download full file at http://testbankinstant.com
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Chapter 1
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, download full file at http://testbankinstant.com gg gg gg gg
1. The nurse is caring for four clients on a medical–surgical unit. Which client
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should the nurse see initially?
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1.
A client admitted with hepatitis A who has had severe diarrhea for
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the last 24 hours
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2.
A client admitted with pneumonia who is has small
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amounts of yellowproductive sputum
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3.
A client admitted with fever of unknown origin (FUO) who
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has been without fever for the last 48 hours
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4.
A client admitted with a wound infection whose WBC is 8,500 mm3
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Answer: 1 gg
Rationale: The nurse must decide which client should be seen on the initial
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rounds of theday. The nurse must remember that the first client to be
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seen should be the client who needs the attention of the nurse initially.
gg gg gg gg gg p gg gg gg gg gg gg gg
A client with hepatitis A does experience diarrhea, but diarrhea for the
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last 24 hours could cause the client to have a problem with dehydration
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and experience a state of fluid volume deficit.
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Cognitive Level: Application
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Client Needs: Safe, Effective
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Care
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EnvironmentNursing Process: Planning
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2. The nurse is preparing to administer influenza vaccines to a mass drive-
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through clinic.Which statement by a client would indicate further questioning
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prior to giving the client the influenza vaccine?
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1. ―I am allergic to horse hair.‖
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2. ―I try to get my vaccine every year.‖
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3. ―I am not allergic to anything except eggs.‖
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4. ―My husband had a severe allergic reaction after he received
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his influenzavaccine.‖
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Answer: 3 gg
Rationale: Influenza vaccines are recommended for person at high risk for
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serious sequelae of influenza. The nurse should be aware that client with
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a sensitivity toeggs should not receive the vaccine. Vaccines prepared
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from chicken or duck embryos are contraindicated in clients who are
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allergic to eggs.
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Cognitive Level: Application
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Client Needs: Safe, Effective Care Environment
gg gg gg gg gg
download g g full g g file
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, download full file at http://testbankinstant.com gg gg gg gg
Nursing Process: Assessment
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3. The nurse is caring for four clients on a medical–surgical unit. The secretary
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gives thenurse the morning labs. Which of the following labs would require that
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the nurse call thephysician and inform the healthcare provider about the client‘s
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abnormalities?
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1.
WBC 14,600 mm3 gg gg
2.
Serum protein 6.9 g/dL gg gg gg
3.
I & D (incision and drainage) showing no growth for the last 24
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gghours
4.
Albumin 4.2 g/dL gg gg
Answer: 1 gg
Rationale: When the nurse is caring for several clients, all of the labs should be
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checkedfrequently throughout the shift to assess for any abnormalities. The WBC
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in option 1 is abnormal. (Normal WBC 4,000–10,000 mm3.) All of the other lab
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
results are within acceptable range; therefore, the results should not be called in to
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the physician.
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Cognitive Level: Application gg gg
Client Needs: Physiologic
gg gg gg
IntegrityNursing Process:
gg gg
Assessment
4. The nurse is orienting a new graduate. The nurse is reinforcing the
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importance of standard precautions. Which of the following observations by the
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nurse would requirefurther education regarding standard precautions?
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1. The graduate nurse understands to wash hands when entering
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and exitingthe client‘s room.
gg gg gg gg
2. The graduate nurse wears gloves when serving breakfast trays
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to variousclients.
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3. The graduate nurse wears a gown, gloves, and goggles when
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suctioning a client.
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4. The graduate nurse leaves all supplies in the room of a client
gg gg gg gg gg gg gg gg gg gg gg
who is incontact isolation.
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Answer: 2 gg
Rationale: The nurse must have an understanding of standard precautions.
gg gg gg gg gg gg gg gg gg
Prevention is the most important measure to prevent nosocomial
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infections. Standard precautions were published in 1996 that provide
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guidelines for the handling of blood and other body fluids. These
gg gg gg gg gg gg gg gg gg gg gg
guidelines are used with all clients, regardlessof whether they have a
gg gg gg gg gg gg gg gg gg gg gg
download g g full g g file
at
, download full file at http://testbankinstant.com
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known infectious disease. Standard precautions are used by all healthcare
gg gg gg gg gg gg gg gg gg gg
workers who have direct contact with clients or with their body
gg gg gg gg gg gg gg gg gg gg gg
download g g full g g file
at
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Chapter 1
gg
download g g full g g file
at
, download full file at http://testbankinstant.com gg gg gg gg
1. The nurse is caring for four clients on a medical–surgical unit. Which client
gg gg gg gg gg gg gg gg gg gg gg gg
should the nurse see initially?
gg gg pp gg gg
1.
A client admitted with hepatitis A who has had severe diarrhea for
gg gg gg gg gg gg gg gg gg gg gg
the last 24 hours
gg gg pp gg
2.
A client admitted with pneumonia who is has small
gg gg gg gg gg gg gg gg
amounts of yellowproductive sputum
gg gg gg gg
3.
A client admitted with fever of unknown origin (FUO) who
gg gg gg gg gg gg gg gg gg
has been without fever for the last 48 hours
gg gg p gg gg gg gg gg gg
4.
