I I I 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.IWhichIactionIwillItheInur
seIimplementIfirst?
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:IPati
ent-CenteredICare
AACNIDomainsIandIComps.:IDomainI2:IPerson-
CenteredICareINLNICompetencies:I RelationshipICenteredICare
2) TheInurseIisIobservingItheIUAPItakingItheItemperatureIofIanIunconsciousIclient.IWhichIrouteIwil
lItheInurseIquestionItheIUAPIusing?
A) Oral
B) Rectal
C) Scanner
D) TympanicI
ANSWER:I A
Explanation:IA)ITheItemperatureIofIanIunconsciousIclientIisIneverItakenIbyImouth.ITheIrectal,Itymp
anic,IorIscannerImethodIisIpreferred.
B) TheIrectal,Itympanic,IorIscannerImethodIisIpreferred.
C) TheIrectal,Itympanic,IorIscannerImethodIisIpreferred.
D) TheIrectal,Itympanic,IorIscannerImethodIisIpreferred.I
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CognitiveILevel:I Applying
ClientINeed/Sub:III SafeIandIEffectiveICareIEnvironment:ISafetyIandIInfectionIControlIStandards:I N
ursingIProcess:IEvaluationI|ILearningIOutcome:I1.1I|IQSENICompetencies:ISafetyIAACNIDomainsIa
ndIComps.:I DomainI5:IQualityIandISafety
NLNICompetencies:I QualityI&ISafety
1
, 3) TheInurseIisIchangingIaI2-month-
oldIclient'sIdiaperIandInotesItheIclientIfeelsIwarmItoItouch.IWhichImethodIshouldItheInurseIuseIto
I checkItheIbaby'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:ISafetyIAAC
NIDomainsIandIComps.:I DomainI5:IQualityIandISafety
NLNICompetencies:I QualityI&ISafety
4) AIclientIcomesIinIwithIexacerbationIofIchronicIobstructiveIpulmonaryIdiseaseI(COPD).IWhichInon
invasiveIdiagnosticItestIwillItheInurseIimplementItoIknowIthatItheIclientIisIreceivingIenoughIoxygen
?
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,IitIisInotIaIdi
agnosticItest.
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CognitiveILevel:I Applying
ClientINeed/Sub:I PhysiologicalIIntegrity:IReductionIofIRiskIPotential
Standards:INursingIProcess:IImplementationI|ILearningIOutcome:I1.3I|IQSENICompetencies:IInfor
matics
AACNIDomainsIandIComps.:I DomainI5:IQualityIandISafetyINLNICom
petencies:I QualityI&ISafety
2