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