Chapter 1
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download full file at
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http://testbankinstant.com
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,1. The nurse is caring for four clients on a medical–surgical unit. Which client should
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thenurse see initially?
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1.
A client admitted with hepatitis A who has had severe diarrhea for the
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last24 hours
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2.
A client admitted with pneumonia who is has small amounts of
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yellowproductive sputum
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3.
A client admitted with fever of unknown origin (FUO) who has
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beenwithout 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 aa
Rationale: The nurse must decide which client should be seen on the initial rounds of
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theday. The nurse must remember that the first client to be seen should be the
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clientwho needs the attention of the nurse initially. A client with hepatitis A
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does experience diarrhea, but diarrhea for the last 24 hours could cause the
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client to have a problem with dehydration and experience a state of fluid
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volume deficit.
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Cognitive Level: Application aa aa
Client Needs: Safe, Effective 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-through
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clinic.Which statement by a client would indicate further questioning prior to giving
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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 his
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influenzavaccine.‖
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Answer: 3 aa
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
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toeggs 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 aa aa
Client Needs: Safe, Effective Care Environment
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download full file at aa aa aa
http://testbankinstant.com
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,Nursing Process: Assessmentaa aa
3. The nurse is caring for four clients on a medical–surgical unit. The secretary gives
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the nurse the morning labs. Which of the following labs would require that the nurse
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call thephysician and inform the healthcare provider about the client‘s abnormalities?
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1.
WBC 14,600 mm3 aa aa
2.
Serum protein 6.9 g/dL aa aa aa
3.
I & D (incision and drainage) showing no growth for the last 24 hours
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4.
Albumin 4.2 g/dL aa aa
Answer: 1 aa
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 in
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option 1 is abnormal. (Normal WBC 4,000–10,000 mm3.) All of the other lab results are
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within acceptable range; therefore, the results should not be called in to the physician.
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Cognitive Level: Application aa aa
Client Needs: Physiologic
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IntegrityNursing Process:
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Assessment
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4. The nurse is orienting a new graduate. The nurse is reinforcing the importance of
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standard precautions. Which of the following observations by the nurse would
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requirefurther education regarding standard precautions?
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1. The graduate nurse understands to wash hands when entering and
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exitingthe client‘s room.
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2. The graduate nurse wears gloves when serving breakfast trays to
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variousclients. aa a
3. The graduate nurse wears a gown, gloves, and goggles when suctioning
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aclient. aa a
4. The graduate nurse leaves all supplies in the room of a client who is
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incontact isolation.
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Answer: 2 aa
Rationale: The nurse must have an understanding of standard precautions. Prevention is
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the most important measure to prevent nosocomial infections. Standard
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precautions were published in 1996 that provide guidelines for the handling of
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blood and other body fluids. These guidelines are used with all clients,
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regardlessof whether they have a known infectious disease. Standard
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precautions are used by all healthcare workers who have direct contact with
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clients or with their body
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download full file at aa aa aa
http://testbankinstant.com
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, fluids. It is not necessary for the nurse to wear gloves while delivering food
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traysto the client, because there is not contact with the client.
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Cognitive Level: Application aa aa
Client Needs: Safe, Effective Care
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EnvironmentNursing Process: Evaluation
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5. The admitting department alerts the nurse on a medical–surgical unit that a client
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withactive tuberculosis (TB) is being admitted to the unit. Which type of isolation is
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appropriate based on the client‘s diagnosis?
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1. Standard precautions aa
2. Airborne precautions aa
3. Droplet precautions aa
4. Contact precautions aa
Answer: 2 aa
In addition to handwashing and standard precautions, the nature and spread of some
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infectious diseases require that special techniques be used to protect uninfected
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clientsand workers. The client with pulmonary tuberculosis will be placed in
aa a aa aa aa aa aa aa aa aa aa aa
airborne precautions. The client should be placed in a private room with special
aa aa aa aa aa aa aa aa aa aa aa aa aa
ventilation thatdoes not allow air to circulate to general hospital ventilation; a mask
aa aa a aa aa aa aa aa aa aa aa aa aa aa
or special filter respirators will be used for everyone entering the room.
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Cognitive Level: Application aa aa
Client Needs: Safe, Effective Care
aa aa aa aa
EnvironmentNursing Process: Assessment
aa a aa aa
6. A client is receiving IV vancomycin for the treatment of Clostridium difficile.
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The nurse understands that the client who develops flushing, tachycardia, and
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hypotensionduring the infusion of vancomycin indicates:
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1. Ototoxicity effect. aa
2. Superinfection.
3. Red man syndrome. aa aa
4. Hives.
Answer: 3 aa
Rationale: Vancomycin inhibits cell wall synthesis, and is used for serious infections. It
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isonly effective against gram-positive bacteria, especially Staphylococcus aureus and
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Staphylococcus epidermidis. The nurse should infuse this medication slowly over 60
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minutes or more to avoid ―red man‖ syndrome. The syndrome is characterized by
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download full file at aa aa aa
http://testbankinstant.com
aa
aa
download full file at
aa aa aa
http://testbankinstant.com
aa
,1. The nurse is caring for four clients on a medical–surgical unit. Which client should
aa aa aa aa aa aa aa aa aa aa aa aa aa
thenurse see initially?
aa a aa aa
1.
