Clinical Nursing Skills A Concept-Based Approach, (Volume 2) 4e By Pearson (Solution Manual with Test Bank)

TestBank forClinicalNursing Skills:
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AConcept-Based Approach
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4th EditionVolumeIII
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byPearson EducationChapters1 -16
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,Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Pearson
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,Clinical Nursing Skills:A Concept-Based Approach, 4e (Pearson)Education Test Bank
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Chapter 1: Assessment
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1) A client on the medical/surgical unit complains of sudden chest pains. Which action will thenurse
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implement first?
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A) Call the healthcare provider. b b b




B) Administerpain medication. b b




C) Reassess a new set of vital signs. b b b b b b




D) Turnclient from supineto lateral. b b b b b




ANSWER: C
b b




Explanation: A) The nurse will need to reassess the client first, before calling the healthcare b b b b b b b b b b b b b b




provider.
b




B) The nurse will need to reassess the client first, before administering pain medication.
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C) The nurse needs to implement a new set of vital signs first when there is a change in
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condition.
b




D) The nurse will need to reassess the client first, before movingthe client, to avoid making thechange
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in client's condition worse.
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Page Ref: 2 b b




Cognitive Level: Applying b b




Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN Competencies:
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Patient-Centered Care
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AACN Domains and Comps.: Domain 2: Person-Centered Care
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NLN Competencies: Relationship Centered Care
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2) The nurse is observing the UAP taking the temperature of an unconscious client. Which routewill
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the nurse question the UAP using?
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A) Oral
B) Rectal
C) Scanner
D) Tympanic
ANSWER:
b




A
b




Explanation: A) The temperature of an unconscious client is never taken by mouth. The rectal, b b b b b b b b b b b b b b




tympanic, or scanner method is preferred.
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B) The rectal, tympanic, or scanner method is preferred.
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C) The rectal, tympanic, or scanner method is preferred.
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D) Therectal, tympanic, or scanner method is preferred.
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Page Ref: 24
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Cognitive Level: Applying b b




Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards:
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NursingProcess: Evaluation | Learning Outcome: 1.1 |QSEN Competencies: SafetyAACN Domains
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and Comps.: Domain 5: Quality and Safety
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NLN Competencies: Quality & Safety
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1

, 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch.Which
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method should the nurse use to check the baby's temperature?
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A) Oral
B) Rectal
C) Axillary
D) Tympanic membrane b




ANSWER: C
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Explanation: A) Oral is used for age 3 or older. b b b b b b b b b




B) The rectal route is the least desirable.
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C) The axillaryroute may not be as accurate as other routes for detecting fevers in children.
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D) The tympanic membrane maybe used for 3 months or older.Page
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Ref: 29
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Cognitive Level: Applying b b




Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: NursingProcess: Evaluating | Learning Outcome: 1.2 | QSEN Competencies: Safety
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AACN Domains and Comps.: Domain 5: Quality and Safety
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NLN Competencies: Quality & Safety
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4) A client comes in with exacerbation of chronic obstructive pulmonarydisease (COPD). Which
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noninvasive diagnostic test will the nurse implement to know that the client is receiving enough
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oxygen?
b




A) Chest x-ray b




B) Pulse oximeter b




C) Arterialblood gasses b b




D) Assessmentofrespiratoryrate b b b




ANSWER: B
b b




Explanation: A) A chest x-rayis not an intervention a nurse completes. b b b b b b b b b b b




B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen
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saturation, in the blood and provides a pulse reading, which is especiallyhelpful for the clientwith a
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respiratoryillness or disease.
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C) Arterial blood gases are an invasive diagnostic test. b b b b b b b




D) Assessinga respiratory rate is important for the nurse to implement; however, it is not a
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diagnostic test.
b b




Page Ref: 21b b




Cognitive Level: Applying b b




Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Competencies:
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Informatics
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AACN Domains and Comps.: Domain 5: Quality and SafetyNLN
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Competencies: Quality & Safety
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