Test Bank Complete_
Clinical Nursing Skills: A Concept-Based Approach 4th Edition, (2022)
All Chapters 1-16| Latest Edition With Well Detailed Answers| Grade A+
From: [Bestmaxsolutions.Stuvia
,Chapter 1: Assessment --------------------------------------------------------------------------- 5
I. General Assessment --------------------------------------------------------------------------------------------------5
II. Vital Signs ----------------------------------------------------------------------------------------------------------------5
III. Physical Assessment --------------------------------------------------------------------------------------------------5
IV. Physical Assessment for the Newborn ---------------------------------------------------------------------------5
V. Critical Thinking Options for Unexpected Outcomes ---------------------------------------------------------5
Chapter 2: Caring Interventions--------------------------------------------------------------- 24
I. Bed Care and Activities of Daily Living (ADLs) ---------------------------------------------------------------- 24
II. Medication Administration Systems ---------------------------------------------------------------------------- 24
III. Medication Preparation -------------------------------------------------------------------------------------------- 24
IV. Medication Routes -------------------------------------------------------------------------------------------------- 24
V. Parenteral Routes --------------------------------------------------------------------------------------------------- 24
VI. Critical Thinking Options for Unexpected Outcomes ------------------------------------------------------- 24
Chapter 3: Comfort ------------------------------------------------------------------------------- 45
I. Acute/Chronic Pain Management ------------------------------------------------------------------------------- 45
II. Heat and Cold Application ----------------------------------------------------------------------------------------- 45
III. End-of-Life Care ------------------------------------------------------------------------------------------------------ 45
IV. Critical Thinking Options for Unexpected Outcomes ------------------------------------------------------- 45
Chapter 4: Elimination --------------------------------------------------------------------------- 63
I. Assessment: Collecting Specimens ------------------------------------------------------------------------------ 63
II. Bladder Interventions ---------------------------------------------------------------------------------------------- 63
III. Bowel Interventions ------------------------------------------------------------------------------------------------ 63
IV. Dialysis ----------------------------------------------------------------------------------------------------------------- 63
V. Critical Thinking Options for Unexpected Outcomes ------------------------------------------------------- 63
Chapter 5: Fluids And Electrolytes ------------------------------------------------------------ 82
I. Fluid Balance Measurement -------------------------------------------------------------------------------------- 82
II. Intravenous Therapy ------------------------------------------------------------------------------------------------ 82
III. Critical Thinking Options for Unexpected Outcomes ------------------------------------------------------- 82
Chapter 6: Infection ---------------------------------------------------------------------------- 102
I. Medical Asepsis ---------------------------------------------------------------------------------------------------- 102
, II. Personal Protective Equipment (PPE) and Isolation Precautions ------------------------------------- 102
III. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 102
Chapter 7: Intracranial Regulation --------------------------------------------------------- 119
I. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 119
Chapter 8: Metabolism ------------------------------------------------------------------------ 134
I. General Metabolism ---------------------------------------------------------------------------------------------- 134
II. Diabetes Care ------------------------------------------------------------------------------------------------------- 134
III. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 134
Chapter 9: Mobility ----------------------------------------------------------------------------- 150
I. Balance and Strength --------------------------------------------------------------------------------------------- 150
II. Moving and Transferring a Patient ---------------------------------------------------------------------------- 150
III. Patient Assistive Devices ---------------------------------------------------------------------------------------- 150
IV. Traction and Cast Care ------------------------------------------------------------------------------------------- 150
V. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 150
Chapter 10: Nutrition -------------------------------------------------------------------------- 167
I. Healthy Eating Habits --------------------------------------------------------------------------------------------- 167
II. Enteral Nutrition Using a Feeding Tube ---------------------------------------------------------------------- 167
III. Parenteral Nutrition Using Intravenous Infusion ---------------------------------------------------------- 167
IV. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 167
Chapter 11: Oxygenation --------------------------------------------------------------------- 182
I. Assessment ---------------------------------------------------------------------------------------------------------- 182
II. Interventions-------------------------------------------------------------------------------------------------------- 182
