TESTBANK
Clinical Nursing Skills:
i i
A Concept-Based Approach
i i i
4th Edition Volume III
i i i
by Pearson Education Chapters 1 - 16
i i i i i i
,TestiBankiforiClinicaliNursingiSkills:iAiConcept-BasediApproachi4thiEditioniPearsoni
,ClinicaliNursingiSkills:iAiConcept-
BasediApproach,i4ei(Pearson)iEducationiTestiBankiChapteri1:iAssessment
1) Aiclientionitheimedical/surgicaliuniticomplainsiofisuddenichestipains.iWhichiactioniwillitheinu
rseiimplementifirst?
A) Callitheihealthcareiprovider.
B) Administeripainimedication.
C) Reassessiainewisetiofivitalisigns.
D) Turniclientifromisupineitoilateral.i
ANSWER:i C
Explanation:iA)iTheinurseiwillineeditoireassessitheiclientifirst,ibeforeicallingitheihealthcareipro
vider.
B) Theinurseiwillineeditoireassessitheiclientifirst,ibeforeiadministeringipainimedication.
C) Theinurseineedsitoiimplementiainewisetiofivitalisignsifirstiwhenithereiisiaichangeiinicon
dition.
D) Theinurseiwillineeditoireassessitheiclientifirst,ibeforeimovingitheiclient,itoiavoidimakingitheicha
ngeiiniclient'siconditioniworse.
PageiRef:i2
CognitiveiLevel:i Applying
ClientiNeed/Sub:i PhysiologicaliIntegrity:iReductioniofiRiskiPotential
Standards:iNursingiProcess:iAssessmenti|iLearningiOutcome:i1.1i|iQSENiCompetencies:iPat
ient-CenterediCare
AACNiDomainsiandiComps.:iDomaini2:iPerson-
CenterediCareiNLNiCompetencies:i RelationshipiCenterediCare
2) TheinurseiisiobservingitheiUAPitakingitheitemperatureiofianiunconsciousiclient.iWhichirouteiwi
llitheinurseiquestionitheiUAPiusing?
A) Oral
B) Rectal
C) Scanner
D) Tympanici
ANSWER:i
A
Explanation:iA)iTheitemperatureiofianiunconsciousiclientiisineveritakenibyimouth.iTheirectal,itym
panic,ioriscannerimethodiisipreferred.
B) Theirectal,itympanic,ioriscannerimethodiisipreferred.
C) Theirectal,itympanic,ioriscannerimethodiisipreferred.
D) Theirectal,itympanic,ioriscannerimethodiisipreferred.iP
ageiRef:i24
CognitiveiLevel:i Applying
ClientiNeed/Sub:iii SafeiandiEffectiveiCareiEnvironment:iSafetyiandiInfectioniControliStandards:i
NursingiProcess:iEvaluationi|iLearningiOutcome:i1.1i|iQSENiCompetencies:iSafetyiAACNiDomai
nsiandiComps.:i Domaini5:iQualityiandiSafety
NLNiCompetencies:i Qualityi&iSafety
1
, 3) Theinurseiisichangingiai2-month-
oldiclient'sidiaperiandinotesitheiclientifeelsiwarmitoitouch.iWhichimethodishoulditheinurseiuseitoic
heckitheibaby'sitemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanicimembranei
ANSWER:i C
Explanation:i A)iOraliisiusediforiagei3ioriolder.
B) Theirectalirouteiisitheileastidesirable.
C) Theiaxillaryirouteimayinotibeiasiaccurateiasiotheriroutesiforidetectingifeversiinichildren.
D) Theitympanicimembraneimayibeiusedifori3imonthsioriolder.iP
ageiRef:i29
CognitiveiLevel:i Applying
ClientiNeed/Sub:i PhysiologicaliIntegrity:iReductioniofiRiskiPotential
Standards:i NursingiProcess:iEvaluatingi|iLearningiOutcome:i1.2i|iQSENiCompetencies:iSafetyiA
ACNiDomainsiandiComps.:i Domaini5:iQualityiandiSafety
NLNiCompetencies:i Qualityi&iSafety
4) Aiclienticomesiiniwithiexacerbationiofichroniciobstructiveipulmonaryidiseasei(COPD).iWhichino
ninvasiveidiagnosticitestiwillitheinurseiimplementitoiknowithatitheiclientiisireceivingienoughioxyge
n?
A) Chestix-ray
B) Pulseioximeter
C) Arterialibloodigasses
D) Assessmentiofirespiratoryiratei
ANSWER:i B
Explanation:i A)iAichestix-rayiisinotianiinterventioniainurseicompletes.
B) Aipulseioximeteriprovidesiainoninvasiveimethodiofimeasuringioxygenation,iorioxygenisatur
ation,iinitheibloodiandiprovidesiaipulseireading,iwhichiisiespeciallyihelpfuliforitheiclientiwithiaire
spiratoryiillnessioridisease.
C) Arterialibloodigasesiareianiinvasiveidiagnosticitest.
D) Assessingiairespiratoryirateiisiimportantiforitheinurseitoiimplement;ihowever,iitiisinotiaidia
gnosticitest.
