Chapter j1
1. The jnurse jis jcaring jfor jfour jclients jon ja jmedical–surgical junit. jWhich jclient jshould
jthejnurse jsee jinitially?
1.
A jclient jadmitted jwith jhepatitis jA jwho jhas jhad jsevere jdiarrhea jfor jthe
jlastj24 jhours
2.
A jclient jadmitted jwith jpneumonia jwho jis jhas jsmall jamounts jof
, jyellowjproductive jsputum
3.
A jclient jadmitted jwith jfever jof junknown jorigin j(FUO) jwho jhas
jbeenjwithout jfever jfor jthe jlast j48 jhours
4.
A jclient jadmitted jwith ja jwound jinfection jwhose jWBC jis j8,500 jmm3
Answer: j1
Rationale: jThe jnurse jmust jdecide jwhich jclient jshould jbe jseen jon jthe jinitial jrounds jof
jthejday. jThe jnurse jmust jremember jthat jthe jfirst jclient jto jbe jseen jshould jbe
jthe jclientjwho jneeds jthe jattention jof jthe jnurse jinitially. jA jclient jwith jhepatitis
jA jdoes jexperience jdiarrhea, jbut jdiarrhea jfor jthe jlast j24 jhours jcould jcause jthe
jclient jto jhave ja jproblem jwith jdehydration jand jexperience ja jstate jof jfluid
jvolume jdeficit.
Cognitive jLevel: jApplication
Client jNeeds: jSafe, jEffective jCare
jEnvironmentjNursing jProcess: jPlanning
2. The jnurse jis jpreparing jto jadminister jinfluenza jvaccines jto ja jmass jdrive-through
jclinic.jWhich jstatement jby ja jclient jwould jindicate jfurther jquestioning jprior jto jgiving
jthe jclient jthe jinfluenza jvaccine?
1. ―I jam jallergic jto jhorse jhair.‖
2. ―I jtry jto jget jmy jvaccine jevery jyear.‖
3. ―I jam jnot jallergic jto janything jexcept jeggs.‖
4. ―My jhusband jhad ja jsevere jallergic jreaction jafter jhe jreceived jhis
jinfluenzajvaccine.‖
Answer: j3
Rationale: jInfluenza jvaccines jare jrecommended jfor jperson jat jhigh jrisk jfor jserious
jsequelae jof jinfluenza. jThe jnurse jshould jbe jaware jthat jclient jwith ja jsensitivity
jtojeggs jshould jnot jreceive jthe jvaccine. jVaccines jprepared jfrom jchicken jor
jduck jembryos jare jcontraindicated jin jclients jwho jare jallergic jto jeggs.
Cognitive jLevel: jApplication
Client jNeeds: jSafe, jEffective jCare jEnvironment
,Nursing jProcess: jAssessment
3. The jnurse jis jcaring jfor jfour jclients jon ja jmedical–surgical junit. jThe jsecretary jgives
jthe jnurse jthe jmorning jlabs. jWhich jof jthe jfollowing jlabs jwould jrequire jthat jthe jnurse
jcall jthejphysician jand jinform jthe jhealthcare jprovider jabout jthe jclient‘s jabnormalities?
1.
WBC j14,600 jmm3
2.
Serum jprotein j6.9 jg/dL
3.
I j& jD j(incision jand jdrainage) jshowing jno jgrowth jfor jthe jlast j24 jhours
4.
Albumin j4.2 jg/dL
Answer: j1
Rationale: jWhen jthe jnurse jis jcaring jfor jseveral jclients, jall jof jthe jlabs jshould jbe
jcheckedjfrequently jthroughout jthe jshift jto jassess jfor jany jabnormalities. jThe jWBC jin
3
joption j1 jis jabnormal. j(Normal jWBC j4,000–10,000 jmm .) jAll jof jthe jother jlab jresults
jare jwithin jacceptable jrange; jtherefore, jthe jresults jshould jnot jbe jcalled jin jto jthe
jphysician.
