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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.‖
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