1. 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
Answer: 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.
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.”
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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
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Client Needs: Safe, Effective Care Environment
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 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.
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?
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.
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, regardless
of whether they have a known infectious disease. Standard precautions are used
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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.
5. The 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.
6. A 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.
Answer: 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
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