Cognitive jLevel: jApplication
jClient jNeeds: jPhysiologic
jIntegrityjNursing jProcess:
jAssessment
4. The jnurse jis jorienting ja jnew jgraduate. jThe jnurse jis jreinforcing jthe jimportance
jof jstandard jprecautions. jWhich jof jthe jfollowing jobservations jby jthe jnurse jwould
jrequirejfurther jeducation jregarding jstandard jprecautions?
1. The jgraduate jnurse junderstands jto jwash jhands jwhen jentering jand
jexitingjthe jclient‘s jroom.
2. The jgraduate jnurse jwears jgloves jwhen jserving jbreakfast jtrays jto
jvariousjclients.
3. The jgraduate jnurse jwears ja jgown, jgloves, jand jgoggles jwhen
jsuctioning jajclient.
4. The jgraduate jnurse jleaves jall jsupplies jin jthe jroom jof ja jclient jwho
jis jinjcontact jisolation.
Answer: j2
Rationale: jThe jnurse jmust jhave jan junderstanding jof jstandard jprecautions. jPrevention
jis jthe jmost jimportant jmeasure jto jprevent jnosocomial jinfections. jStandard
jprecautions jwere jpublished jin j1996 jthat jprovide jguidelines jfor jthe jhandling
jof jblood jand jother jbody jfluids. jThese jguidelines jare jused jwith jall jclients,
jregardlessjof jwhether jthey jhave ja jknown jinfectious jdisease. jStandard
jprecautions jare jused jby jall jhealthcare jworkers jwho jhave jdirect jcontact jwith
jclients jor jwith jtheir jbody
, fluids. jIt jis jnot jnecessary jfor jthe jnurse jto jwear jgloves jwhile jdelivering jfood
jtraysjto jthe jclient, jbecause jthere jis jnot jcontact jwith jthe jclient.
Cognitive jLevel: jApplication
Client jNeeds: jSafe, jEffective jCare
jEnvironmentjNursing jProcess: jEvaluation
5. The jadmitting jdepartment jalerts jthe jnurse jon ja jmedical–surgical junit jthat ja jclient
jwithjactive jtuberculosis j(TB) jis jbeing jadmitted jto jthe junit. jWhich jtype jof jisolation jis
jappropriate jbased jon jthe jclient‘s jdiagnosis?
1. Standard jprecautions
2. Airborne jprecautions
3. Droplet jprecautions
4. Contact jprecautions
Answer: j2
In jaddition jto jhandwashing jand jstandard jprecautions, jthe jnature jand jspread jof
jsome jinfectious jdiseases jrequire jthat jspecial jtechniques jbe jused jto jprotect
juninfected jclientsjand jworkers. jThe jclient jwith jpulmonary jtuberculosis jwill jbe
jplaced jin jairborne jprecautions. jThe jclient jshould jbe jplaced jin ja jprivate jroom jwith
jspecial jventilation jthatjdoes jnot jallow jair jto jcirculate jto jgeneral jhospital
jventilation; ja jmask jor jspecial jfilter jrespirators jwill jbe jused jfor jeveryone jentering
jthe jroom.
Cognitive jLevel: jApplication
Client jNeeds: jSafe, jEffective jCare
jEnvironmentjNursing jProcess: jAssessment
6. A jclient jis jreceiving jIV jvancomycin jfor jthe jtreatment jof jClostridium jdifficile.
jThe jnurse junderstands jthat jthe jclient jwho jdevelops jflushing, jtachycardia, jand
jhypotensionjduring jthe jinfusion jof jvancomycin jindicates:
1. Ototoxicity jeffect.
2. Superinfection.
3. Red jman jsyndrome.
4. Hives.
Answer: j3
Rationale: jVancomycin jinhibits jcell jwall jsynthesis, jand jis jused jfor jserious jinfections. jIt
jisjonly jeffective jagainst jgram-positive jbacteria, jespecially jStaphylococcus jaureus jand
jStaphylococcus jepidermidis. jThe jnurse jshould jinfuse jthis jmedication jslowly jover j60
jminutes jor jmore jto javoid j―red jman‖ jsyndrome. jThe jsyndrome jis jcharacterized jby
1. The jnurse jis jcaring jfor jfour jclients jon ja jmedical–surgical junit. jWhich jclient jshould
jthejnurse jsee jinitially?