III. Supplemental Oxygen Therapy -------------------------------------------------------------------------------- 182
IV. Maintaining a Patent Airway ----------------------------------------------------------------------------------- 182
V. Maintaining Lung Expansion ------------------------------------------------------------------------------------ 182
VI. Life-threatening Situations -------------------------------------------------------------------------------------- 182
VII. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 182
Chapter 12: Perfusion -------------------------------------------------------------------------- 199
I. Maintaining Blood Volume -------------------------------------------------------------------------------------- 199
II. Antiembolism Devices -------------------------------------------------------------------------------------------- 199
, III. Electrical Conduction in the Heart----------------------------------------------------------------------------- 199
IV. Arterial Line --------------------------------------------------------------------------------------------------------- 199
V. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 199
Chapter 13: Perioperative Care ------------------------------------------------------------- 214
I. General Perioperative Care ------------------------------------------------------------------------------------- 214
II. Using Sterile Technique ------------------------------------------------------------------------------------------ 214
III. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 214
Chapter 14: Reproduction -------------------------------------------------------------------- 229
I. Antepartum Care -------------------------------------------------------------------------------------------------- 229
II. Intrapartum Care -------------------------------------------------------------------------------------------------- 229
III. Postpartum Care --------------------------------------------------------------------------------------------------- 229
IV. Newborn Care ------------------------------------------------------------------------------------------------------ 229
V. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 229
Chapter 15: Safety ------------------------------------------------------------------------------ 248
I. Patient Safety ------------------------------------------------------------------------------------------------------- 248
II. Environmental Safety --------------------------------------------------------------------------------------------- 248
III. Immobilizers and Restraints ------------------------------------------------------------------------------------ 248
IV. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 248
Chapter 16: Tissue Integrity ------------------------------------------------------------------ 264
I. General Assessment ---------------------------------------------------------------------------------------------- 264
II. Dressings and Binders -------------------------------------------------------------------------------------------- 264
III. Wound Care --------------------------------------------------------------------------------------------------------- 264
IV. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 264
,Chapter 1: Assessment
Clinical Nursing Skills: A Concept-Based Approach 4th Edition, (2022) Test Bank
Chapter 1: Covers
I. General Assessment
II. Vital Signs
III. Physical Assessment
IV. Physical Assessment for the Newborn
V. Critical Thinking Options for Unexpected Outcomes
MULTIPLE CHOICE
1) A Client On The Medical/Surgical Unit Complains Of Sudden Chest Pains. Which
Action Will The Nurse Implement First?
A) Call The Healthcare Provider.
B) Administer Pain Medication.
C) Reassess A New Set Of Vital Signs.
D) Turn Client From Supine To Lateral.
ANSWER: C
Explanation:
A) The Nurse Will Need To Reassess The Client First, Before Calling The Healthcare
Provider.
B) The Nurse Will Need To Reassess The Client First, Before Administering Pain
Medication.
C) The Nurse Needs To Implement A New Set Of Vital Signs First When There Is A
Change In Condition.
D) The Nurse Will Need To Reassess The Client First, Before Moving The Client, To
Avoid Making The Change In Client's Condition Worse.
Page Ref: 2
Cognitive Level: Applying
,Client Need/Sub: Physiological Integrity: Reduction Of Risk Potential
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | Qsen Competencies:
Patient-Centered Care
AACN Domains And Comps.: Domain 2: Person-Centered Care Nln Competencies:
Relationship Centered Care
2) The Nurse Is Observing The UAP Taking The Temperature Of An Unconscious
Client. Which Route Will The Nurse Question The UAP Using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
ANSWER: A
Explanation:
A) The Temperature Of An Unconscious Client Is Never Taken By Mouth. The Rectal,
Tympanic, Or Scanner Method Is Preferred.
B) The Rectal, Tympanic, Or Scanner Method Is Preferred.
C) The Rectal, Tympanic, Or Scanner Method Is Preferred.
D) The Rectal, Tympanic, Or Scanner Method Is Preferred.
Page Ref: 24
Cognitive Level: Applying
Client Need/Sub: Safe And Effective Care Environment: Safety And Infection Control
Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | Qsen Competencies:
Safety AACN Domains And Comps.: Domain 5: Quality And Safety
Nln Competencies: Quality & Safety
3) The Nurse Is Changing A 2-Month-Old Client's Diaper And Notes The Client Feels
Warm To Touch. Which Method Should The Nurse Use To Check The Baby's
Temperature?
A) Oral
,B) Rectal
C) Axillary
D) Tympanic Membrane
ANSWER: C
Explanation:
A) Oral Is Used For Age 3 Or Older.
B) The Rectal Route Is The Least Desirable.
C) The Axillary Route May Not Be As Accurate As Other Routes For Detecting Fevers
In Children.
D) The Tympanic Membrane May Be Used For 3 Months Or Older.
