,Test Bank for Clinical Nursing Skills: A Concept-
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Based Approach 4th Edition Pearsonii
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,Clinical Nursing Skills: A Concept- d t d t dt d t
Based Approach, 4e (Pearson) Education Test BankiiChapter 1: Assessment
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1) A client on the medical/surgical unit complains of sudden chest pains. Which act
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ion will theiinurse implement first?
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A) Call the healthcare provider. d t d t d t
B) Administer pain medication. d t d t
C) Reassess a new set of vital signs. d t d t d t d t d t d t
D) Turn client from supine to l dt dt dt dt dt
ateral.iiANSWER: C d t
Explanation: A) The nurse will need to reassess the client first, before calling the he
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althcareprovider.
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 i
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s a change iniicondition.
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D) The nurse will need to reassess the client first, before moving the client, to av
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oid making theiichange in client's condition worse.
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Page Ref: 2 d t d t
Cognitive Level: Applying d t
Client Need/Sub: d t
Physiological Integrity: Reduction of Risk Potential S d t d t d t dt d t dt
tandards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSE
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N Competencies:Patient-Centered Care
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AACN Domains and Comps.: Domain 2: Person-
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Centered CareiiNLN Competencies: Relationship Centered Car
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e
2) The nurse is observing the UAP taking the temperature of an unconscious cli
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ent. Which routeiiwill the nurse question the UAP using?
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A) Oral
B) Rectal
C) Scanner
D) Tympanic
iiANSWER:
A
Explanation: A) The temperature of an unconscious client is never taken by mouth.
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The rectal,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) The rectal, tympanic, or scanner method is
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preferred.Page Ref: 24 d t d t
Cognitive Level: Applying d t
Client Need/Sub: d t
Safe and Effective Care Environment: Safety and Infection Control d t d t d t dt d t dt d t d t dt
Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies
d t dt d t d t d t d t d t d t dt d t
: SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
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NLN Competencies: d t Quality & Safety d t d t
1
, 3) The nurse is changing a 2-month- d t d t d t d t d t
old client's diaper and notes the client feels warm to touch.Which method should the
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nurse use to check the baby's temperature?
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A) Oral
B) Rectal
C) Axillary
D) Tympanic membra dt
neiiANSWER:
C
Explanation: A) Oral is used for age 3 or older. d t d t d t d t d t d t d t d t
B) The rectal route is the least desirable. d t d t d t d t d t d t
C) The axillary route may not be as accurate as other routes for detecting fevers in children.
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D) The tympanic membrane may be used for 3 months or
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older.Page Ref: 29
dt d t d t
Cognitive Level: Applying d t
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencie
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s: SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
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NLN Competencies: Quality & Safety
d t d t d t
4) A client comes in with exacerbation of chronic obstructive pulmonary disease (COP
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D). Whichiinoninvasive diagnostic test will the nurse implement to know that the clien
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t is receiving enough oxygen?
d t dt d t d t
A) Chest x-ray d t
B) Pulse oximeter d t
C) Arterial blood gasses d t d t
D) Assessment of respiratory dt dt dt
rateiiANSWER: B d t
Explanation: A) A chest x-ray is not an intervention a nurse completes.
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B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxyg
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en saturation, in the blood and provides a pulse reading, which is especially helpful for
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the clientiiwith a respiratory illness or disease.
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C) Arterial blood gases are an invasive diagnostic test. d t d t d t d t d t d t d t
D) Assessing a respiratory rate is important for the nurse to implement; however,
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it is not aiidiagnostic test.
d t dt d t d t d t
Page Ref: 21 d t d t
Cognitive Level: Applying d t
Client Need/Sub: d t
Physiological Integrity: Reduction of Risk Potential Stand d t d t d t dt d t dt
ards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Co
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mpetencies:Informatics
AACN Domains and Comps.: Domain 5: Quality and Safety
d t d t d t d t d t d t dt d t
NLN Competencies: Quality & Safety
dt d t d t dt d t
2
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Based Approach 4th Edition Pearsonii
d t d t d t dt
,Clinical Nursing Skills: A Concept- d t d t dt d t
Based Approach, 4e (Pearson) Education Test BankiiChapter 1: Assessment
d t d t d t dt d t dt d t d t
1) A client on the medical/surgical unit complains of sudden chest pains. Which act
d t d t d t d t d t d t d t d t d t d t d t d t
ion will theiinurse implement first?
dt d t d t d t
A) Call the healthcare provider. d t d t d t
B) Administer pain medication. d t d t
C) Reassess a new set of vital signs. d t d t d t d t d t d t
D) Turn client from supine to l dt dt dt dt dt
ateral.iiANSWER: C d t
Explanation: A) The nurse will need to reassess the client first, before calling the he
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althcareprovider.
