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ATI Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon (2021), (A Grade), Questions and Answers, All Correct Study Guide, Download to Score A$16.49
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ATI Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon (2021), (A Grade), Questions and Answers, All Correct Study Guide, Download to Score A
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Course
Nursing Pediatrics
Institution
Nursing Pediatrics
ATI Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon (2021), (A Grade), Questions and Answers, All Correct Study Guide, Download to Score A
Chapter 1
1. A client is receiving IV vancomycin for the treatment of Clostridium difficile. The nurse ...
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ATI Test Bank for Medical-Surgical Nursing
Critical Thinking in Client Care, 4th Edition
Priscilla LeMon (2021), (A Grade), Questions
and Answers, All Correct Study Guide,
Download to Score A
Chapter 1
1. 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.
2. 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.
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.
4. 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.
5. 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.
6. 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
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.
7. 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
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