Page Ref: 29
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction Of Risk Potential
Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | Qsen Competencies:
Safety AACN Domains And Comps.: Domain 5: Quality And Safety
Nln Competencies: Quality & Safety
4) A Client Comes In With Exacerbation Of Chronic Obstructive Pulmonary Disease
(COPD). Which Noninvasive Diagnostic Test Will The Nurse Implement To Know That
The Client Is Receiving Enough Oxygen?
A) Chest X-Ray
B) Pulse Oximeter
C) Arterial Blood Gasses
D) Assessment Of Respiratory Rate
ANSWER: B
Explanation:
A) A Chest X-Ray Is Not An Intervention A Nurse Completes.
, B) A Pulse Oximeter Provides A Noninvasive Method Of Measuring Oxygenation, Or
Oxygen Saturation, In The Blood And Provides A Pulse Reading, Which Is Especially
Helpful For The Client With A Respiratory Illness Or Disease.
C) Arterial Blood Gases Are An Invasive Diagnostic Test.
D) Assessing A Respiratory Rate Is Important For The Nurse To Implement; However, It
Is Not A Diagnostic Test.
Page Ref: 21
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction Of Risk Potential
Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | Qsen
Competencies: Informatics
AACN Domains And Comps.: Domain 5: Quality And Safety Nln Competencies: Quality
& Safety
5) The Nurse Is Preparing To Assess A Client's Musculoskeletal System. Which Question
Should The Nurse Ask Before Beginning This Assessment?
A) "Do You Exercise Every Day?"
B) "Do You Have A History Of Any Sports Injuries?"
C) "Do You Take A Hot Bath To Relax Your Muscles?"
D) "Do You Want Pain Medication Before I Begin?"
ANSWER: B
Explanation:
A) Knowing If A Client Exercises Is An Important Question But Knowing If There Are
Any Sports Injuries To Know About First, Is Most Important Before Doing A Routine
Musculoskeletal Assessment.
B) It Is Important To Note If The Client Has A History Of Any Sports Injuries First To
Know What The Client Will Or Will Not Be Able To Do During A Routine
Musculoskeletal Assessment.
C) Knowing If The Client Takes A Hot Bath To Relax The Muscles Is Not The Most
Important Thing To Ask Before Performing A Routine Musculoskeletal Assessment.
Clinical Nursing Skills: A Concept-Based Approach 4th Edition, (2022)
All Chapters 1-16| Latest Edition With Well Detailed Answers| Grade A+
From: [Bestmaxsolutions.Stuvia
,Chapter 1: Assessment --------------------------------------------------------------------------- 5
I. General Assessment --------------------------------------------------------------------------------------------------5
II. Vital Signs ----------------------------------------------------------------------------------------------------------------5
III. Physical Assessment --------------------------------------------------------------------------------------------------5
IV. Physical Assessment for the Newborn ---------------------------------------------------------------------------5
V. Critical Thinking Options for Unexpected Outcomes ---------------------------------------------------------5
Chapter 2: Caring Interventions--------------------------------------------------------------- 24
I. Bed Care and Activities of Daily Living (ADLs) ---------------------------------------------------------------- 24
II. Medication Administration Systems ---------------------------------------------------------------------------- 24
III. Medication Preparation -------------------------------------------------------------------------------------------- 24
IV. Medication Routes -------------------------------------------------------------------------------------------------- 24
V. Parenteral Routes --------------------------------------------------------------------------------------------------- 24
VI. Critical Thinking Options for Unexpected Outcomes ------------------------------------------------------- 24
Chapter 3: Comfort ------------------------------------------------------------------------------- 45
I. Acute/Chronic Pain Management ------------------------------------------------------------------------------- 45
II. Heat and Cold Application ----------------------------------------------------------------------------------------- 45
III. End-of-Life Care ------------------------------------------------------------------------------------------------------ 45
IV. Critical Thinking Options for Unexpected Outcomes ------------------------------------------------------- 45
Chapter 4: Elimination --------------------------------------------------------------------------- 63
I. Assessment: Collecting Specimens ------------------------------------------------------------------------------ 63
II. Bladder Interventions ---------------------------------------------------------------------------------------------- 63
III. Bowel Interventions ------------------------------------------------------------------------------------------------ 63
IV. Dialysis ----------------------------------------------------------------------------------------------------------------- 63
V. Critical Thinking Options for Unexpected Outcomes ------------------------------------------------------- 63
Chapter 5: Fluids And Electrolytes ------------------------------------------------------------ 82
I. Fluid Balance Measurement -------------------------------------------------------------------------------------- 82
II. Intravenous Therapy ------------------------------------------------------------------------------------------------ 82
III. Critical Thinking Options for Unexpected Outcomes ------------------------------------------------------- 82
Chapter 6: Infection ---------------------------------------------------------------------------- 102
I. Medical Asepsis ---------------------------------------------------------------------------------------------------- 102
, II. Personal Protective Equipment (PPE) and Isolation Precautions ------------------------------------- 102
III. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 102