A client admitted with a wound infection whose WBC is 8,500 mm3
gg gg gg gg gg gg gg gg gg gg gg
Answer: 1 gg
Rationale: The nurse must decide which client should be seen on the initial
gg gg gg gg gg gg gg gg gg gg gg gg
rounds of theday. The nurse must remember that the first client to be
gg gg gg gg gg gg gg gg gg gg gg gg gg
seen should be the client who needs the attention of the nurse initially.
gg gg gg gg gg p gg gg gg gg gg gg gg
A client with hepatitis A does experience diarrhea, but diarrhea for the
gg gg gg gg gg gg gg gg gg gg gg gg
last 24 hours could cause the client to have a problem with dehydration
gg gg gg gg gg gg gg gg gg gg gg gg gg
and experience a state of fluid volume deficit.
gg gg gg gg gg gg gg gg
Cognitive Level: Application
gg gg
Client Needs: Safe, Effective
gg gg gg gg
Care
gg
EnvironmentNursing Process: Planning
p gg gg
2. The nurse is preparing to administer influenza vaccines to a mass drive-
gg gg gg gg gg gg gg gg gg gg gg
through clinic.Which statement by a client would indicate further questioning
gg gg gg gg gg gg gg gg gg
prior to giving the client the influenza vaccine?
gg gg gg gg gg gg gg gg
1. ―I am allergic to horse hair.‖
gg gg gg gg gg
2. ―I try to get my vaccine every year.‖
gg gg gg gg gg gg gg
3. ―I am not allergic to anything except eggs.‖
gg gg gg gg gg gg gg
4. ―My husband had a severe allergic reaction after he received
gg gg gg gg gg gg gg gg gg
his influenzavaccine.‖
gg gg p
Answer: 3 gg
Rationale: Influenza vaccines are recommended for person at high risk for
gg gg gg gg gg gg gg gg gg gg
serious sequelae of influenza. The nurse should be aware that client with
gg gg gg gg gg gg gg gg gg gg gg gg
a sensitivity toeggs should not receive the vaccine. Vaccines prepared
gg gg gg gg gg gg gg gg gg gg
from chicken or duck embryos are contraindicated in clients who are
gg gg gg gg gg gg gg gg gg gg gg
allergic to eggs.
gg gg gg
Cognitive Level: Application
gg gg
Client Needs: Safe, Effective Care Environment
gg gg gg gg gg
download g g full g g file
at
, download full file at http://testbankinstant.com gg gg gg gg
Nursing Process: Assessment
gg gg
3. The nurse is caring for four clients on a medical–surgical unit. The secretary
gg gg gg gg gg gg gg gg gg gg gg gg
gives thenurse the morning labs. Which of the following labs would require that
gg gg gg gg gg gg gg gg gg gg gg gg gg
the nurse call thephysician and inform the healthcare provider about the client‘s
gg gg g g gg gg gg gg gg gg gg gg gg
abnormalities?
gg
1.
WBC 14,600 mm3 gg gg
2.
Serum protein 6.9 g/dL gg gg gg
3.
I & D (incision and drainage) showing no growth for the last 24
gg gg gg gg gg gg gg gg gg gg gg gg
gghours
4.
Albumin 4.2 g/dL gg gg
Answer: 1 gg
Rationale: When the nurse is caring for several clients, all of the labs should be
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
checkedfrequently throughout the shift to assess for any abnormalities. The WBC
gg gg gg gg gg gg gg gg gg gg gg
in option 1 is abnormal. (Normal WBC 4,000–10,000 mm3.) All of the other lab
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
results are within acceptable range; therefore, the results should not be called in to
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
the physician.
gg gg
Cognitive Level: Application gg gg
Client Needs: Physiologic
gg gg gg
IntegrityNursing Process:
gg gg
Assessment
4. The nurse is orienting a new graduate. The nurse is reinforcing the
gg gg gg gg gg gg gg gg gg gg gg
importance of standard precautions. Which of the following observations by the
gg gg gg gg gg gg gg gg gg gg gg
nurse would requirefurther education regarding standard precautions?
gg gg gg gg gg gg gg
1. The graduate nurse understands to wash hands when entering
gg gg gg gg gg gg gg gg
and exitingthe client‘s room.
gg gg gg gg
2. The graduate nurse wears gloves when serving breakfast trays
gg gg gg gg gg gg gg gg
to variousclients.
gg gg
3. The graduate nurse wears a gown, gloves, and goggles when
gg gg gg gg gg gg gg gg gg
suctioning a client.
gg gg p
4. The graduate nurse leaves all supplies in the room of a client
gg gg gg gg gg gg gg gg gg gg gg
who is incontact isolation.
gg gg gg gg
Answer: 2 gg
Rationale: The nurse must have an understanding of standard precautions.
gg gg gg gg gg gg gg gg gg
Prevention is the most important measure to prevent nosocomial
gg g g gg gg gg gg gg gg gg
infections. Standard precautions were published in 1996 that provide
gg gg gg gg gg gg gg gg gg
guidelines for the handling of blood and other body fluids. These
gg gg gg gg gg gg gg gg gg gg gg
guidelines are used with all clients, regardlessof whether they have a
gg gg gg gg gg gg gg gg gg gg gg
download g g full g g file
at
, download full file at http://testbankinstant.com
gg gg gg gg
known infectious disease. Standard precautions are used by all healthcare
gg gg gg gg gg gg gg gg gg gg
workers who have direct contact with clients or with their body
gg gg gg gg gg gg gg gg gg gg gg
download g g full g g file
at
