Chapter 14 Medical Surgical Nursing Preparation For Practice 2nd Edition

Chapter 14  Medical Surgical Nursing Preparation For Practice 2nd Edition

Complete Chapter Questions And Answers
 

Sample Questions

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