with active tuberculosis is being admitted to the hospital. The nurse should prepare for this patient to be placed in which type of isolation?

1. Airborne precautions

2. Standard precautions

3. Droplet precautions

4. Contact precautions

Correct Answer: 1

Rationale 1: The patient with pulmonary tuberculosis will be placed in an airborne infection isolation room, a private room with special ventilation, and masks with filter respirators will be used by everyone entering the room.

Rationale 2: Standard precautions are those infection control practices used for every patient.

Rationale 3: Droplet precautions reduce the risk of droplet transmission of infectious agents. Pulmonary tuberculosis is not spread by droplet transmission.

Rationale 4: Contact precautions reduce the risk of transmission by direct or indirect contact. Direct contact transmission involves skin-to-skin contact and physical transfer of organisms. Pulmonary tuberculosis is not spread by direct contact transmission.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 14-3

Question 8

Type: MCSA

The nurse needs to obtain a sputum specimen for culture and sensitivity from a patient. When should the nurse obtain this specimen?

1. Before the first dose of antibiotics is administered

2. Immediately after the first dose of antibiotic is administered

3. 30 minutes after the first dose of antibiotics is administered

4. As the first dose of antibiotics is administered

Correct Answer: 1

Rationale 1: When collecting a specimen for culture and sensitivity, the nurse should collect the specimen before the first dose of antibiotics is administered to ensure adequate organisms for culture.

Rationale 2: If the specimen were collected after the first dose of the antibiotic, there might not be sufficient microorganisms available for culture.

Rationale 3: If the specimen were collected after the first dose of the antibiotic, there might not be sufficient microorganisms available for culture.

Rationale 4: It would not be appropriate to obtain the first specimen as the first dose of antibiotics is being administered.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 14-3

Question 9

Type: MCSA

The nurse needs to change a patients abdominal wound dressing. Which precautions should be implemented?

1. Standard precautions

2. Contact precautions

3. Droplet precautions

4. Airborne precautions

Correct Answer: 1

Rationale 1: Standard precautions are used on all patients, regardless of whether they have a known infectious disease. Standard precautions are used by all health care workers who have direct contact with patients or with their body fluids. Because the patient has an abdominal dressing, the nurse will use standard precautions.

Rationale 2: The patient does not have a diagnosed wound infection, so contact precautions are not necessary.

Rationale 3: The patient does not have a diagnosed disorder that would necessitate droplet precautions.

Rationale 4: The patient does not have a diagnosed disorder that would necessitate airborne precautions.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 14-3

Question 10

Type: MCSA

The nurse has completed caring for a patients indwelling urinary catheter. What should the nurse do after clearing used supplies and removing the gloves?

1. Wash the hands with soap.

2. Document the care provided.

3. Prepare medications for the patient.

4. Discuss with the nursing assistant additional care needs for the patient.

Correct Answer: 1

Rationale 1: After completing procedures, the nurse should wash the hands with soap and water. This is the most effective way to reduce the spread of infection.

Rationale 2: The nurse can document the care provided after performing another step.

Rationale 3: The nurse can prepare medications after performing another step.

Rationale 4: The nurse can discuss further care needs after performing another step.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-5

Question 11

Type: MCSA

When caring for a patient with an infection, the nurse uses a stethoscope that remains in the patients room. At which point is the nurse interrupting the chain of infection?

1. The reservoir

2. Portal of exit

3. Mode of transmission

4. Susceptible host

Correct Answer: 3

Rationale 1: The patient is the reservoir of infection. Nothing has changed with the patient to interrupt the chain of infection.

Rationale 2: In a respiratory illness, the portal of exit is the respiratory system. Exit occurs through coughing, sneezing, laughing, or talking.

Rationale 3: To move to another place, the organism must have a mode of transmission. If the nurse does not take the stethoscope out of the room, the organism does not have a way to move from patient to patient.

Rationale 4: To cause an infection, the organism must encounter a susceptible host. The stethoscope is not a host.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-2

Question 12

Type: MCSA

A patient with a wound has these laboratory results. Which type of precautions will the nurse observe?

1. Contact precautions

2. Droplet precautions

3. Airborne precautions

4. Protective isolation precautions

Correct Answer: 1

Rationale 1: A patient with an infected open wound must be placed under contact precautions to avoid cross-contamination with other patients and staff.

Rationale 2: There is nothing to indicate that the patient has a respiratory infection.

Rationale 3: There is nothing to indicate that the patient has a respiratory infection.

Rationale 4: Protective isolation is for the patient who is immunocompromised.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-3

Question 13

Type: MCSA

A patient comes to the emergency department complaining of dyspnea. After analyzing the lab results, the nurse suspects which problem?

1. Pancytopenia

2. Chronic bacterial infection

3. A respiratory infection

4. A hypersensitivity response

Correct Answer: 4

Rationale 1: Pancytopenia would be indicated by very low levels of the laboratory values.

Rationale 2: The patient with a chronic bacterial infection would have an increased WBC count.

