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TestBankforMedical-SurgicalNursingCriticalThinkinginClientCare,4thEditionPriscillaLeMon

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hapter11.The nurse is caring for four clients on a medical–surgical unit. Which client should thenurseseeinitially?1.A client admitted with hepatitis A who has had severe diarrhea for the last24 hou ... rs2.A client admitted with pneumonia who is has small amounts of yellowproductive sputum3.A client admitted with fever of unknown origin (FUO) who has beenwithout fever for thelast48 hours4.AclientadmittedwithawoundinfectionwhoseWBCis8,500mm3Answer:1Rationale: 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 doesexperience diarrhea, but diarrhea for the last 24 hours could cause the client tohaveaproblemwithdehydration andexperienceastateoffluidvolumedeficit.CognitiveLevel:ApplicationClient Needs: Safe, Effective Care EnvironmentNursingProcess:Planning2.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 clientthe influenzavaccine?1.“Iamallergictohorsehair.”2.“Itrytogetmyvaccineevery year.”3.“Iamnotallergicto anythingexcepteggs.”4.“My husband had a severe allergic reaction after he received his influenzavaccine.”Answer:3Rationale: Influenza vaccines are recommended for person at high risk for serioussequelae of influenza. The nurse should be aware that client with a sensitivity toeggs should not receive the vaccine. Vaccines prepared from chicken or duckembryosarecontraindicatedincli [Show More]

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