A Concept-Based Approach
4th Edition Volume III
by Pearson Education Chapters 1 - 16
,Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Pearson
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,Clinical Nursing Skills: A Concept- FS FS FS FS
Based Approach, 4e (Pearson) Education Test BankChapter 1: Assessment
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1) A client on the medical/surgical unit complains of sudden chest pains. Which action will then
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urse implement first?
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A) Call the healthcare provider. FS FS FS
B) Administer pain medication. FS FS
C) Reassess a new set of vital signs. FS FS FS FS FS FS
D) Turn client from supine to lateral. FS FS FS FS FS FS
ANSWER: C FS
Explanation: A) The nurse will need to reassess the client first, before calling the healthcarepr
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ovider.
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 inc
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ondition.
D) The nurse will need to reassess the client first, before moving the client, to avoid making thec
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hange in client's condition worse.
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Cognitive Level: Applying FS F S
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN Competencies:Pa
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tient-Centered Care FS
AACN Domains and Comps.: Domain 2: Person-
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Centered CareNLN Competencies: Relationship Centered Care
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2) The nurse is observing the UAP taking the temperature of an unconscious client. Which route
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will the nurse question the UAP using?
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A) Oral
B) Rectal
C) Scanner
D) Tympanic FS
ANSWER: A FS
Explanation: A) The temperature of an unconscious client is never taken by mouth. The rectal,ty
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mpanic, or scanner method is preferred. FS FS FS FS FS
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 preferred.
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Cognitive Level: Applying FS F S
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards:
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Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: SafetyAACN Domain
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s 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- FS FS FS FS FS
old client's diaper and notes the client feels warm to touch.Which method should the nurse use
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to check the baby's temperature?
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A) Oral
B) Rectal
C) Axillary
D) Tympanic membran FS
eANSWER: C
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Explanation: A) Oral is used for age 3 or older. F S FS FS FS FS FS FS FS FS
B) The rectal route is the least desirable. FS FS FS FS FS FS
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 older.
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Cognitive Level: Applying FS F S
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies: SafetyAA
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CN 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 pulmonary disease (COPD). Whichno
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ninvasive diagnostic test will the nurse implement to know that the client is receiving enough oxyg
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en?
A) Chest x-ray FS
B) Pulse oximeter FS
C) Arterial blood gasses FS FS
D) Assessment of respiratory rate FS FS FS FS
ANSWER: B F S
Explanation: A) A chest x-ray is not an intervention a nurse completes. F S FS FS FS FS FS FS FS FS FS FS
B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen satu
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ration, in the blood and provides a pulse reading, which is especially helpful for the clientwith a
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respiratory illness or disease.
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C) Arterial blood gases are an invasive diagnostic test. FS FS FS FS FS FS FS
D) Assessing a respiratory rate is important for the nurse to implement; however, it is not a
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diagnostic test. FS
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Cognitive Level: Applying FS F S
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Competencies:Inf
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ormatics
AACN Domains and Comps.: Domain 5: Quality and SafetyNLN Co
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mpetencies: Quality & Safety F S FS FS
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