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,download full file at http://testbankinstant.com
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,download full file at http://testbankinstant.com
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, Chapter 1:critical thinking ,critical judgment and the nursing process
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1. The nurse is caring for four clients on a medical–surgical unit. Which client should the
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nurse see initially?
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1. A client admitted with hepatitis A who has had severe diarrhea for the last
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24 hours ju ju
2. A client admitted with pneumonia who is has small amounts of yellow
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productive sputum ju ju
3. A client admitted with fever of unknown origin (FUO) who has been
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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 ju
Rationale: The nurse must decide which client should be seen on the initial rounds of the
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day. The nurse must remember that the first client to be seen should be the client
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who needs the attention of the nurse initially. A client with hepatitis A does
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experience diarrhea, but diarrhea for the last 24 hours could cause the client to
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have a problem with dehydration and experience a state of fluid volume deficit.
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Cognitive Level: Application
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Client Needs: Safe, Effective Care Environment
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Nursing Process: Planning
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2. The nurse is preparing to administer influenza vaccines to a mass drive-through clinic.
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Which statement by a client would indicate further questioning prior to giving the client
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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 his influenza
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vaccine.‖
ju
Answer: 3 ju
Rationale: Influenza vaccines are recommended for person at high risk for serious
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sequelae of influenza. The nurse should be aware that client with a sensitivity to
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eggs should not receive the vaccine. Vaccines prepared from chicken or duck
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embryos are contraindicated in clients who are allergic to eggs.
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Cognitive Level: Application
ju ju
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ju ju ju ju
,download full file at http://testbankinstant.com
ju ju ju ju
,download full file at http://testbankinstant.com
ju ju ju ju
, Chapter 1:critical thinking ,critical judgment and the nursing process
ju ju ju ju ju ju ju ju
1. The nurse is caring for four clients on a medical–surgical unit. Which client should the
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
nurse see initially?
ju ju ju
1. A client admitted with hepatitis A who has had severe diarrhea for the last
ju ju ju ju ju ju ju ju ju ju ju ju ju
24 hours ju ju
2. A client admitted with pneumonia who is has small amounts of yellow
ju ju ju ju ju ju ju ju ju ju ju
productive sputum ju ju
3. A client admitted with fever of unknown origin (FUO) who has been
ju ju ju ju ju ju ju ju ju ju ju
without fever for the last 48 hours
ju ju ju ju ju ju ju
4. A client admitted with a wound infection whose WBC is 8,500 mm3
ju ju ju ju ju ju ju ju ju ju ju
Answer: 1 ju
Rationale: The nurse must decide which client should be seen on the initial rounds of the
ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
day. The nurse must remember that the first client to be seen should be the client
ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
who needs the attention of the nurse initially. A client with hepatitis A does
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
experience diarrhea, but diarrhea for the last 24 hours could cause the client to
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
have a problem with dehydration and experience a state of fluid volume deficit.
ju ju ju ju ju ju ju ju ju ju ju ju ju
Cognitive Level: Application
ju ju
Client Needs: Safe, Effective Care Environment
ju ju ju ju ju
Nursing Process: Planning
ju ju ju
2. The nurse is preparing to administer influenza vaccines to a mass drive-through clinic.
ju ju ju ju ju ju ju ju ju ju ju ju
Which statement by a client would indicate further questioning prior to giving the client
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the influenza vaccine?
ju ju ju
1. ―I am allergic to horse hair.‖
ju ju ju ju ju
2. ―I try to get my vaccine every year.‖
ju ju ju ju ju ju ju
3. ―I am not allergic to anything except eggs.‖
ju ju ju ju ju ju ju
4. ―My husband had a severe allergic reaction after he received his influenza
ju ju ju ju ju ju ju ju ju ju ju
vaccine.‖
ju
Answer: 3 ju
Rationale: Influenza vaccines are recommended for person at high risk for serious
ju ju ju ju ju ju ju ju ju ju ju
sequelae of influenza. The nurse should be aware that client with a sensitivity to
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
eggs should not receive the vaccine. Vaccines prepared from chicken or duck
ju ju ju ju ju ju ju ju ju ju ju ju
embryos are contraindicated in clients who are allergic to eggs.
ju ju ju ju ju ju ju ju ju ju
Cognitive Level: Application
ju ju
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