TEST BANK
nj nj
for Clinical Nursing Skills:
nj nj nj
nj A Concept-Based Approach
nj nj
4th Edition Volume III
nj nj nj
by Pearson Education Chapters 1 - 16
nj nj nj nj nj nj
,TestnjBanknjfornjClinicalnjNursingnjSkills:njAnjConcept-
BasednjApproachnj4thnjEditionnjPearsonnj
,ClinicalnjNursingnjSkills:njAnjConcept-
BasednjApproach,nj4enj(Pearson)njEducationnjTestnjBankC
j hapternj1:njAssessment
n
1) Anjclientnjonnjthenjmedical/surgicalnjunitnjcomplainsnjofnjsuddennjchestnjpains.njWhichnjactionnjwillnj
thenjnursenjimplementnjfirst?
A) Callnjthenjhealthcarenjprovider.
B) Administernjpainnjmedication.
C) Reassessnjanjnewnjsetnjofnjvitalnjsigns.
D) Turnnjclientnjfromnjsupinenjtonjlateral
.njANSWER:n j C
Explanation:njA)njThenjnursenjwillnjneednjtonjreassessnjthenjclientnjfirst,njbeforenjcallingnjthenjhealthca
renjprovider.
B) Thenjnursenjwillnjneednjtonjreassessnjthenjclientnjfirst,njbeforenjadministeringnjpainnjmedication.
C) Thenjnursenjneedsnjtonjimplementnjanjnewnjsetnjofnjvitalnjsignsnjfirstnjwhennjtherenjisnjanjchang
enjinnjcondition.
D) Thenjnursenjwillnjneednjtonjreassessnjthenjclientnjfirst,njbeforenjmovingnjthenjclient,njtonjavoidnjmakingnj
thenjchangenjinnjclient'snjconditionnjworse.
PagenjRef:nj2
CognitivenjLevel:n j Applying
ClientnjNeed/Sub:n j PhysiologicalnjIntegrity:njReductionnjofnjRisknjPotential
Standards:njNursingnjProcess:njAssessmentnj|njLearningnjOutcome:nj1.1nj|njQSENnjCompetencies
:njPatient-CenterednjCare
AACNnjDomainsnjandnjComps.:njDomainnj2:njPerson-
CenterednjCarenjNLNnjCompetencies:n j RelationshipnjCenterednjCare
2) ThenjnursenjisnjobservingnjthenjUAPnjtakingnjthenjtemperaturenjofnjannjunconsciousnjclient.njWhichnjro
utenjwillnjthenjnursenjquestionnjthenjUAPnjusing?
A) Oral
B) Rectal
C) Scanner
D) Tympanicnj
ANSWER:nj
A
Explanation:njA)njThenjtemperaturenjofnjannjunconsciousnjclientnjisnjnevernjtakennjbynjmouth.njThenjrecta
l,njtympanic,njornjscannernjmethodnjisnjpreferred.
B) Thenjrectal,njtympanic,njornjscannernjmethodnjisnjpreferred.
C) Thenjrectal,njtympanic,njornjscannernjmethodnjisnjpreferred.
D) Thenjrectal,njtympanic,njornjscannernjmethodnjisnjpreferre
d.njPagenjRef:nj24
CognitivenjLevel:n j Applying
ClientnjNeed/Sub:njnjn j SafenjandnjEffectivenjCarenjEnvironment:njSafetynjandnjInfectionnjControlnjStanda
rds:nj NursingnjProcess:njEvaluationnj|njLearningnjOutcome:nj1.1nj|njQSENnjCompetencies:njSafetynjAAC
NnjDomainsnjandnjComps.:n j Domainnj5:njQualitynjandnjSafety
NLNnjCompetencies:n j Qualitynj&njSafety
1
, 3) Thenjnursenjisnjchangingnjanj2-month-
oldnjclient'snjdiapernjandnjnotesnjthenjclientnjfeelsnjwarmnjtonjtouch.njWhichnjmethodnjshouldnjthenjnursenju
senjtonjchecknjthenjbaby'snjtemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanicnjmembran
enjANSWER:n j C
Explanation:n j A)njOralnjisnjusednjfornjagenj3njornjolder.
B) Thenjrectalnjroutenjisnjthenjleastnjdesirable.
C) Thenjaxillarynjroutenjmaynjnotnjbenjasnjaccuratenjasnjothernjroutesnjfornjdetectingnjfeversnjinnjchildren.
