TABLE OF CONTENTS
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UNIT I Actions Basic to Nursing Care
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Chapter 1 Asepsis and Infection Control
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Chapter 2 Vital Signs
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Chapter 3 Health Assessment
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Chapter 4 Safety
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Chapter 5 Medications
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Chapter 6 Perioperative Nursing
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UNIT II Promoting Healthy Physiologic Responses
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Chapter 7 Hygiene
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Chapter 8 Skin Integrity and Wound Care
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Chapter 9 Activity
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Chapter 10 Comfort and Pain Management
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Chapter 11 Nutrition
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Chapter 12 Urinary Elimination
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Chapter 13 Bowel Elimination
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Chapter 14 Oxygenation
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Chapter 15 Perfusion
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Chapter 16 Fluid, Electrolyte, and Acid–Base Balance
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,Chapter 17 Neurologic Care
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Chapter 18 Laboratory Specimen Collection
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,Prof.Exams
1. A nurse is attempting to obtain vital signs from a restless toddler who is clinging to his m
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other's legs and asking to go home. Which of the following would be the best nursing
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intervention to accomplish this task? ag ag ag ag
A) Perform the blood pressure assessment first because it is the most frightening
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procedure for a child. ag ag ag
B) Perform as many of the assessments as possible with the child seated on the
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parent's lap. ag
C) Do not allow the child to see the instruments until they are ready to be used.
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D) Remove any distractions (e.g., toys/dolls from the room to improve concentration).
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2. A nurse assesses the rectal temperature of a patient who is postoperative following oral
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surgery. What patient assessment needs to be made before taking this temperature?
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A) Pain assessment
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B) Pulse rate ag
C) Platelet count ag
D) Fecal occult blood test
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3. A patient informs the nurse that she still uses a mercury thermometer to take the temperatu
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re of her children when they are sick. Which of the following is a
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recommended teaching guideline for patients using these types of thermometers? ag ag ag ag ag ag ag ag ag
A) Teach patient safety related to accidental breakage of the thermometer.
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B) Tell patients using mercury thermometers to throw them in the trash and buy a new
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type of instrument.
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C) Encourage patients to use alternative devices to assess temperature in their home.
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D) Tell patients that mercury thermometers should be used only in a hospital setting
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with appropriate safeguards.
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4. A nurse is obtaining vital signs from patients using the tympanic method for measuring te
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mperature. Which of the following guidelines should be followed when taking a
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tympanic temperature? ag
A) Do not take a tympanic temperature if the patient has an earache.
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B) Do not take a tympanic temperature if there is noticeable earwax present.
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C) Do not take a tympanic temperature if the patient has an ear infection.
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D) If the patient has been sleeping with head to one side, take the temperature in the
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ear facing down.
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, Taylor's Clinical Nursing Skills 6thEdition(Lynn)
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6. A nurse teaching a student nurse how to take temperatures with a nonmercury glass
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thermometer would be correct in stating the following: ag ag ag ag ag ag ag
A) If the thermometer is stored in a chemical solution, wipe the thermometer dry with
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a soft tissue, using a firm, twisting motion from the fingers to the bulb.
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B) Grasp the thermometer firmly with the thumb and the forefinger and, using strong
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wrist movements, shake it until the chemical line reaches at least 92ºF.
ag ag ag ag ag ag ag ag ag ag ag
C) Read the thermometer by holding it horizontally at eye level, and rotate it between
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your fingers until you can see the chemical line.
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D) Leave the thermometer in place for 3 minutes for oral, rectal, and axillary routes or
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according to agency protocol. ag ag ag
7. Which of the following patients would be an appropriate candidate for the use of a
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radiant heater? ag
A) An older adult suffering from hypothermia
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B) A premature infant
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C) An infant with jaundice
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D) A child recovering from a near-drowning incident
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8. A nurse responds to an order to place an infant in an overhead radiant heater. Which of
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the following are recommended guidelines the nurse should follow?
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A) Attach the probe to the infant's skin over a bony area.
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B) Allow the blankets to warm before placing the infant under the warmer.
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C) Make sure nothing is covering the probe to allow it to register an accurate
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temperature.
