Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Volume III by Pearson Education Chapters 1 - 16 complete

Test Bank for Clinical Nursing Skills:
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A Concept-Based Approach
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4th Edition Volume III
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by Pearson Education Chapters 1 - 16
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,TestbBankbforbClinicalbNursingbSkills:bAbConcept-BasedbApproachb4thbEditionbPearsonb

,prepared by stevesalvardo
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for any inquiry and further request emai
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l:


ClinicalbNursingbSkills:bAbConcept-
BasedbApproach,b4eb(Pearson)bEducationbTestbBankbChapterb1:bAssessment

1) bAbclientbonbthebmedical/surgicalbunitbcomplainsbofbsuddenbchestbpains.bWhichbactionbwillbtheb
nursebimplementbfirst?
A) Callbthebhealthcarebprovider.
B) Administerbpainbmedication.
C) Reassessbabnewbsetbofbvitalbsigns.
D) Turnbclientbfrombsupinebtoblateral.b
ANSWER:b C
Explanation:bA)bThebnursebwillbneedbtobreassessbthebclientbfirst,bbeforebcallingbthebhealthcarebpr
ovider.
B) Thebnursebwillbneedbtobreassessbthebclientbfirst,bbeforebadministeringbpainbmedication.
C) Thebnursebneedsbtobimplementbabnewbsetbofbvitalbsignsbfirstbwhenbtherebisbabchangebinbc
ondition.
D) Thebnursebwillbneedbtobreassessbthebclientbfirst,bbeforebmovingbthebclient,btobavoidbmakingbthebc
hangebinbclient'sbconditionbworse.
PagebRef:b2
CognitivebLevel:b Applying
ClientbNeed/Sub:b PhysiologicalbIntegrity:bReductionbofbRiskbPotential
Standards:bNursingbProcess:bAssessmentb|bLearningbOutcome:b1.1b|bQSENbCompetencies:bP
atient-CenteredbCare
AACNbDomainsbandbComps.:bDomainb2:bPerson-
CenteredbCarebNLNbCompetencies:b RelationshipbCenteredbCare

2) ThebnursebisbobservingbthebUAPbtakingbthebtemperaturebofbanbunconsciousbclient.bWhichbrouteb
willbthebnursebquestionbthebUAPbusing?
A) Oral
B) Rectal
C) Scanner
D) Tympanicb
ANSWER:b
A
Explanation:bA)bThebtemperaturebofbanbunconsciousbclientbisbneverbtakenbbybmouth.bThebrectal,bty
mpanic,borbscannerbmethodbisbpreferred.
B) Thebrectal,btympanic,borbscannerbmethodbisbpreferred.
C) Thebrectal,btympanic,borbscannerbmethodbisbpreferred.

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,D) Thebrectal,btympanic,borbscannerbmethodbisbpreferred.b
PagebRef:b24
CognitivebLevel:b Applying
ClientbNeed/Sub:bbb SafebandbEffectivebCarebEnvironment:bSafetybandbInfectionbControlbStandards:
b NursingbProcess:bEvaluationb|bLearningbOutcome:b1.1b|bQSENbCompetencies:bSafetybAACNbDom

ainsbandbComps.:b Domainb5:bQualitybandbSafety
NLNbCompetencies:b Qualityb&bSafety




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,3) Thebnursebisbchangingbab2-month-
oldbclient'sbdiaperbandbnotesbthebclientbfeelsbwarmbtobtouch.bWhichbmethodbshouldbthebnursebusebt
obcheckbthebbaby'sbtemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanicbmembraneb
ANSWER:b C
Explanation:b A)bOralbisbusedbforbageb3borbolder.
B) Thebrectalbroutebisbthebleastbdesirable.
C) Thebaxillarybroutebmaybnotbbebasbaccuratebasbotherbroutesbforbdetectingbfeversbinbchildren.
D) Thebtympanicbmembranebmaybbebusedbforb3bmonthsborbolder.b
PagebRef:b29
CognitivebLevel:b Applying
ClientbNeed/Sub:b PhysiologicalbIntegrity:bReductionbofbRiskbPotential
Standards:b NursingbProcess:bEvaluatingb|bLearningbOutcome:b1.2b|bQSENbCompetencies:bSafetybA
ACNbDomainsbandbComps.:b Domainb5:bQualitybandbSafety
NLNbCompetencies:b Qualityb&bSafety

