Chapter 1

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

client should thenurse see initially?

1. A client admitted with hepatitis A who has had severe

diarrhea for the last24 hours

2. A client admitted with pneumonia who is has small

amounts of yellowproductive sputum

3. A client admitted with fever of unknown origin (FUO) who

has beenwithout 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 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 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.

Cognitive Level: Application

Client Needs: Safe, Effective Care

EnvironmentNursing Process: Planning

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 influenzavaccine.‖