Test Bank for Medical Surgical Nursing Critical Thinking in Client Care 4th Edition

Chapter 1
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,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 vv




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.
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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 vv




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
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,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 vv vv

2.
Serum protein 6.9 g/dL vv vv vv

3.
I & D (incision and drainage) showing no growth for the last 24
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vvhours
4.
Albumin 4.2 g/dL vv vv




Answer: 1 vv




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
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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 vv vv


Client Needs: Physiologic
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IntegrityNursing Process:
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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.
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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
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who is incontact isolation.
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Answer: 2 vv




Rationale: The nurse must have an understanding of standard precautions.
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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
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guidelines are used with all clients, regardlessof whether they have a
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, known infectious disease. Standard precautions are used by all healthcare
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workers who have direct contact with clients or with their body
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