4) Abclientbcomesbinbwithbexacerbationbofbchronicbobstructivebpulmonarybdiseaseb(COPD).bWhichbn
oninvasivebdiagnosticbtestbwillbthebnursebimplementbtobknowbthatbthebclientbisbreceivingbenoughboxy
gen?
A) Chestbx-ray
B) Pulseboximeter
C) Arterialbbloodbgasses
D) Assessmentbofbrespiratorybrateb
ANSWER:b B
Explanation:b A)bAbchestbx-raybisbnotbanbinterventionbabnursebcompletes.
B) Abpulseboximeterbprovidesbabnoninvasivebmethodbofbmeasuringboxygenation,borboxygenbsatu
ration,binbthebbloodbandbprovidesbabpulsebreading,bwhichbisbespeciallybhelpfulbforbthebclientbwithb
abrespiratorybillnessborbdisease.
C) Arterialbbloodbgasesbarebanbinvasivebdiagnosticbtest.
D) Assessingbabrespiratorybratebisbimportantbforbthebnursebtobimplement;bhowever,bitbisbnotbabd
iagnosticbtest.
PagebRef:b21
CognitivebLevel:b Applying
ClientbNeed/Sub:b PhysiologicalbIntegrity:bReductionbofbRiskbPotential
Standards:bNursingbProcess:bImplementationb|bLearningbOutcome:b1.3b|bQSENbCompetencies:bInf
ormatics
AACNbDomainsbandbComps.:b Domainb5:bQualitybandbSafetybNLNb
Competencies:b Qualityb&bSafety




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,5) Thebnursebisbpreparingbtobassessbabclient'sbmusculoskeletalbsystem.bWhichbquestionbshouldbthebn
ursebaskbbeforebbeginningbthisbassessment?
A) "Dobyoubexercisebeverybday?"
B) "Dobyoubhavebabhistorybofbanybsportsbinjuries?"
C) "Dobyoubtakebabhotbbathbtobrelaxbyourbmuscles?"
D) "DobyoubwantbpainbmedicationbbeforebIbbegin?"b
ANSWER:b B
Explanation:bA)bKnowingbifbabclientbexercisesbisbanbimportantbquestionbbutbknowingbifbtherebareban
ybsportsbinjuriesbtobknowbaboutbfirst,bisbmostbimportantbbeforebdoingbabroutinebmusculoskeletalbasse
ssment.
B) Itbisbimportantbtobnotebifbthebclientbhasbabhistorybofbanybsportsbinjuriesbfirstbtobknowbwhatbthebcl
ientbwillborbwillbnotbbebablebtobdobduringbabroutinebmusculoskeletalbassessment.
C) Knowingbifbthebclientbtakesbabhotbbathbtobrelaxbthebmusclesbisbnotbthebmostbimportantbthingbtoba
skbbeforebperformingbabroutinebmusculoskeletalbassessment.
D) Tobknowbifbabclientbisbexperiencingbanybpainbisbanbimportantbquestion;bhowever,bthisbquestionbis
bassumingbthebclient bisbinbpainbbybaskingbifbthebclientbwantsbabpainbmedicationbbeforebbeginningbabr

outinebmusculoskeletalbassessment.
PagebRef:b62
CognitivebLevel:b Applying
ClientbNeed/Sub:b SafebandbEffectivebCarebEnvironment:bSafetybandbInfectionbControlbStandar
ds:bNursingbProcess:bAssessmentb|bLearningbOutcome:b1.5b|bQSENbCompetencies:bSafety
AACNbDomainsbandbComps.:b Domainb5:bQualitybandbSafetybNLNb
Competencies:b Qualityb&bSafety

6) Anbadultbchildbmentionsbthatbthebclientbseemsbtobhavebabdeclinebinbmentalbstatusbandbseemsbtobb
ebforgettingbmanybthingsbinbtheirbconversationbsincebbeingbhospitalized.bWhichbresponsebshouldbth
ebnursebmake?
A) "Givebyourbmombtime,bbecausebitbwillbtakebherbablittleblongerbwhenbansweringbquestions."
B) "Letbmebcheckbthebcranialbnervebfunctionbtobseebifbtherebisbabdefectbinbherbmentalbstatus."
C) "Youbdobnotbneedbtobworry.bThisbdeclinebisbpartbofbthebnormalbprocessbofbaging."
D) "Ifbyoubbringbsomebthingsbfrombherbhome,bitbmightbreducebthebconfusion."b
ANSWER:b D
Explanation:bA)bThisbisbexpectedbtobgivebsomebolderbadultsbtimebtobrespond,bbutbthebdaughterbisbco
ncernedbaboutbherbforgetting,bnotbtheblengthbofbthebresponse.
B) Cranialbnervebfunctionbisbanbassessmentbofbthebcranialbnervesbandbnotbthebmentalbstatusbofbabc
lient.
C) Abdeclinebinbmentalbstatusbisbnotbabnormalbresultbofbaging,bsobthisbresponsebisbnotbtrue.
D) Thebstressbofbbeingbinbunfamiliarbsituationsbcanbcausebconfusionbinbsomebolderbadults.bP
agebRef:b75
CognitivebLevel:b Applying
ClientbNeed/Sub:b PsychosocialbIntegrity
Standards:bNursingbProcess:bPlanningb|bLearningbOutcome:b1.6b|bQSENbCompetencies:bPatient-
bCenteredbCare