1.
A jclient jadmitted jwith jhepatitis jA jwho jhas jhad jsevere jdiarrhea jfor jthe
jlastj24 jhours
2.
A jclient jadmitted jwith jpneumonia jwho jis jhas jsmall jamounts jof
, jyellowjproductive jsputum
3.
A jclient jadmitted jwith jfever jof junknown jorigin j(FUO) jwho jhas
jbeenjwithout jfever jfor jthe jlast j48 jhours
4.
A jclient jadmitted jwith ja jwound jinfection jwhose jWBC jis j8,500 jmm3
Answer: j1
Rationale: jThe jnurse jmust jdecide jwhich jclient jshould jbe jseen jon jthe jinitial jrounds jof
jthejday. jThe jnurse jmust jremember jthat jthe jfirst jclient jto jbe jseen jshould jbe
jthe jclientjwho jneeds jthe jattention jof jthe jnurse jinitially. jA jclient jwith jhepatitis
jA jdoes jexperience jdiarrhea, jbut jdiarrhea jfor jthe jlast j24 jhours jcould jcause jthe
jclient jto jhave ja jproblem jwith jdehydration jand jexperience ja jstate jof jfluid
jvolume jdeficit.
Cognitive jLevel: jApplication
Client jNeeds: jSafe, jEffective jCare
jEnvironmentjNursing jProcess: jPlanning
2. The jnurse jis jpreparing jto jadminister jinfluenza jvaccines jto ja jmass jdrive-through
jclinic.jWhich jstatement jby ja jclient jwould jindicate jfurther jquestioning jprior jto jgiving
jthe jclient jthe jinfluenza jvaccine?
1. ―I jam jallergic jto jhorse jhair.‖
2. ―I jtry jto jget jmy jvaccine jevery jyear.‖
3. ―I jam jnot jallergic jto janything jexcept jeggs.‖
4. ―My jhusband jhad ja jsevere jallergic jreaction jafter jhe jreceived jhis
jinfluenzajvaccine.‖
Answer: j3
Rationale: jInfluenza jvaccines jare jrecommended jfor jperson jat jhigh jrisk jfor jserious
jsequelae jof jinfluenza. jThe jnurse jshould jbe jaware jthat jclient jwith ja jsensitivity
jtojeggs jshould jnot jreceive jthe jvaccine. jVaccines jprepared jfrom jchicken jor
jduck jembryos jare jcontraindicated jin jclients jwho jare jallergic jto jeggs.
Cognitive jLevel: jApplication
Client jNeeds: jSafe, jEffective jCare jEnvironment
,Nursing jProcess: jAssessment
3. The jnurse jis jcaring jfor jfour jclients jon ja jmedical–surgical junit. jThe jsecretary jgives
jthe jnurse jthe jmorning jlabs. jWhich jof jthe jfollowing jlabs jwould jrequire jthat jthe jnurse
jcall jthejphysician jand jinform jthe jhealthcare jprovider jabout jthe jclient‘s jabnormalities?
1.
WBC j14,600 jmm3
2.
Serum jprotein j6.9 jg/dL
3.
I j& jD j(incision jand jdrainage) jshowing jno jgrowth jfor jthe jlast j24 jhours
4.
Albumin j4.2 jg/dL
Answer: j1
Rationale: jWhen jthe jnurse jis jcaring jfor jseveral jclients, jall jof jthe jlabs jshould jbe
jcheckedjfrequently jthroughout jthe jshift jto jassess jfor jany jabnormalities. jThe jWBC jin
3
joption j1 jis jabnormal. j(Normal jWBC j4,000–10,000 jmm .) jAll jof jthe jother jlab jresults
jare jwithin jacceptable jrange; jtherefore, jthe jresults jshould jnot jbe jcalled jin jto jthe
jphysician.