A client admitted with hepatitis A who has had severe diarrhea for the
aa aa aa aa aa aa aa aa aa aa aa aa
last24 hours
aa a aa
2.
A client admitted with pneumonia who is has small amounts of
aa aa aa aa aa aa aa aa aa aa
yellowproductive sputum
aa a aa
3.
A client admitted with fever of unknown origin (FUO) who has
aa aa aa aa aa aa aa aa aa aa
beenwithout fever for the last 48 hours
aa a aa aa aa aa aa aa
4.
A client admitted with a wound infection whose WBC is 8,500 mm3
aa aa aa aa aa aa aa aa aa aa aa
Answer: 1 aa
Rationale: The nurse must decide which client should be seen on the initial rounds of
aa aa aa aa aa aa aa aa aa aa aa aa aa aa
theday. The nurse must remember that the first client to be seen should be the
aa a aa aa aa aa aa aa aa aa aa aa aa aa aa aa
clientwho needs the attention of the nurse initially. A client with hepatitis A
aa a aa aa aa aa aa aa aa aa aa aa aa aa
does experience diarrhea, but diarrhea for the last 24 hours could cause the
aa aa aa aa aa aa aa aa aa aa aa aa aa
client to have a problem with dehydration and experience a state of fluid
aa aa aa aa aa aa aa aa aa aa aa aa aa
volume deficit.
aa aa
Cognitive Level: Application aa aa
Client Needs: Safe, Effective Care
aa aa aa aa
EnvironmentNursing Process: Planning
aa a aa aa
2. The nurse is preparing to administer influenza vaccines to a mass drive-through
aa aa aa aa aa aa aa aa aa aa aa
clinic.Which statement by a client would indicate further questioning prior to giving
aa a aa aa aa aa aa aa aa aa aa aa aa
the client the influenza vaccine?
aa aa aa aa aa
1. ―I am allergic to horse hair.‖
aa aa aa aa aa
2. ―I try to get my vaccine every year.‖
aa aa aa aa aa aa aa
3. ―I am not allergic to anything except eggs.‖
aa aa aa aa aa aa aa
4. ―My husband had a severe allergic reaction after he received his
aa aa aa aa aa aa aa aa aa aa
influenzavaccine.‖
aa a
Answer: 3 aa
Rationale: Influenza vaccines are recommended for person at high risk for serious
aa aa aa aa aa aa aa aa aa aa aa
sequelae of influenza. The nurse should be aware that client with a sensitivity
aa aa aa aa aa aa aa aa aa aa aa aa aa
toeggs should not receive the vaccine. Vaccines prepared from chicken or duck
aa a aa aa aa aa aa aa aa aa aa aa aa
embryos are contraindicated in clients who are allergic to eggs.
aa aa aa aa aa aa aa aa aa aa
Cognitive Level: Application aa aa
Client Needs: Safe, Effective Care Environment
aa aa aa aa aa
download full file at aa aa aa
http://testbankinstant.com
aa
,Nursing Process: Assessmentaa aa
3. The nurse is caring for four clients on a medical–surgical unit. The secretary gives
aa aa aa aa aa aa aa aa aa aa aa aa aa
the nurse the morning labs. Which of the following labs would require that the nurse
aa a aa aa aa aa aa aa aa aa aa aa aa aa aa
call thephysician and inform the healthcare provider about the client‘s abnormalities?
aa aa a aa aa aa aa aa aa aa aa aa
1.
WBC 14,600 mm3 aa aa
2.
Serum protein 6.9 g/dL aa aa aa
3.
I & D (incision and drainage) showing no growth for the last 24 hours
aa aa aa aa aa aa aa aa aa aa aa aa aa
4.
