ii ii ii ii ii
A Concept-Based Approach
ii ii ii
4th Edition Volume III
ii ii ii
by Pearson Education Chapters 1 - 16
ii ii ii ii ii ii
,Test iiBank iifor iiClinical iiNursing iiSkills: iiA iiConcept-Based iiApproach ii4th iiEdition
iiPearsoni
,Clinical iiNursing iiSkills: iiA iiConcept-Based iiApproach, ii4e ii(Pearson) iiEducation iiTest
iiBankiChapter ii1: iiAssessment
1) A iiclient iion iithe iimedical/surgical iiunit iicomplains iiof iisudden iichest iipains. iiWhich iiaction
iiwill iitheni urse iiimplement iifirst?
A) Call iithe iihealthcare iiprovider.
B) Administer iipain iimedication.
C) Reassess iia iinew iiset iiof iivital iisigns.
D) Turn iiclient iifrom iisupine iito
iilateral. iANSWER: i i C
Explanation: iiA) iiThe iinurse iiwill iineed iito iireassess iithe iiclient iifirst, iibefore iicalling iithe
iihealthcareiprovider.
B) The iinurse iiwill iineed iito iireassess iithe iiclient iifirst, iibefore iiadministering iipain iimedication.
C) The iinurse iineeds iito iiimplement iia iinew iiset iiof iivital iisigns iifirst iiwhen iithere iiis iia
iichange iiinicondition.
D) The iinurse iiwill iineed iito iireassess iithe iiclient iifirst, iibefore iimoving iithe iiclient, iito iiavoid
iimaking iitheichange iiin iiclient's iicondition iiworse.
Page iiRef: ii2
Cognitive iiLevel: i i Applying
Client iiNeed/Sub: i i Physiological iiIntegrity: iiReduction iiof iiRisk iiPotential
Standards: iiNursing iiProcess: iiAssessment ii| iiLearning iiOutcome: ii1.1 ii| iiQSEN
iiCompetencies:iPatient-Centered iiCare
AACN iiDomains iiand iiComps.: iiDomain ii2: iiPerson-Centered
iiCareiNLN iiCompetencies: i i Relationship iiCentered iiCare
2) The iinurse iiis iiobserving iithe iiUAP iitaking iithe iitemperature iiof iian iiunconscious iiclient.
iiWhich iiroutew i ill iithe iinurse iiquestion iithe iiUAP iiusing?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
iANSWER:
iiA
Explanation: iiA) iiThe iitemperature iiof iian iiunconscious iiclient iiis iinever iitaken iiby iimouth. iiThe
iirectal,itympanic, iior iiscanner iimethod iiis iipreferred.
B) The iirectal, iitympanic, iior iiscanner iimethod iiis iipreferred.
C) The iirectal, iitympanic, iior iiscanner iimethod iiis iipreferred.
D) The iirectal, iitympanic, iior iiscanner iimethod iiis
iipreferred.iPage iiRef: ii24
Cognitive iiLevel: i i Applying
Client iiNeed/Sub: ii ii i i Safe iiand iiEffective iiCare iiEnvironment: iiSafety iiand iiInfection iiControl
iiStandards: i i Nursing iiProcess: iiEvaluation ii| iiLearning iiOutcome: ii1.1 ii| iiQSEN iiCompetencies:
iiSafetyiAACN iiDomains iiand iiComps.: i i Domain ii5: iiQuality iiand iiSafety
NLN iiCompetencies: i i Quality ii& iiSafety
1
, 3) The iinurse iiis iichanging iia ii2-month-old iiclient's iidiaper iiand iinotes iithe iiclient iifeels iiwarm iito
iitouch.iWhich iimethod iishould iithe iinurse iiuse iito iicheck iithe iibaby's iitemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
iimembraneiANSWER:
iiC
Explanation: i i A) iiOral iiis iiused iifor iiage ii3 iior iiolder.
B) The iirectal iiroute iiis iithe iileast iidesirable.
C) The iiaxillary iiroute iimay iinot iibe iias iiaccurate iias iiother iiroutes iifor iidetecting iifevers iiin iichildren.
D) The iitympanic iimembrane iimay iibe iiused iifor ii3 iimonths iior
iiolder.iPage iiRef: ii29
Cognitive iiLevel: i i Applying
Client iiNeed/Sub: i i Physiological iiIntegrity: iiReduction iiof iiRisk iiPotential
Standards: i i Nursing iiProcess: iiEvaluating ii| iiLearning iiOutcome: ii1.2 ii| iiQSEN iiCompetencies:
iiSafetyiAACN iiDomains iiand iiComps.: i i Domain ii5: iiQuality iiand iiSafety
NLN iiCompetencies: i i Quality ii& iiSafety
4) A iiclient iicomes iiin iiwith iiexacerbation iiof iichronic iiobstructive iipulmonary iidisease ii(COPD).
iiWhichinoninvasive iidiagnostic iitest iiwill iithe iinurse iiimplement iito iiknow iithat iithe iiclient iiis
iireceiving iienough iioxygen?
A) Chest iix-ray
B) Pulse iioximeter
C) Arterial iiblood iigasses
D) Assessment iiof iirespiratory
iirateiANSWER: i i B
Explanation: i i A) iiA iichest iix-ray iiis iinot iian iiintervention iia iinurse iicompletes.
B) A iipulse iioximeter iiprovides iia iinoninvasive iimethod iiof iimeasuring iioxygenation, iior
iioxygen iisaturation, iiin iithe iiblood iiand iiprovides iia iipulse iireading, iiwhich iiis ii especially
iihelpful iifor iithe iiclientiwith iia iirespiratory iiillness iior iidisease.
C) Arterial iiblood iigases iiare iian iiinvasive iidiagnostic iitest.
D) Assessing iia iirespiratory iirate iiis iiimportant iifor iithe iinurse iito iiimplement; iihowever, iiit
iiis iinot iiaidiagnostic iitest.
Page iiRef: ii21
Cognitive iiLevel: i i Applying
Client iiNeed/Sub: i i Physiological iiIntegrity: iiReduction iiof iiRisk iiPotential
Standards: iiNursing iiProcess: iiImplementation ii| iiLearning iiOutcome: ii1.3 ii| iiQSEN
iiCompetencies:iInformatics
AACN iiDomains iiand iiComps.: i i Domain ii5: iiQuality iiand iiSafety
iNLN iiCompetencies: i i Quality ii& iiSafety
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