Medical-Surgical Nursing: Critical Thinking in Patient Care 5th Edition
MEDICAL-SURGICAL NURSING: CRITICAL
THINKING IN PATIENT CARE5TH EDITION
PRISCILLA LEMON BY PRISCILLA LEMONE (AUTHOR).
, Medical-Surgical Nursing: Critical Thinking in Patient Care 5th Edition
CHAPTER 1
1. The Nurse Is Caring For Four Clients On A Medical–Surgical Unit. Which Client
Should TheNurse See Initially?
1.
A Client Admitted With Hepatitis A Who Has Had Severe Diarrhea For
The Last24 Hours
2.
A Client Admitted With Pneumonia Who Is Has Small Amounts Of
YellowProductive Sputum
3.
A Client Admitted With Fever Of Unknown Origin (Fuo) Who Has
BeenWithout Fever For The Last 48 Hours
4.
A Client Admitted With A Wound Infection Whose Wbc Is 8,500 Mm3
Answer: 1
Rationale: The Nurse Must Decide Which Client Should Be Seen On The Initial Rounds
Of TheDay. The Nurse Must Remember That The First Client To Be Seen
Should Be The ClientWho 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.
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
InfluenzaVaccine.”
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 ToEggs 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
, Medical-Surgical Nursing: Critical Thinking in Patient Care 5th Edition
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.
Wbc 14,600 Mm3
2.
Serum Protein 6.9 G/Dl
3.
I & D (Incision And Drainage) Showing No Growth For The Last 24 Hours
4.
Albumin 4.2 G/Dl
Answer: 1
Rationale: When The Nurse Is Caring For Several Clients, All Of The Labs Should Be
CheckedFrequently 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.
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 RequireFurther Education Regarding Standard Precautions?
1. The Graduate Nurse Understands To Wash Hands When Entering And
ExitingThe Client’s Room.
2. The Graduate Nurse Wears Gloves When Serving Breakfast Trays To
VariousClients.
3. The Graduate Nurse Wears A Gown, Gloves, And Goggles When
Suctioning AClient.
4. The Graduate Nurse Leaves All Supplies In The Room Of A Client
Who Is InContact Isolation.
Answer: 2
Rationale: The Nurse Must Have An Understanding Of Standard Precautions.
Prevention Is The Most Important Measure To Prevent Nosocomial Infections.
Standard Precautions Were Published In 1996 That Provide Guidelines For The
Handling Of Blood And Other Body Fluids. These Guidelines Are Used With
All Clients, RegardlessOf Whether They Have A Known Infectious Disease.
Standard Precautions Are Used By All Healthcare Workers Who Have Direct
Contact With Clients Or With Their Body
, Medical-Surgical Nursing: Critical Thinking in Patient Care 5th Edition
Fluids. It Is Not Necessary For The Nurse To Wear Gloves While Delivering
Food TraysTo The Client, Because There Is Not Contact With The Client.
5. The Admitting Department Alerts The Nurse On A Medical–Surgical Unit That A
Client WithActive Tuberculosis (Tb) Is Being Admitted To The Unit. Which Type Of
Isolation Is Appropriate Based On The Client’s Diagnosis?
In Addition To Handwashing And Standard Precautions, The Nature And Spread Of
Some Infectious Diseases Require That Special Techniques Be Used To Protect
Uninfected ClientsAnd Workers. The Client With Pulmonary Tuberculosis Will Be
Placed In Airborne Precautions. The Client Should Be Placed In A Private Room
With Special Ventilation ThatDoes Not Allow Air To Circulate To General Hospital
Ventilation; A Mask Or Special Filter Respirators Will Be Used For Everyone
Entering The Room.
6. A Client Is Receiving Iv Vancomycin For The Treatment Of Clostridium Difficile.
The Nurse Understands That The Client Who Develops Flushing, Tachycardia, And
HypotensionDuring The Infusion Of Vancomycin Indicates:
1. Ototoxicity Effect.
2. Superinfection.
3. Red Man Syndrome.
4. Hives.
Answer: 3
Rationale: Vancomycin Inhibits Cell Wall Synthesis, And Is Used For Serious Infections.
It IsOnly Effective Against Gram-Positive Bacteria, Especially Staphylococcus Aureus
And Staphylococcus Epidermidis. The Nurse Should Infuse This Medication Slowly
Over 60 Minutes Or More To Avoid “Red Man” Syndrome. The Syndrome Is
Characterized By
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