1. The nurse is caring for four clients on a medical–surgical unit. Which client should the

nurse see initially?

A. A client admitted with hepatitis A who has had severe diarrhea for the last

24 hours

B. A client admitted with pneumonia who is has small amounts of yellow

productive sputum

C. A client admitted with fever of unknown origin (FUO) who has been

without fever for the last 48 hours

D. A client admitted with a wound infection whose WBC is 8,500 mm3

Answer: A

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?

A. “I am allergic to horse hair.”

B. “I try to get my vaccine every year.”

C. “I am not allergic to anything except eggs.”

D. “My husband had a severe allergic reaction after he received his influenza

vaccine.”

Answer: C

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.

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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?

A. WBC 14,600 mm3

B. Serum protein 6.9 g/dL

C. I & D (incision and drainage) showing no growth for the last 24 hours