Cognitive jLevel: jApplication
jClient jNeeds: jPhysiologic
jIntegrityjNursing jProcess:
jAssessment
4. The jnurse jis jorienting ja jnew jgraduate. jThe jnurse jis jreinforcing jthe jimportance
jof jstandard jprecautions. jWhich jof jthe jfollowing jobservations jby jthe jnurse jwould
jrequirejfurther jeducation jregarding jstandard jprecautions?
1. The jgraduate jnurse junderstands jto jwash jhands jwhen jentering jand
jexitingjthe jclient‘s jroom.
2. The jgraduate jnurse jwears jgloves jwhen jserving jbreakfast jtrays jto
jvariousjclients.
3. The jgraduate jnurse jwears ja jgown, jgloves, jand jgoggles jwhen
jsuctioning jajclient.
4. The jgraduate jnurse jleaves jall jsupplies jin jthe jroom jof ja jclient jwho
jis jinjcontact jisolation.
Answer: j2
Rationale: jThe jnurse jmust jhave jan junderstanding jof jstandard jprecautions. jPrevention
jis jthe jmost jimportant jmeasure jto jprevent jnosocomial jinfections. jStandard
jprecautions jwere jpublished jin j1996 jthat jprovide jguidelines jfor jthe jhandling
jof jblood jand jother jbody jfluids. jThese jguidelines jare jused jwith jall jclients,
jregardlessjof jwhether jthey jhave ja jknown jinfectious jdisease. jStandard
jprecautions jare jused jby jall jhealthcare jworkers jwho jhave jdirect jcontact jwith
jclients jor jwith jtheir jbody
, fluids. jIt jis jnot jnecessary jfor jthe jnurse jto jwear jgloves jwhile jdelivering jfood
jtraysjto jthe jclient, jbecause jthere jis jnot jcontact jwith jthe jclient.
Cognitive jLevel: jApplication
Client jNeeds: jSafe, jEffective jCare
jEnvironmentjNursing jProcess: jEvaluation
5. The jadmitting jdepartment jalerts jthe jnurse jon ja jmedical–surgical junit jthat ja jclient
jwithjactive jtuberculosis j(TB) jis jbeing jadmitted jto jthe junit. jWhich jtype jof jisolation jis
jappropriate jbased jon jthe jclient‘s jdiagnosis?
1. Standard jprecautions
2. Airborne jprecautions
3. Droplet jprecautions
4. Contact jprecautions
Answer: j2
In jaddition jto jhandwashing jand jstandard jprecautions, jthe jnature jand jspread jof
jsome jinfectious jdiseases jrequire jthat jspecial jtechniques jbe jused jto jprotect
juninfected jclientsjand jworkers. jThe jclient jwith jpulmonary jtuberculosis jwill jbe
jplaced jin jairborne jprecautions. jThe jclient jshould jbe jplaced jin ja jprivate jroom jwith
jspecial jventilation jthatjdoes jnot jallow jair jto jcirculate jto jgeneral jhospital
jventilation; ja jmask jor jspecial jfilter jrespirators jwill jbe jused jfor jeveryone jentering
jthe jroom.
Cognitive jLevel: jApplication
Client jNeeds: jSafe, jEffective jCare
jEnvironmentjNursing jProcess: jAssessment
6. A jclient jis jreceiving jIV jvancomycin jfor jthe jtreatment jof jClostridium jdifficile.
jThe jnurse junderstands jthat jthe jclient jwho jdevelops jflushing, jtachycardia, jand
jhypotensionjduring jthe jinfusion jof jvancomycin jindicates:
1. Ototoxicity jeffect.
2. Superinfection.
3. Red jman jsyndrome.
4. Hives.
Answer: j3
Rationale: jVancomycin jinhibits jcell jwall jsynthesis, jand jis jused jfor jserious jinfections. jIt
jisjonly jeffective jagainst jgram-positive jbacteria, jespecially jStaphylococcus jaureus jand
jStaphylococcus jepidermidis. jThe jnurse jshould jinfuse jthis jmedication jslowly jover j60
jminutes jor jmore jto javoid j―red jman‖ jsyndrome. jThe jsyndrome jis jcharacterized jby