D) Thenjtympanicnjmembranenjmaynjbenjusednjfornj3njmonthsnjornjold
er.njPagenjRef:nj29
CognitivenjLevel:n j Applying
ClientnjNeed/Sub:n j PhysiologicalnjIntegrity:njReductionnjofnjRisknjPotential
Standards:n j NursingnjProcess:njEvaluatingnj|njLearningnjOutcome:nj1.2nj|njQSENnjCompetencies:njSafet
ynjAACNnjDomainsnjandnjComps.:n j Domainnj5:njQualitynjandnjSafety
NLNnjCompetencies:n j Qualitynj&njSafety
4) Anjclientnjcomesnjinnjwithnjexacerbationnjofnjchronicnjobstructivenjpulmonarynjdiseasenj(COPD).njWhi
chnjnoninvasivenjdiagnosticnjtestnjwillnjthenjnursenjimplementnjtonjknownjthatnjthenjclientnjisnjreceivingnjeno
ughnjoxygen?
A) Chestnjx-ray
B) Pulsenjoximeter
C) Arterialnjbloodnjgasses
D) Assessmentnjofnjrespiratorynjrat
enjANSWER:n j B
Explanation:n j A)njAnjchestnjx-raynjisnjnotnjannjinterventionnjanjnursenjcompletes.
B) Anjpulsenjoximeternjprovidesnjanjnoninvasivenjmethodnjofnjmeasuringnjoxygenation,njornjoxygennj
saturation,njinnjthenjbloodnjandnjprovidesnjanjpulsenjreading,njwhichnjisnjespeciallynjhelpfulnjfornjthenjcli
entnjwithnjanjrespiratorynjillnessnjornjdisease.
C) Arterialnjbloodnjgasesnjarenjannjinvasivenjdiagnosticnjtest.
D) Assessingnjanjrespiratorynjratenjisnjimportantnjfornjthenjnursenjtonjimplement;njhowever,njitnjisnjno
tnjanjdiagnosticnjtest.
PagenjRef:nj21
CognitivenjLevel:n j Applying
ClientnjNeed/Sub:n j PhysiologicalnjIntegrity:njReductionnjofnjRisknjPotential
Standards:njNursingnjProcess:njImplementationnj|njLearningnjOutcome:nj1.3nj|njQSENnjCompetencies:njI
nformatics
AACNnjDomainsnjandnjComps.:n j Domainnj5:njQualitynjandnjSafetynjNL
NnjCompetencies:n j Qualitynj&njSafety
2
nj nj
for Clinical Nursing Skills:
nj nj nj
nj A Concept-Based Approach
nj nj
4th Edition Volume III
nj nj nj
by Pearson Education Chapters 1 - 16
nj nj nj nj nj nj
,TestnjBanknjfornjClinicalnjNursingnjSkills:njAnjConcept-
BasednjApproachnj4thnjEditionnjPearsonnj
,ClinicalnjNursingnjSkills:njAnjConcept-
BasednjApproach,nj4enj(Pearson)njEducationnjTestnjBankC
j hapternj1:njAssessment
n
1) Anjclientnjonnjthenjmedical/surgicalnjunitnjcomplainsnjofnjsuddennjchestnjpains.njWhichnjactionnjwillnj
thenjnursenjimplementnjfirst?
A) Callnjthenjhealthcarenjprovider.
B) Administernjpainnjmedication.
C) Reassessnjanjnewnjsetnjofnjvitalnjsigns.
D) Turnnjclientnjfromnjsupinenjtonjlateral
.njANSWER:n j C
Explanation:njA)njThenjnursenjwillnjneednjtonjreassessnjthenjclientnjfirst,njbeforenjcallingnjthenjhealthca
renjprovider.
B) Thenjnursenjwillnjneednjtonjreassessnjthenjclientnjfirst,njbeforenjadministeringnjpainnjmedication.
C) Thenjnursenjneedsnjtonjimplementnjanjnewnjsetnjofnjvitalnjsignsnjfirstnjwhennjtherenjisnjanjchang
enjinnjcondition.
D) Thenjnursenjwillnjneednjtonjreassessnjthenjclientnjfirst,njbeforenjmovingnjthenjclient,njtonjavoidnjmakingnj
thenjchangenjinnjclient'snjconditionnjworse.
PagenjRef:nj2
CognitivenjLevel:n j Applying
ClientnjNeed/Sub:n j PhysiologicalnjIntegrity:njReductionnjofnjRisknjPotential
Standards:njNursingnjProcess:njAssessmentnj|njLearningnjOutcome:nj1.1nj|njQSENnjCompetencies
:njPatient-CenterednjCare
AACNnjDomainsnjandnjComps.:njDomainnj2:njPerson-
CenterednjCarenjNLNnjCompetencies:n j RelationshipnjCenterednjCare
2) ThenjnursenjisnjobservingnjthenjUAPnjtakingnjthenjtemperaturenjofnjannjunconsciousnjclient.njWhichnjro
utenjwillnjthenjnursenjquestionnjthenjUAPnjusing?
