The nurse is caring for four clients on a medical-surgical unit. Which client should the
nurse see initially?
1. A client admitted with hepatitis A who has had severe diarrhea for the last
24 hours
2. A client admitted with pneumonia who is has small amounts of yellow
productive sputum
3...
The nurse is caring for four clients on a medical-surgical unit. Which client should the
nurse see initially?
1. A client admitted with hepatitis A who has had severe diarrhea for the last
24 hours
2. A client admitted with pneumonia who is has small amounts of yellow
productive sputum
3. A client admitted with fever of unknown origin (FUO) who has been
without fever for the last 48 hours
4. A client admitted with a wound infection whose WBC is 8,500 mm3 -
ANSWERAnswer: 1
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.
AnswerThe 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." - ANSWERAnswer: 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.
AnswerEach client's response to pain may be influenced by multiple factors. Select all
that
apply:
a. Age
b. Past experience with pain
,c. Cultural influences
d. Knowledge - ANSWERCorrect Answers: a; b; c; d
Rationale: All factors listed can influence a client's response to pain.
AnswerThe 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 - ANSWERAnswer: 1
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.
AnswerThe 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?
1. The graduate nurse understands to wash hands when entering and exiting
the client's room.
2. The graduate nurse wears gloves when serving breakfast trays to various
clients.
3. The graduate nurse wears a gown, gloves, and goggles when suctioning a
client.
4. The graduate nurse leaves all supplies in the room of a client who is in
contact isolation. - ANSWERAnswer: 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, regardless
of 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
fluids. It is not necessary for the nurse to wear gloves while delivering food trays
to the client, because there is not contact with the client.
AnswerA 45-year-old woman presents to the ambulatory clinic for a gynecological
,examination. The health history reveals no significant personal or family medical history.
What information concerning health-promotion behaviors should be presented to the
client?
a. It is time to begin having mammograms every other year.
b. If the client is in a monogamous relationship, Pap smears will not be needed.
c. Bone density examinations are indicated every year.
d. Recommended calcium intake is at least 1,200 mg per day. - ANSWERAnswer: d
Rationale: The recommended calcium intake is at least 1,200 mg per day. This will be
beneficial in the prevention of osteoporosis. Women should begin having annual
mammograms by age 40. Pap smears are continued for women in monogamous
relationships. For women with no significant risk for the development of osteoporosis,
bone density examinations should be done every other year.
AnswerThe admitting department alerts the nurse on a medical-surgical unit that a
client with
active 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 clients
and workers. The client with pulmonary tuberculosis will be placed in airborne
precautions. The client should be placed in a private room with special ventilation that
does not allow air to circulate to general hospital ventilation; a mask or special filter
respirators will be used for everyone entering the room.
AnswerA 75-year-old client seeks care at an ambulatory clinic. The client reports
having
experienced extreme drowsiness after recently taking dosages of an over-the-counter
cold
medication. When collecting data, the nurse notes the client reports taking only the
prescribed amount of the preparation. What inferences can be made by the nurse
concerning the events?
a. The client likely has taken more of the preparation than stated.
b. The client likely has experienced a reaction between the cold medication and other
routine medications.
c. The client's age has influenced his response to the medication.
d. The client is allergic to the cold medication. - ANSWERAnswer: c
, Rationale: Older clients often experience altered responses to medications. These
changes
are in response to age-related developments in the kidneys and liver. There is no
evidence
the client has taken too much medication. There is no information provided to indicate
the client is taking other medications. Allergic reactions typically manifest with
integumentary- or respiratory-related symptoms.
AnswerThe nurse is colleting data from a client regarding past alcohol use history.
What
question will provide the greatest amount of information?
1. Are you a heavy drinker?
2. How often do you use alcohol?
3. Drinking doesn't cause any problems for you, does it?
4. Is alcohol use a concern for you? - ANSWERAnswer: 2
Rationale: Open-ended questions will elicit the greatest amount of information. Asking
closed questions will limit the information obtained.
AnswerA client is receiving IV vancomycin for the treatment of Clostridium difficile. The
nurse understands that the client who develops flushing, tachycardia, and hypotension
during the infusion of vancomycin indicates:
1. Ototoxicity effect.
2. Superinfection.
3. Red man syndrome.
4. Hives. - ANSWERAnswer: 3
Rationale: Vancomycin inhibits cell wall synthesis, and is used for serious infections. It
is
only 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
erythematous rash, flushing, tachycardia, and hypotension. Clients can become dizzy
and
agitated.
AnswerThe physician has ordered for the client to receive a trough blood level to
evaluate the
therapeutic effect of an antibiotic. The nurse understands that the trough should be
ordered:
1. A few minutes before the next scheduled dose of medication.
2. 1-2 hours after the oral administration of the medication.
3. 30 minutes after the IV administration.
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