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