AACNbDomainsbandbComps.:bDomainb2:bPerson-
CenteredbCarebNLNbCompetencies:b ContextbandbEnvironment

7) Whenbassessingbbreathbsounds,bthebnursebhearsbmoderate-intensitybandbmoderate-pitch

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,"blowing"bsoundsbbetweenbthebscapulaebandblateralbtobthebsternumbatbthebfirstbandbsecondbi
ntercostalbspaces.bWhichbactionbshouldbthebnursebtake?
A) Encouragebthebclientbtobcoughbandbdeepbbreathe.
B) Notifybthebhealthcarebproviderbofbabnormalbbreathbsounds.
C) Documentbassessmentbfindingsbasbnormalbbreathbsounds.
D) Raisebthebheadbofbthebbedbtoballowbmaximumbairbexcursion.b
ANSWER:b C
Explanation:b A)bTherebisbnobreasonbtobencouragebthebclientbtobtakebdeepbbreathsbandbcough.
B) Thebnursebwouldbnotifybthebhealthcarebproviderbifbthesebwerebadventitiousblungbsounds;bh
owever,bthesebarebbronchovesicularbsounds.
C) Thesebarebbronchovesicularbsounds.
D) Thebnursebwouldbimplementbthisbifbthesebwerebadventitiousblungbsounds;bhowever,bthesebarebb
ronchovesicularbsounds.
PagebRef:b88
CognitivebLevel:b Applying
ClientbNeed/Sub:b HealthbPromotionbandbMaintenance
Standards:bNursingbProcess:bAssessmentb|bLearningbOutcome:b1.7b|bQSENbCompetencies:bP
atient-CenteredbCare
AACNbDomainsbandbComps.:bDomainb2:bPerson-
CenteredbCarebNLNbCompetencies:b ContextbandbEnvironment

8) Abclientbseeksbmedicalbattentionbforbshortnessbofbbreathbandbabfever.bWhichbamountbofbtimebs
houldbthebnursebcountbthebperipheralbpulse?
A) 15bseconds
B) 30bseconds
C) 1bminute
D) 2bminutesb
ANSWER:b
C
Explanation:b A)bCountbforbabfullbminutebifbtakingbabclient'sbpulsebforbthebfirstbtime.
B) Countbforbabfullbminutebifbtakingbabclient'sbpulsebforbthebfirstbtime.
C) Countbforbabfullbminutebifbtakingbabclient'sbpulsebforbthebfirstbtime.
D) Countbforbabfullbminutebifbtakingbabclient'sbpulsebforbthebfirstbtime.bP
agebRef:b19
CognitivebLevel:b Applying
ClientbNeed/Sub:b HealthbPromotionbandbMaintenance
Standards:bNursingbProcess:bAssessmentb|bLearningbOutcome:b1.8b|bQSENbCompetencies:bP
atient-CenteredbCare
AACNbDomainsbandbComps.:bDomainb2:bPerson-
CenteredbCarebNLNbCompetencies:b Qualityb&bSafety




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,9) Thebnursebisbpreparingbabdosebofbdigoxinbforbabclient.bWhichbassessmentbwillbthebnursebc
ompletebpriorbtobgivingbthisbmedication?
A) Temperature
B) Apicalbpulse
C) Respiratorybrate
D) Painbusingbabpainbscaleb
ANSWER:b B
Explanation:b A)bThebtemperaturebdoesbnotbneedbtobbebassessedbbeforebgivingbdigoxin.
B) Thebnursebshouldbassessbthebapicalbpulsebbeforebthebadministrationbofbabmedicationbthatbcouldba
ffectbthebcardiovascularbsystem,bsuchbasbbeforebgivingbabdigitalisbpreparation.
C) Thebrespiratorybratebdoesbnotbneedbtobbebassessedbbeforebgivingbdigoxin.
D) Painblevelbdoesbnotbneedbtobbebassessedbbeforebgivingbdigoxin.b
PagebRef:b18
CognitivebLevel:b Applying
ClientbNeed/Sub:bPhysiologicalbIntegrity:bPharmacologicalbandbParenteralbTherapiesbStand
ards:bNursingbProcess:bAssessmentb|bLearningbOutcome:b1.4b|bQSENbCompetencies:bPatient-
CenteredbCare
AACNbDomainsbandbComps.:b Domainb5:bQualitybandbSafetybNLNb
Competencies:b Qualityb&bSafety