Chapter 7: Intracranial Regulation --------------------------------------------------------- 119
I. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 119
Chapter 8: Metabolism ------------------------------------------------------------------------ 134
I. General Metabolism ---------------------------------------------------------------------------------------------- 134
II. Diabetes Care ------------------------------------------------------------------------------------------------------- 134
III. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 134
Chapter 9: Mobility ----------------------------------------------------------------------------- 150
I. Balance and Strength --------------------------------------------------------------------------------------------- 150
II. Moving and Transferring a Patient ---------------------------------------------------------------------------- 150
III. Patient Assistive Devices ---------------------------------------------------------------------------------------- 150
IV. Traction and Cast Care ------------------------------------------------------------------------------------------- 150
V. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 150
Chapter 10: Nutrition -------------------------------------------------------------------------- 167
I. Healthy Eating Habits --------------------------------------------------------------------------------------------- 167
II. Enteral Nutrition Using a Feeding Tube ---------------------------------------------------------------------- 167
III. Parenteral Nutrition Using Intravenous Infusion ---------------------------------------------------------- 167
IV. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 167
Chapter 11: Oxygenation --------------------------------------------------------------------- 182
I. Assessment ---------------------------------------------------------------------------------------------------------- 182
II. Interventions-------------------------------------------------------------------------------------------------------- 182
III. Supplemental Oxygen Therapy -------------------------------------------------------------------------------- 182
IV. Maintaining a Patent Airway ----------------------------------------------------------------------------------- 182
V. Maintaining Lung Expansion ------------------------------------------------------------------------------------ 182
VI. Life-threatening Situations -------------------------------------------------------------------------------------- 182
VII. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 182
Chapter 12: Perfusion -------------------------------------------------------------------------- 199
I. Maintaining Blood Volume -------------------------------------------------------------------------------------- 199
II. Antiembolism Devices -------------------------------------------------------------------------------------------- 199
, III. Electrical Conduction in the Heart----------------------------------------------------------------------------- 199
IV. Arterial Line --------------------------------------------------------------------------------------------------------- 199
V. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 199
Chapter 13: Perioperative Care ------------------------------------------------------------- 214
I. General Perioperative Care ------------------------------------------------------------------------------------- 214
II. Using Sterile Technique ------------------------------------------------------------------------------------------ 214
III. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 214
Chapter 14: Reproduction -------------------------------------------------------------------- 229
I. Antepartum Care -------------------------------------------------------------------------------------------------- 229
II. Intrapartum Care -------------------------------------------------------------------------------------------------- 229
III. Postpartum Care --------------------------------------------------------------------------------------------------- 229
IV. Newborn Care ------------------------------------------------------------------------------------------------------ 229
V. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 229
Chapter 15: Safety ------------------------------------------------------------------------------ 248
I. Patient Safety ------------------------------------------------------------------------------------------------------- 248
II. Environmental Safety --------------------------------------------------------------------------------------------- 248
III. Immobilizers and Restraints ------------------------------------------------------------------------------------ 248
IV. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 248
Chapter 16: Tissue Integrity ------------------------------------------------------------------ 264
I. General Assessment ---------------------------------------------------------------------------------------------- 264
II. Dressings and Binders -------------------------------------------------------------------------------------------- 264
III. Wound Care --------------------------------------------------------------------------------------------------------- 264
IV. Critical Thinking Options for Unexpected Outcomes ----------------------------------------------------- 264
,Chapter 1: Assessment
Clinical Nursing Skills: A Concept-Based Approach 4th Edition, (2022) Test Bank
Chapter 1: Covers
I. General Assessment
II. Vital Signs
III. Physical Assessment
IV. Physical Assessment for the Newborn
V. Critical Thinking Options for Unexpected Outcomes
MULTIPLE CHOICE
1) A Client On The Medical/Surgical Unit Complains Of Sudden Chest Pains. Which
Action Will The Nurse Implement First?
A) Call The Healthcare Provider.
B) Administer Pain Medication.
C) Reassess A New Set Of Vital Signs.