D) Keep the setting of the warmer on manual and adjust it at 15-minute intervals
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according to the temperature registered. ag ag ag ag
9. A nurse is using a cooling blanket on an adult patient with an uncontrolled fever. Which o
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f the following statements accurately describes a recommended guideline for using this
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type of equipment? ag ag
A) Position the blanket under the patient so that the top edge of the pad is aligned with
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the patient's neck.
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B) For patients who are comatose or anesthetized, use a rectal probe to monitor core
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body temperature. ag
C) Cover the hypothermia blanket with a thick blanket or mattress pad.
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ag ag
UNIT I Actions Basic to Nursing Care
ag ag ag ag ag
Chapter 1 Asepsis and Infection Control
ag ag ag ag ag
Chapter 2 Vital Signs
ag ag ag
Chapter 3 Health Assessment
ag ag ag
Chapter 4 Safety
ag ag
Chapter 5 Medications
ag ag
Chapter 6 Perioperative Nursing
ag ag ag
UNIT II Promoting Healthy Physiologic Responses
ag ag ag ag
Chapter 7 Hygiene
ag ag
Chapter 8 Skin Integrity and Wound Care
ag ag ag ag ag ag
Chapter 9 Activity
ag ag
Chapter 10 Comfort and Pain Management
ag ag ag ag ag
Chapter 11 Nutrition
ag ag
Chapter 12 Urinary Elimination
ag ag ag
Chapter 13 Bowel Elimination
ag ag ag
Chapter 14 Oxygenation
ag ag
Chapter 15 Perfusion
ag ag
Chapter 16 Fluid, Electrolyte, and Acid–Base Balance
ag ag ag ag ag ag
,Chapter 17 Neurologic Care
ag ag ag
Chapter 18 Laboratory Specimen Collection
ag ag ag ag
,Prof.Exams
1. A nurse is attempting to obtain vital signs from a restless toddler who is clinging to his m
ag ag ag ag ag ag ag ag ag ag ag ag ag ag ag ag ag
other's legs and asking to go home. Which of the following would be the best nursing
ag ag ag ag ag ag ag ag ag ag ag ag ag ag ag
intervention to accomplish this task? ag ag ag ag
A) Perform the blood pressure assessment first because it is the most frightening
ag ag ag ag ag ag ag ag ag ag ag
procedure for a child. ag ag ag
B) Perform as many of the assessments as possible with the child seated on the
ag ag ag ag ag ag ag ag ag ag ag ag ag
parent's lap. ag
C) Do not allow the child to see the instruments until they are ready to be used.
ag ag ag ag ag ag ag ag ag ag ag ag ag ag ag
D) Remove any distractions (e.g., toys/dolls from the room to improve concentration).
ag ag ag ag ag ag ag ag ag ag
2. A nurse assesses the rectal temperature of a patient who is postoperative following oral
ag ag ag ag ag ag ag ag ag ag ag ag ag
surgery. What patient assessment needs to be made before taking this temperature?
ag ag ag ag ag ag ag ag ag ag ag
A) Pain assessment
ag
B) Pulse rate ag
C) Platelet count ag
D) Fecal occult blood test
ag ag ag
3. A patient informs the nurse that she still uses a mercury thermometer to take the temperatu
ag ag ag ag ag ag ag ag ag ag ag ag ag ag ag
re of her children when they are sick. Which of the following is a
ag ag ag ag ag ag ag ag ag ag ag ag ag
recommended teaching guideline for patients using these types of thermometers? ag ag ag ag ag ag ag ag ag
A) Teach patient safety related to accidental breakage of the thermometer.
ag ag ag ag ag ag ag ag ag
B) Tell patients using mercury thermometers to throw them in the trash and buy a new
ag ag ag ag ag ag ag ag ag ag ag ag ag ag
type of instrument.
ag ag
C) Encourage patients to use alternative devices to assess temperature in their home.
ag ag ag ag ag ag ag ag ag ag ag
D) Tell patients that mercury thermometers should be used only in a hospital setting
ag ag ag ag ag ag ag ag ag ag ag ag
with appropriate safeguards.