10) Thebnursebisbcompletingbabgeneralbassessmentbofbabnewborn.bWhichbtechniquebshouldbthebn
ursebuse?
A) Wrapbthebtapebmeasurebaroundbthebheadbbelowbthebears.
B) Wrapbthebtapebmeasurebaroundbthebheadbstartingbatbthebnose.
C) Wrapbthebtapebmeasurebaroundbthebabdomenbatbthebumbilicus.
D) Wrapbthebtapebmeasurebaroundbthebchestbbelowbthebnipplebline.b
ANSWER:b C
Explanation:bA)bWhenbmeasuringbthebheadbcircumference,bwrapbthebtapebaroundbthebheadbatbthebsu
praorbitalbprominencebabovebthebeyebrows,babovebthebears,bandbaroundbtheboccipitalbprominence.
B) Whenbmeasuringbthebheadbcircumference,bwrapbthebtapebaroundbthebheadbatbthebsupraorbitalbp
rominencebabovebthebeyebrows,babovebthebears,bandbaroundbtheboccipitalbprominence.
C) Whenbmeasuringbthebabdomenbcircumference,bwrapbthebtapebaroundbthebabdomenbatbtheblevelbo
fbthebumbilicus.
D) Whenbmeasuringbthebchestbcircumference,bwrapbthebtapebmeasurebaroundbthebchest,bplacedbjustbu
nderbthebaxillabandbatbthebnipplebline.
PagebRef:b31
CognitivebLevel:b Applying
ClientbNeed/Sub:b HealthbPromotionbandbMaintenance
Standards:bNursingbProcess:bAssessmentb|bLearningbOutcome:b1.4b|bQSENbCompetencies:bP
atient-CenteredbCare
AACNbDomainsbandbComps.:bDomainb2:bPerson-
CenteredbCarebNLNbCompetencies:b Qualityb&bSafety




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, 11) Thebnursebisbmeasuringbthebbloodbpressurebofbanbadultbclient.bWhichbtechniquebwouldbcauseba
nberroneouslyblowbbloodbpressure?
A) Bladderbtobcuffbratiobtoobwide
B) Armbunsupported
C) Cuffbwrappedbtoobloosely
D) Armbbelowbheartblevelb
ANSWER:b A
Explanation:bA)bThebwidthbofbthebbladderbcuffbneedsbtobbeb40%bofbthebcircumferenceborb20%bwider
bthanbthebdiameterbofbthebmidpoint.

B) Ifbthebarmbisbunsupported,bitbwillbcausebanberroneouslybhighbbloodbpressure.
C) Ifbthebcuffbisbwrappedbtoobloosely,bitbwillbcausebanberroneouslybhighbbloodbpressure.
D) Ifbthebarmbisbbelowbheartblevel,bitbwillbcausebanberroneouslybhighbbloodbpressure.bP
agebRef:b11
CognitivebLevel:b Applying
ClientbNeed/Sub:b HealthbPromotionbandbMaintenance
Standards:bNursingbProcess:bAssessmentb|bLearningbOutcome:b1.4b|bQSENbCompetencies:bP
atient-CenteredbCare
AACNbDomainsbandbComps.:bDomainb2:bPerson-
CenteredbCarebNLNbCompetencies:b Qualityb&bSafety

12) Thebnursebisbreviewingbcollectedbdata.bWhichbclientbshouldbthebnursebseebfirst?
A) Infantbrespirationsb38/min
B) 2-year-oldbpulseb112/min
C) 6-year-oldbaxillarybtemperatureb97.5°F
D) 10-year-
oldbbloodbpressureb138/88bANSWER:b
D
Explanation:b A)bAnbinfant'sbrespirationbrangebisb20-40/min.
B) Ab2-year-oldbchild'sbpulsebrangebisb70-120/min.
C) Ab6-year-oldbchild'sbtemperaturebrangebisb98.6°Fbbutbaxillarybisb1°Fblowerbthanboral.
D) Ab10-year-oldbchild'sbbloodbpressurebrangebisbsystolicb95-116bandbdiastolicb60-
70.bThisbisbmuchbhigherbthanbthebrangebforbthebagebofbthisbclient.
PagebRef:b15
CognitivebLevel:b Analyzing
ClientbNeed/Sub:b HealthbPromotionbandbMaintenance
Standards:bNursingbProcess:bAssessmentb|bLearningbOutcome:b1.4b|bQSENbCompetencies:bP
atient-CenteredbCare
AACNbDomainsbandbComps.:bDomainb2:bPerson-
CenteredbCarebNLNbCompetencies:b Qualityb&bSafety




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