PageiRef:i21
CognitiveiLevel:i Applying
ClientiNeed/Sub:i PhysiologicaliIntegrity:iReductioniofiRiskiPotential
Standards:iNursingiProcess:iImplementationi|iLearningiOutcome:i1.3i|iQSENiCompetencies:iInfor
matics
AACNiDomainsiandiComps.:i Domaini5:iQualityiandiSafetyiNLNi
Competencies:i Qualityi&iSafety
2
Clinical Nursing Skills:
i i
A Concept-Based Approach
i i i
4th Edition Volume III
i i i
by Pearson Education Chapters 1 - 16
i i i i i i
,TestiBankiforiClinicaliNursingiSkills:iAiConcept-BasediApproachi4thiEditioniPearsoni
,ClinicaliNursingiSkills:iAiConcept-
BasediApproach,i4ei(Pearson)iEducationiTestiBankiChapteri1:iAssessment
1) Aiclientionitheimedical/surgicaliuniticomplainsiofisuddenichestipains.iWhichiactioniwillitheinu
rseiimplementifirst?
A) Callitheihealthcareiprovider.
B) Administeripainimedication.
C) Reassessiainewisetiofivitalisigns.
D) Turniclientifromisupineitoilateral.i
ANSWER:i C
Explanation:iA)iTheinurseiwillineeditoireassessitheiclientifirst,ibeforeicallingitheihealthcareipro
vider.
B) Theinurseiwillineeditoireassessitheiclientifirst,ibeforeiadministeringipainimedication.
C) Theinurseineedsitoiimplementiainewisetiofivitalisignsifirstiwhenithereiisiaichangeiinicon
dition.
D) Theinurseiwillineeditoireassessitheiclientifirst,ibeforeimovingitheiclient,itoiavoidimakingitheicha
ngeiiniclient'siconditioniworse.
PageiRef:i2
CognitiveiLevel:i Applying
ClientiNeed/Sub:i PhysiologicaliIntegrity:iReductioniofiRiskiPotential
Standards:iNursingiProcess:iAssessmenti|iLearningiOutcome:i1.1i|iQSENiCompetencies:iPat
ient-CenterediCare
AACNiDomainsiandiComps.:iDomaini2:iPerson-
CenterediCareiNLNiCompetencies:i RelationshipiCenterediCare
2) TheinurseiisiobservingitheiUAPitakingitheitemperatureiofianiunconsciousiclient.iWhichirouteiwi
llitheinurseiquestionitheiUAPiusing?
A) Oral
B) Rectal
C) Scanner
D) Tympanici
ANSWER:i
A
Explanation:iA)iTheitemperatureiofianiunconsciousiclientiisineveritakenibyimouth.iTheirectal,itym
panic,ioriscannerimethodiisipreferred.
B) Theirectal,itympanic,ioriscannerimethodiisipreferred.
C) Theirectal,itympanic,ioriscannerimethodiisipreferred.
D) Theirectal,itympanic,ioriscannerimethodiisipreferred.iP
ageiRef:i24
CognitiveiLevel:i Applying
ClientiNeed/Sub:iii SafeiandiEffectiveiCareiEnvironment:iSafetyiandiInfectioniControliStandards:i
NursingiProcess:iEvaluationi|iLearningiOutcome:i1.1i|iQSENiCompetencies:iSafetyiAACNiDomai
nsiandiComps.:i Domaini5:iQualityiandiSafety
NLNiCompetencies:i Qualityi&iSafety
1
, 3) Theinurseiisichangingiai2-month-
oldiclient'sidiaperiandinotesitheiclientifeelsiwarmitoitouch.iWhichimethodishoulditheinurseiuseitoic
heckitheibaby'sitemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanicimembranei
ANSWER:i C
Explanation:i A)iOraliisiusediforiagei3ioriolder.
B) Theirectalirouteiisitheileastidesirable.
C) Theiaxillaryirouteimayinotibeiasiaccurateiasiotheriroutesiforidetectingifeversiinichildren.
D) Theitympanicimembraneimayibeiusedifori3imonthsioriolder.iP
ageiRef:i29
CognitiveiLevel:i Applying
ClientiNeed/Sub:i PhysiologicaliIntegrity:iReductioniofiRiskiPotential
Standards:i NursingiProcess:iEvaluatingi|iLearningiOutcome:i1.2i|iQSENiCompetencies:iSafetyiA
ACNiDomainsiandiComps.:i Domaini5:iQualityiandiSafety
NLNiCompetencies:i Qualityi&iSafety
4) Aiclienticomesiiniwithiexacerbationiofichroniciobstructiveipulmonaryidiseasei(COPD).iWhichino
ninvasiveidiagnosticitestiwillitheinurseiimplementitoiknowithatitheiclientiisireceivingienoughioxyge
n?
A) Chestix-ray
B) Pulseioximeter
C) Arterialibloodigasses
D) Assessmentiofirespiratoryiratei
ANSWER:i B
Explanation:i A)iAichestix-rayiisinotianiinterventioniainurseicompletes.
B) Aipulseioximeteriprovidesiainoninvasiveimethodiofimeasuringioxygenation,iorioxygenisatur
ation,iinitheibloodiandiprovidesiaipulseireading,iwhichiisiespeciallyihelpfuliforitheiclientiwithiaire
spiratoryiillnessioridisease.
C) Arterialibloodigasesiareianiinvasiveidiagnosticitest.
D) Assessingiairespiratoryirateiisiimportantiforitheinurseitoiimplement;ihowever,iitiisinotiaidia
gnosticitest.
PageiRef:i21
CognitiveiLevel:i Applying
ClientiNeed/Sub:i PhysiologicaliIntegrity:iReductioniofiRiskiPotential
Standards:iNursingiProcess:iImplementationi|iLearningiOutcome:i1.3i|iQSENiCompetencies:iInfor
matics
AACNiDomainsiandiComps.:i Domaini5:iQualityiandiSafetyiNLNi
Competencies:i Qualityi&iSafety
2
