Test Bank for Concept-Based Clinical Nursing Skills, 2nd Edition by Loren Stein
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Course
Clinical Nursing
Institution
Clinical Nursing
Test Bank for Concept-Based Clinical Nursing Skills, 2nd Edition 2e by Loren Stein, Connie J Hollen.
Full Chapters test bank are included - Chap 1 to 20 (Complete Chapters)
UNIT I: Fundamental Nursing Skills
1. Foundations of Safe Client Care
2. Personal Care and Hygiene
3. Vital Signs a...
1. To meet a requirement of the 2021 American Association of Colleges
of Nursing Essentials, what topic does nursing faculty focus on
throughout the curriculum?
a. Nursing process
b. Safety science
c. Ergonomics
d. Information technology
ANS: b
The 2021 AACN Essentials states that "Provision of safe, quality care
necessitates knowing and using established and emerging principles of
safety science in care delivery" (p. 43). Nursing students are taught to
use the nursing process, but this is not confined to patient safety.
Ergonomics is a subset of safety science that studies people and their
work environments. Information technology can be used to improve
safety.
PTS: 1
DIF: Cognitive Level: Remembering
TOP: Integrated Process: Teaching-Learning
2.A nurse meets the assigned clients at the start of a shift. After
performing hand hygiene and introducing one's self, what does the nurse
do next?
a. Begin a head-to-toe assessment.
b. Identify the client using two identifiers.
c. Assess the client for pain.
d. Ensure the call light is within reach.
ANS: b
A critical task in healthcare for safety, client identification is paramount
for preventing errors. After performing hand hygiene and introducing
him- or herself, the nurse identifies the client using two unique
,identifiers. The head-to-toe and pain assessments come shortly
afterward. The nurse ensures the client can reach the call light prior to
leaving the room.
PTS: 1
DIF: Cognitive Level: Understanding
TOP: Nursing Process: Assessment
3. A nurse has worked with the same client for 2 days. When entering
the room to administer medications, the nurse performs hand hygiene.
What action does the nurse take next?
a. Provide any needed teaching.
b. Ask if the client has any care requests.
c. Assess vital signs and pain.
d. Identify the client using two identifiers.
ANS: d
Every time the client is to receive medication, diagnostic studies, or any
other healthcare intervention, the nurse must identify the client using
two unique identifiers, even if the client is well known to the nurse.
Assessments, teaching, and determining client requests would come
afterward.
PTS: 1
DIF: Cognitive Level: Applying
TOP: Nursing Process: Assessment
4.A nurse's neighbor states "My father got a nosocomial infection after
surgery!" What does the nurse understand happened to the client?
a. The client received contaminated blood products.
b. The client nearly died from a postoperative infection.
c. The client acquired an infection while in the hospital.
d. The client received poor preoperative skin preparation.
ANS: c
A nosocomial infection is one acquired in the hospital. It does not
designate how the infection occurred, so the client might have become
infected through contaminated blood products or from poor preoperative
,skin preparation. It does not mean the client had a life-threatening
infection, only that is occurred in hospital.
PTS: 1
DIF: Cognitive Level: Understanding
TOP: Integrated Process: Teaching-Learning
5.A nurse is making rounds on clients at risk for infection. Which client
does the nurse see first?
a. A client with an intravenous (IV) line
b. A client who has a central line
c. A client with an indwelling bladder catheter
d. A client with an IV and bladder catheter
ANS: d
One of the biggest risk factors for hospital acquired infections (HAIs) is
the presence of invasive lines. The more lines, the more risk. The client
with both an IV and a catheter has the highest risk. The clients with an
IV or a catheter have less risk.
PTS: 1
DIF: Cognitive Level: Applying
TOP: Nursing Process: Assessment
6.A nursing manager concerned about the infection rate on the unit
wants to implement measures to reduce the transmission of infectious
organisms. What action by the manager is best?
a. Provide a stethoscope dedicated to each client.
b. Ensure gloves are well-stocked in each room.
c. Restrict all plants and fresh foods from rooms.
d. Screen all visitors for contagious illnesses.
ANS: a
In the chain of infection, one of the most important components is the
mode of transmission. Stethoscopes can serve as a mode of indirect
contact transmission unless they are disinfected appropriately between
clients. Providing each client with an individual stethoscope will reduce
this risk. Gloves are important, but they can become contaminated too
, and serve as a mode of transmission. Plants and fresh foods are an
uncommon source of transmission unless the client is
immunosuppressed. Screening visitors for contagious illness is an
unrealistic long-term action plan.
PTS: 1
DIF: Cognitive Level: Applying
TOP: Nursing Process: Implementation
7.A nurse is observing a student nurse. What action by the student
demonstrates the need for more education on Standard Precautions?
a. The student performs hand hygiene before all client contacts.
b. The student conscientiously wears gloves when taking vital signs.
c. The student confirms that urine possibly contains infectious microbes.
d. The student wears a gown when cleaning liquid stool off the client.
ANS: b
Standard Precautions operates under the principle that all bodily fluids
other than sweat could potentially contain infectious microbial agents
that pose a risk to the healthcare worker. Contact with skin, if free of
those fluids, does not require wearing gloves, so the nurse would provide
more education to the student. Hand hygiene is the first step of Standard
Precautions. The student is being prudent by confirming a possible
source of contamination. Nurses determine which infection prevention
practice to use based upon the type of client–nurse interaction and the
possibility of exposure to blood, other body fluids, or pathogens, so
wearing a gown while cleaning liquid stool is appropriate.
PTS: 1
DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Evaluation
8. A faculty member has taught the correct technique for taking gloves
off (doffing). While observing students practice, which action by a
student indicates the need to review the material?
a. Pulls glove off dominant hand first.
b. Takes first glove off by grasping it on the outside.
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