Rationale 3: The patient with a respiratory infection would have an increased WBC count.

Rationale 4: The eosinophils (normal 1-4%) and basophils (0.5%-1%) respond in hypersensitivity responses. The lab values and dyspnea suggest a hypersensitivity response.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 14-6

Question 14

Type: MCMA

A patient is receiving an aminoglycoside. The nurse would immediately report which findings?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A history of allergy to penicillins

2. A weight gain of 5 kg in 2 days

3. Symptoms of vertigo

4. A fluid intake below 2000 mL/day

5. A peak level lower than anticipated

Correct Answer: 2,3,5

Rationale 1: A history of allergy to penicillin would apply to cephalosporins.

Rationale 2: Aminoglycosides are nephrotoxic. A sudden weight gain indicates possible kidney damage and should be immediately reported.

Rationale 3: The nurse should report the patients complaints of vertigo because aminoglycosides are ototoxic.

Rationale 4: A patient on fluoroquinolones or sulfonamides must maintain a fluid intake of 2000 to 3000 mL/day.

Rationale 5: Peak and trough levels are important indicators of drug absorption. Any finding outside the expected levels should be reported.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-6

Question 15

Type: FIB

Linezolid (Zyvox) 600 mg BID, IV has been ordered for a patient. The nurse receives 600 mg/300 mL with direction to give over 120 minutes. An IV line labeled 15 drops per mL is available. The drop rate will be ______ drops/minute.

Standard Text:

Correct Answer: 38

Rationale : 300 mL 15 drops/mL / 120 min.
4500. 120 = 37.5
37. 5 rounds to 38 drops/min.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-6

Question 16

Type: MCMA

A patient has been prescribed cefadroxil (Duricef). Patient teaching must include which instructions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Take on an empty stomach.

2. Avoid alcohol.

3. Report any hearing loss.

4. Drink additional water.

5. Complete the prescription.

Correct Answer: 1,2,4,5

Rationale 1: Cefadroxil is a cephalosporin and must be taken on an empty stomach.

Rationale 2: This medication can cause alcohol intolerance.

Rationale 3: Hearing loss applies to the aminoglycosides, not the cephalosporins.

Rationale 4: Adequate hydration should be maintained.

Rationale 5: The entire prescription must be completed in order to be effective.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-6

Question 17

Type: MCSA

A patient with a compromised immune system is admitted to the hospital with an infection. What will most likely be done to help this patient?

1. Discharge the patient early to recover from the infection at home.

2. Place the patient in a semiprivate room.

3. Use isolation techniques to protect the patient from further infection.

4. Place the patient in respiratory isolation.

Correct Answer: 3

Rationale 1: Patients with suppressed or impaired immune function are more susceptible to disease and require protection from exposure to environmental elements.

Rationale 2: Patients with suppressed or impaired immune function are more susceptible to disease and require protection from exposure to environmental elements.

Rationale 3: Patients with suppressed or impaired immune function are more susceptible to disease and require protection from exposure to environmental elements. Isolation techniques should be employed to prevent the spread of disease and to protect immune-suppressed patients.

Rationale 4: The scenario presented does not suggest the need for a specific type of isolation.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 14-3

Question 18

Type: MCSA

A school district is not requiring vaccinations for children who are starting school. The nurse realizes that this action could have which effect?

1. Healthier children

2. A reduction in the number of colds and flu in the school

3. A decrease in school costs

4. An epidemic of an illness that could have been avoided with a vaccination

Correct Answer: 4

Rationale 1: Healthier children are not the product of reduced usage of immunizations.

Rationale 2: Immunizations do not impact the number of colds and flu outbreaks in a school system.

Rationale 3: High rates of illness may increase school costs.

Rationale 4: For many diseases, the potential consequences of a single disease episode on the individual and society make prevention desirable, especially for highly contagious diseases that are capable of causing epidemics. In these instances, immunization or vaccination is used to provide artificially acquired immunity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 14-3

Question 19

Type: MCSA

A patient wants to know why he developed an infection after being cut on the leg with a piece of wood but his friend who was also cut did not. How should the nurse explain this phenomenon to the patient?

1. Maybe the wood that cut your friend wasnt dirty and infected.

2. You must have an autoimmune disorder.

3. The organism found you more susceptible to infection.

4. Your friend will get an infection too. It will just occur later.

Correct Answer: 3

Rationale 1: This is an unlikely situation.

Rationale 2: This is a situation of normal infection and does not indicate an autoimmune disorder.

Rationale 3: For a microorganism to cause infection, it must have disease-causing potential (virulence), be transmitted from its reservoir, and gain entry into a susceptible host.

Rationale 4: There is no evidence to indicate that the friend will develop an infection.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14-2

Question 20

Type: MCSA

A patient with methicillin-resistant Staphylococcus aureus (MRSA) is no longer responding to the medication vancomycin (Vancocin). The nurse realizes that this patient is most likely demonstrating which condition?

1. A superinfection

2. VISA

3. VRE

4. PRSP

Correct Answer: 2

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