D) Turn Client From Supine To Lateral.
ANSWER: C
Explanation:
A) The Nurse Will Need To Reassess The Client First, Before Calling The Healthcare
Provider.
B) The Nurse Will Need To Reassess The Client First, Before Administering Pain
Medication.
C) The Nurse Needs To Implement A New Set Of Vital Signs First When There Is A
Change In Condition.
D) The Nurse Will Need To Reassess The Client First, Before Moving The Client, To
Avoid Making The Change In Client's Condition Worse.
Page Ref: 2
Cognitive Level: Applying
,Client Need/Sub: Physiological Integrity: Reduction Of Risk Potential
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | Qsen Competencies:
Patient-Centered Care
AACN Domains And Comps.: Domain 2: Person-Centered Care Nln Competencies:
Relationship Centered Care
2) The Nurse Is Observing The UAP Taking The Temperature Of An Unconscious
Client. Which Route Will The Nurse Question The UAP Using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
ANSWER: A
Explanation:
A) The Temperature Of An Unconscious Client Is Never Taken By Mouth. The Rectal,
Tympanic, Or Scanner Method Is Preferred.
B) The Rectal, Tympanic, Or Scanner Method Is Preferred.
C) The Rectal, Tympanic, Or Scanner Method Is Preferred.
D) The Rectal, Tympanic, Or Scanner Method Is Preferred.
Page Ref: 24
Cognitive Level: Applying
Client Need/Sub: Safe And Effective Care Environment: Safety And Infection Control
Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | Qsen Competencies:
Safety AACN Domains And Comps.: Domain 5: Quality And Safety
Nln Competencies: Quality & Safety
3) The Nurse Is Changing A 2-Month-Old Client's Diaper And Notes The Client Feels
Warm To Touch. Which Method Should The Nurse Use To Check The Baby's
Temperature?
A) Oral
,B) Rectal
C) Axillary
D) Tympanic Membrane
ANSWER: C
Explanation:
A) Oral Is Used For Age 3 Or Older.
B) The Rectal Route Is The Least Desirable.
C) The Axillary Route May Not Be As Accurate As Other Routes For Detecting Fevers
In Children.
D) The Tympanic Membrane May Be Used For 3 Months Or Older.
Page Ref: 29
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction Of Risk Potential
Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | Qsen Competencies:
Safety AACN Domains And Comps.: Domain 5: Quality And Safety
Nln Competencies: Quality & Safety
4) A Client Comes In With Exacerbation Of Chronic Obstructive Pulmonary Disease
(COPD). Which Noninvasive Diagnostic Test Will The Nurse Implement To Know That
The Client Is Receiving Enough Oxygen?
A) Chest X-Ray
B) Pulse Oximeter
C) Arterial Blood Gasses
D) Assessment Of Respiratory Rate
ANSWER: B
Explanation:
A) A Chest X-Ray Is Not An Intervention A Nurse Completes.
, B) A Pulse Oximeter Provides A Noninvasive Method Of Measuring Oxygenation, Or
Oxygen Saturation, In The Blood And Provides A Pulse Reading, Which Is Especially
Helpful For The Client With A Respiratory Illness Or Disease.
C) Arterial Blood Gases Are An Invasive Diagnostic Test.
D) Assessing A Respiratory Rate Is Important For The Nurse To Implement; However, It
Is Not A Diagnostic Test.
Page Ref: 21
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction Of Risk Potential
Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | Qsen
Competencies: Informatics
AACN Domains And Comps.: Domain 5: Quality And Safety Nln Competencies: Quality
& Safety
5) The Nurse Is Preparing To Assess A Client's Musculoskeletal System. Which Question
Should The Nurse Ask Before Beginning This Assessment?
A) "Do You Exercise Every Day?"
B) "Do You Have A History Of Any Sports Injuries?"
C) "Do You Take A Hot Bath To Relax Your Muscles?"
D) "Do You Want Pain Medication Before I Begin?"
ANSWER: B
Explanation:
A) Knowing If A Client Exercises Is An Important Question But Knowing If There Are
Any Sports Injuries To Know About First, Is Most Important Before Doing A Routine
Musculoskeletal Assessment.
B) It Is Important To Note If The Client Has A History Of Any Sports Injuries First To
Know What The Client Will Or Will Not Be Able To Do During A Routine
Musculoskeletal Assessment.
C) Knowing If The Client Takes A Hot Bath To Relax The Muscles Is Not The Most
Important Thing To Ask Before Performing A Routine Musculoskeletal Assessment.