ag ag
4. A nurse is obtaining vital signs from patients using the tympanic method for measuring te
ag ag ag ag ag ag ag ag ag ag ag ag ag ag
mperature. Which of the following guidelines should be followed when taking a
ag ag ag ag ag ag ag ag ag ag ag
tympanic temperature? ag
A) Do not take a tympanic temperature if the patient has an earache.
ag ag ag ag ag ag ag ag ag ag ag
B) Do not take a tympanic temperature if there is noticeable earwax present.
ag ag ag ag ag ag ag ag ag ag ag
C) Do not take a tympanic temperature if the patient has an ear infection.
ag ag ag ag ag ag ag ag ag ag ag ag
D) If the patient has been sleeping with head to one side, take the temperature in the
ag ag ag ag ag ag ag ag ag ag ag ag ag ag ag
ear facing down.
ag ag
, Taylor's Clinical Nursing Skills 6thEdition(Lynn)
ag ag ag ag
6. A nurse teaching a student nurse how to take temperatures with a nonmercury glass
ag ag ag ag ag ag ag ag ag ag ag ag ag
thermometer would be correct in stating the following: ag ag ag ag ag ag ag
A) If the thermometer is stored in a chemical solution, wipe the thermometer dry with
ag ag ag ag ag ag ag ag ag ag ag ag ag
a soft tissue, using a firm, twisting motion from the fingers to the bulb.
ag ag ag ag ag ag ag ag ag ag ag ag ag
B) Grasp the thermometer firmly with the thumb and the forefinger and, using strong
ag ag ag ag ag ag ag ag ag ag ag ag
wrist movements, shake it until the chemical line reaches at least 92ºF.
ag ag ag ag ag ag ag ag ag ag ag
C) Read the thermometer by holding it horizontally at eye level, and rotate it between
ag ag ag ag ag ag ag ag ag ag ag ag ag
your fingers until you can see the chemical line.
ag ag ag ag ag ag ag ag
D) Leave the thermometer in place for 3 minutes for oral, rectal, and axillary routes or
ag ag ag ag ag ag ag ag ag ag ag ag ag ag
according to agency protocol. ag ag ag
7. Which of the following patients would be an appropriate candidate for the use of a
ag ag ag ag ag ag ag ag ag ag ag ag ag ag
radiant heater? ag
A) An older adult suffering from hypothermia
ag ag ag ag ag
B) A premature infant
ag ag
C) An infant with jaundice
ag ag ag
D) A child recovering from a near-drowning incident
ag ag ag ag ag ag
8. A nurse responds to an order to place an infant in an overhead radiant heater. Which of
ag ag ag ag ag ag ag ag ag ag ag ag ag ag ag ag
the following are recommended guidelines the nurse should follow?
ag ag ag ag ag ag ag ag
A) Attach the probe to the infant's skin over a bony area.
ag ag ag ag ag ag ag ag ag ag
B) Allow the blankets to warm before placing the infant under the warmer.
ag ag ag ag ag ag ag ag ag ag ag
C) Make sure nothing is covering the probe to allow it to register an accurate
ag ag ag ag ag ag ag ag ag ag ag ag ag
temperature.
D) Keep the setting of the warmer on manual and adjust it at 15-minute intervals
ag ag ag ag ag ag ag ag ag ag ag ag ag
according to the temperature registered. ag ag ag ag
9. A nurse is using a cooling blanket on an adult patient with an uncontrolled fever. Which o
ag ag ag ag ag ag ag ag ag ag ag ag ag ag ag ag
f the following statements accurately describes a recommended guideline for using this
ag ag ag ag ag ag ag ag ag ag ag
type of equipment? ag ag
A) Position the blanket under the patient so that the top edge of the pad is aligned with
ag ag ag ag ag ag ag ag ag ag ag ag ag ag ag ag
the patient's neck.
ag ag
B) For patients who are comatose or anesthetized, use a rectal probe to monitor core
ag ag ag ag ag ag ag ag ag ag ag ag ag
body temperature. ag
C) Cover the hypothermia blanket with a thick blanket or mattress pad.
ag ag ag ag ag ag ag ag ag ag