B) The nurse will need to reassess the client first, before administering pain medication.
d t d t d t d t d t d t d t d t d t d t d t d t
C) The nurse needs to implement a new set of vital signs first when there i
d t d t d t d t d t d t d t d t d t d t d t d t d t d t
s a change iniicondition.
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D) The nurse will need to reassess the client first, before moving the client, to av
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oid making theiichange in client's condition worse.
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Page Ref: 2 d t d t
Cognitive Level: Applying d t
Client Need/Sub: d t
Physiological Integrity: Reduction of Risk Potential S d t d t d t dt d t dt
tandards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSE
d t d t d t d t d t d t d t d t d t
N Competencies:Patient-Centered Care
dt d t
AACN Domains and Comps.: Domain 2: Person-
d t d t d t d t d t d t
Centered CareiiNLN Competencies: Relationship Centered Car
dt d t d t d t d t
e
2) The nurse is observing the UAP taking the temperature of an unconscious cli
d t d t d t d t d t d t d t d t d t d t d t d t
ent. Which routeiiwill the nurse question the UAP using?
dt d t d t d t d t d t d t d t
A) Oral
B) Rectal
C) Scanner
D) Tympanic
iiANSWER:
A
Explanation: A) The temperature of an unconscious client is never taken by mouth.
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The rectal,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) The rectal, tympanic, or scanner method is
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preferred.Page Ref: 24 d t d t
Cognitive Level: Applying d t
Client Need/Sub: d t
Safe and Effective Care Environment: Safety and Infection Control d t d t d t dt d t dt d t d t dt
Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies
d t dt d t d t d t d t d t d t dt d t
: SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
dt d t d t d t d t d t d t d t d t
NLN Competencies: d t Quality & Safety d t d t
1
, 3) The nurse is changing a 2-month- d t d t d t d t d t
old client's diaper and notes the client feels warm to touch.Which method should the
d t d t d t d t d t d t d t d t d t dt d t d t d t d
nurse use to check the baby's temperature?
t d t d t d t d t d t d t
A) Oral
B) Rectal
C) Axillary
D) Tympanic membra dt
neiiANSWER:
C
Explanation: A) Oral is used for age 3 or older. d t d t d t d t d t d t d t d t
B) The rectal route is the least desirable. d t d t d t d t d t d t
C) The axillary route may not be as accurate as other routes for detecting fevers in children.
d t dt d t d t d t d t d t d t d t d t d t d t d t d t d t
D) The tympanic membrane may be used for 3 months or
dt d t d t dt d t d t dt d t d t
older.Page Ref: 29
dt d t d t
Cognitive Level: Applying d t
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
d t d t d t d t d t d t
Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencie
d t d t d t d t d t d t d t d t d t d t
s: SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
dt d t d t d t d t d t d t d t d t
NLN Competencies: Quality & Safety
d t d t d t
4) A client comes in with exacerbation of chronic obstructive pulmonary disease (COP
d t d t d t d t d t d t d t d t d t dt d t
D). Whichiinoninvasive diagnostic test will the nurse implement to know that the clien
dt d t d t d t d t d t d t d t d t d t d t d t
t is receiving enough oxygen?
d t dt d t d t
A) Chest x-ray d t
B) Pulse oximeter d t
C) Arterial blood gasses d t d t
D) Assessment of respiratory dt dt dt
rateiiANSWER: B d t
Explanation: A) A chest x-ray is not an intervention a nurse completes.
d t d t d t d t d t d t d t d t d t d t d t d t d t
B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxyg
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en saturation, in the blood and provides a pulse reading, which is especially helpful for
dt dt dt dt dt dt dt dt dt dt dt dt dt d t d
the clientiiwith a respiratory illness or disease.
t d t d t d t dt d t d t
C) Arterial blood gases are an invasive diagnostic test. d t d t d t d t d t d t d t
D) Assessing a respiratory rate is important for the nurse to implement; however,
d t d t d t d t d t d t d t d t d t d t d t
it is not aiidiagnostic test.
d t dt d t d t d t
Page Ref: 21 d t d t
Cognitive Level: Applying d t
Client Need/Sub: d t
Physiological Integrity: Reduction of Risk Potential Stand d t d t d t dt d t dt
ards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Co
d t d t d t d t d t d t d t d t d t dt
mpetencies:Informatics
AACN Domains and Comps.: Domain 5: Quality and Safety
d t d t d t d t d t d t dt d t
NLN Competencies: Quality & Safety
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2