Albumin 4.2 g/dL aa aa
Answer: 1 aa
Rationale: When the nurse is caring for several clients, all of the labs should be
aa aa aa aa aa aa aa aa aa aa aa aa aa aa
checkedfrequently throughout the shift to assess for any abnormalities. The WBC in
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option 1 is abnormal. (Normal WBC 4,000–10,000 mm3.) All of the other lab results are
aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa
within acceptable range; therefore, the results should not be called in to the physician.
aa aa aa aa aa aa aa aa aa aa aa aa aa aa
Cognitive Level: Application aa aa
Client Needs: Physiologic
aa aa aa
IntegrityNursing Process:
aa a aa
Assessment
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4. The nurse is orienting a new graduate. The nurse is reinforcing the importance of
aa aa aa aa aa aa aa aa aa aa aa aa aa
standard precautions. Which of the following observations by the nurse would
aa aa aa aa aa aa aa aa aa aa aa
requirefurther education regarding standard precautions?
aa a aa aa aa aa
1. The graduate nurse understands to wash hands when entering and
aa aa aa aa aa aa aa aa aa
exitingthe client‘s room.
aa a aa aa
2. The graduate nurse wears gloves when serving breakfast trays to
aa aa aa aa aa aa aa aa aa
variousclients. aa a
3. The graduate nurse wears a gown, gloves, and goggles when suctioning
aa aa aa aa aa aa aa aa aa aa
aclient. aa a
4. The graduate nurse leaves all supplies in the room of a client who is
aa aa aa aa aa aa aa aa aa aa aa aa aa
incontact isolation.
aa a aa
Answer: 2 aa
Rationale: The nurse must have an understanding of standard precautions. Prevention is
aa aa aa aa aa aa aa aa aa aa aa
the most important measure to prevent nosocomial infections. Standard
aa aa aa aa aa aa aa aa aa
precautions were published in 1996 that provide guidelines for the handling of
aa aa aa aa aa aa aa aa aa aa aa aa
blood and other body fluids. These guidelines are used with all clients,
aa aa aa aa aa aa aa aa aa aa aa aa
regardlessof whether they have a known infectious disease. Standard
aa a aa aa aa aa aa aa aa aa
precautions are used by all healthcare workers who have direct contact with
aa aa aa aa aa aa aa aa aa aa aa aa
clients or with their body
aa aa aa aa aa
download full file at aa aa aa
http://testbankinstant.com
aa
, fluids. It is not necessary for the nurse to wear gloves while delivering food
aa aa aa aa aa aa aa aa aa aa aa aa aa
traysto the client, because there is not contact with the client.
aa a aa aa aa aa aa aa aa aa aa aa
Cognitive Level: Application aa aa
Client Needs: Safe, Effective Care
aa aa aa aa
EnvironmentNursing Process: Evaluation
aa a aa aa
5. The admitting department alerts the nurse on a medical–surgical unit that a client
aa aa aa aa aa aa aa aa aa aa aa aa
withactive tuberculosis (TB) is being admitted to the unit. Which type of isolation is
aa a aa aa aa aa aa aa aa aa aa aa aa aa aa
appropriate based on the client‘s diagnosis?
aa aa aa aa aa aa
1. Standard precautions aa
2. Airborne precautions aa
3. Droplet precautions aa
4. Contact precautions aa
Answer: 2 aa
In addition to handwashing and standard precautions, the nature and spread of some
aa aa aa aa aa aa aa aa aa aa aa aa
infectious diseases require that special techniques be used to protect uninfected
aa aa aa aa aa aa aa aa aa aa aa
clientsand workers. The client with pulmonary tuberculosis will be placed in
aa a aa aa aa aa aa aa aa aa aa aa
airborne precautions. The client should be placed in a private room with special
aa aa aa aa aa aa aa aa aa aa aa aa aa
ventilation thatdoes not allow air to circulate to general hospital ventilation; a mask
aa aa a aa aa aa aa aa aa aa aa aa aa aa
or special filter respirators will be used for everyone entering the room.
aa aa aa aa aa aa aa aa aa aa aa aa
Cognitive Level: Application aa aa
Client Needs: Safe, Effective Care
aa aa aa aa
EnvironmentNursing Process: Assessment
aa a aa aa
6. A client is receiving IV vancomycin for the treatment of Clostridium difficile.
aa aa aa aa aa aa aa aa aa aa aa
The nurse understands that the client who develops flushing, tachycardia, and
aa aa aa aa aa aa aa aa aa aa aa
hypotensionduring the infusion of vancomycin indicates:
aa a aa aa aa aa aa
1. Ototoxicity effect. aa
2. Superinfection.
3. Red man syndrome. aa aa
4. Hives.
Answer: 3 aa
Rationale: Vancomycin inhibits cell wall synthesis, and is used for serious infections. It
aa aa aa aa aa aa aa aa aa aa aa aa
isonly effective against gram-positive bacteria, especially Staphylococcus aureus and
aa a aa aa aa aa aa aa aa aa
Staphylococcus epidermidis. The nurse should infuse this medication slowly over 60
aa aa aa aa aa aa aa aa aa aa aa
minutes or more to avoid ―red man‖ syndrome. The syndrome is characterized by
aa aa aa aa aa aa aa aa aa aa aa aa aa
download full file at aa aa aa
http://testbankinstant.com
aa
