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