Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon

Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon1. The nurse is caring for four clients on a medical–surgical unit. Which client should the
nurse see initially?
1.
2.
3.
4.
Answer: 1
A client admitted with hepatitis A who has had severe diarrhea for the last
24 hours
A client admitted with pneumonia who is has small amounts of yellow
productive sputum
A client admitted with fever of unknown origin (FUO) who has been
without fever for the last 48 hours
A client admitted with a wound infection whose WBC is 8,500 mm3
Rationale: The nurse must decide which client should be seen on the initial rounds of the
day. The nurse must remember that the first client to be seen should be the client
who needs the attention of the nurse initially. A client with hepatitis A does
experience diarrhea, but diarrhea for the last 24 hours could cause the client to
have a problem with dehydration and experience a state of fluid volume deficit.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environment
Nursing Process: Planning
2. The nurse is preparing to administer influenza vaccines to a mass drive-through clinic.
Which statement by a client would indicate further questioning prior to giving the client
the influenza vaccine?
1. ―I am allergic to horse hair.‖
2. ―I try to get my vaccine every year.‖
3. ―I am not allergic to anything except eggs.‖
4. ―My husband had a severe allergic reaction after he received his influenza
vaccine.‖
Answer: 3
Rationale: Influenza vaccines are recommended for person at high risk for serious
sequelae of influenza. The nurse should be aware that client with a sensitivity to
eggs should not receive the vaccine. Vaccines prepared from chicken or duck
embryos are contraindicated in clients who are allergic to eggs.
Cognitive Level: Application
Client Needs: Safe, Effective Care Environment
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Test Bank for Medical-Surgical Nursing Critical
Thinking in Client Care, 4th Edition Priscilla LeMon
Nursing Process: Assessment
3. The nurse is caring for four clients on a medical–surgical unit. The secretary gives the
nurse the morning labs. Which of the following labs would require that the nurse call the
physician and inform the healthcare provider about the client‘s abnormalities?
1.
2.
3.
4.
Answer: 1
WBC 14,600 mm3
Serum protein 6.9 g/dL
I & D (incision and drainage) showing no growth for the last 24 hours
Albumin 4.2 g/dL
Rationale: When the nurse is caring for several clients, all of the labs should be checked
frequently throughout the shift to assess for any abnormalities. The WBC in option 1 is
abnormal. (Normal WBC 4,000–10,000 mm3.) All of the other lab results are within
acceptable range; therefore, the results should not be called in to the physician.
Cognitive Level: Application
Client Needs: Physiologic Integrity
Nursing Process: Assessment
4. The nurse is orienting a new graduate. The nurse is reinforcing the importance of
standard precautions. Which of the following observations by the nurse would require
further education regarding standard precautions?