,Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Pearson
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Education
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Table of Contents
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Chapter 1. Assessment
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Chapter 2. Caring Interventions
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Chapter 3. Comfort
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Chapter 4. Elimination
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Chapter 5. Fluids and Electrolytes
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Chapter 6. Infection
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Chapter 7. Intracranial Regulation
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Chapter 8. Metabolism
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Chapter 9. Mobility
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Chapter 10. Nutrition
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Chapter 11. Oxygenation
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Chapter 12. Perfusion
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Chapter 13. Perioperative Care
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Chapter 14. Reproduction
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Chapter 15. Safety
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Chapter 16. Tissue Integrity
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,Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Education Test Bank
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Chapter 1: Assessment
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1) A client on the medical/surgical unit complains of sudden chest pains. Which action will the
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nurse implement first?
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A) Call the healthcare provider. f f f
B) Administer pain medication. f f
C) Reassess a new set of vital signs. f f f f f f
D) Turn client from supine to lateral. f f f f f
Answer: C
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Explanation: A) The nurse will need to reassess the client first, before calling the healthcare f f f f f f f f f f f f f f
provider.
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B) The nurse will need to reassess the client first, before administering pain medication.
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C) The nurse needs to implement a new set of vital signs first when there is a change in
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condition.
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D) The nurse will need to reassess the client first, before moving the client, to avoid making the
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change in client's condition worse.
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Cognitive Level: Applying f f f
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN Competencies:
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Patient-Centered Care
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AACN Domains and Comps.: Domain 2: Person-Centered Care
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NLN Competencies: Relationship Centered Care
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2) The nurse is observing the UAP taking the temperature of an unconscious client. Which route
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will the nurse question the UAP using?
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A) Oral
B) Rectal
C) Scanner
D) Tympanic
Answer: A
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Explanation: A) The temperature of an unconscious client is never taken by mouth. The rectal, tympanic,
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or scanner method is preferred.
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B) The rectal, tympanic, or scanner method is preferred.
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C) The rectal, tympanic, or scanner method is preferred.
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D) The rectal, tympanic, or scanner method is preferred.
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Page Ref: 24
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Cognitive Level: Applying f f f
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards:
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fNursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: Safety AACN
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Domains and Comps.: Domain 5: Quality and Safety
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NLN Competencies: Quality & Safety
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1
, 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch.
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Which method should the nurse use to check the baby's temperature?
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A) Oral
B) Rectal
C) Axillary
D) Tympanic membrane f
Answer: C
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Explanation: A) Oral is used for age 3 or older. f f f f f f f f f f
B) The rectal route is the least desirable.
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C) The axillary route may not be as accurate as other routes for detecting fevers in children.
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D) The tympanic membrane may be used for 3 months or older.
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Page Ref: 29
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Cognitive Level: Applying f f f
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies: Safety
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AACN Domains and Comps.: Domain 5: Quality and Safety
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NLN Competencies: Quality & Safety
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4) A client comes in with exacerbation of chronic obstructive pulmonary disease (COPD). Which
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noninvasive diagnostic test will the nurse implement to know that the client is receiving enough
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oxygen?
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A) Chest x-ray f
B) Pulse oximeter f
C) Arterial blood gasses f f
D) Assessment of respiratory rate f f f
Answer: B
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Explanation: A) A chest x-ray is not an intervention a nurse completes.
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B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen
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saturation, in the blood and provides a pulse reading, which is especially helpful for the client
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with a respiratory illness or disease.
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C) Arterial blood gases are an invasive diagnostic test.f f f f f f f
D) Assessing a respiratory rate is important for the nurse to implement; however, it is not a
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diagnostic test.
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Page Ref: 21
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Cognitive Level: Applying f f f
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Competencies: Informatics
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AACN Domains and Comps.: Domain 5: Quality and Safety
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NLN Competencies: Quality & Safety
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2
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