A) Oral
B) Rectal
C) Scanner
D) Tympanicnj
ANSWER:nj
A
Explanation:njA)njThenjtemperaturenjofnjannjunconsciousnjclientnjisnjnevernjtakennjbynjmouth.njThenjrecta
l,njtympanic,njornjscannernjmethodnjisnjpreferred.
B) Thenjrectal,njtympanic,njornjscannernjmethodnjisnjpreferred.
C) Thenjrectal,njtympanic,njornjscannernjmethodnjisnjpreferred.
D) Thenjrectal,njtympanic,njornjscannernjmethodnjisnjpreferre
d.njPagenjRef:nj24
CognitivenjLevel:n j Applying
ClientnjNeed/Sub:njnjn j SafenjandnjEffectivenjCarenjEnvironment:njSafetynjandnjInfectionnjControlnjStanda
rds:nj NursingnjProcess:njEvaluationnj|njLearningnjOutcome:nj1.1nj|njQSENnjCompetencies:njSafetynjAAC
NnjDomainsnjandnjComps.:n j Domainnj5:njQualitynjandnjSafety
NLNnjCompetencies:n j Qualitynj&njSafety
1
, 3) Thenjnursenjisnjchangingnjanj2-month-
oldnjclient'snjdiapernjandnjnotesnjthenjclientnjfeelsnjwarmnjtonjtouch.njWhichnjmethodnjshouldnjthenjnursenju
senjtonjchecknjthenjbaby'snjtemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanicnjmembran
enjANSWER:n j C
Explanation:n j A)njOralnjisnjusednjfornjagenj3njornjolder.
B) Thenjrectalnjroutenjisnjthenjleastnjdesirable.
C) Thenjaxillarynjroutenjmaynjnotnjbenjasnjaccuratenjasnjothernjroutesnjfornjdetectingnjfeversnjinnjchildren.
D) Thenjtympanicnjmembranenjmaynjbenjusednjfornj3njmonthsnjornjold
er.njPagenjRef:nj29
CognitivenjLevel:n j Applying
ClientnjNeed/Sub:n j PhysiologicalnjIntegrity:njReductionnjofnjRisknjPotential
Standards:n j NursingnjProcess:njEvaluatingnj|njLearningnjOutcome:nj1.2nj|njQSENnjCompetencies:njSafet
ynjAACNnjDomainsnjandnjComps.:n j Domainnj5:njQualitynjandnjSafety
NLNnjCompetencies:n j Qualitynj&njSafety
4) Anjclientnjcomesnjinnjwithnjexacerbationnjofnjchronicnjobstructivenjpulmonarynjdiseasenj(COPD).njWhi
chnjnoninvasivenjdiagnosticnjtestnjwillnjthenjnursenjimplementnjtonjknownjthatnjthenjclientnjisnjreceivingnjeno
ughnjoxygen?
A) Chestnjx-ray
B) Pulsenjoximeter
C) Arterialnjbloodnjgasses
D) Assessmentnjofnjrespiratorynjrat
enjANSWER:n j B
Explanation:n j A)njAnjchestnjx-raynjisnjnotnjannjinterventionnjanjnursenjcompletes.
B) Anjpulsenjoximeternjprovidesnjanjnoninvasivenjmethodnjofnjmeasuringnjoxygenation,njornjoxygennj
saturation,njinnjthenjbloodnjandnjprovidesnjanjpulsenjreading,njwhichnjisnjespeciallynjhelpfulnjfornjthenjcli
entnjwithnjanjrespiratorynjillnessnjornjdisease.
C) Arterialnjbloodnjgasesnjarenjannjinvasivenjdiagnosticnjtest.
D) Assessingnjanjrespiratorynjratenjisnjimportantnjfornjthenjnursenjtonjimplement;njhowever,njitnjisnjno
tnjanjdiagnosticnjtest.
PagenjRef:nj21
CognitivenjLevel:n j Applying
ClientnjNeed/Sub:n j PhysiologicalnjIntegrity:njReductionnjofnjRisknjPotential
Standards:njNursingnjProcess:njImplementationnj|njLearningnjOutcome:nj1.3nj|njQSENnjCompetencies:njI
nformatics
AACNnjDomainsnjandnjComps.:n j Domainnj5:njQualitynjandnjSafetynjNL
NnjCompetencies:n j Qualitynj&njSafety
2
