m m m m m
A Concept-Based Approach
m m m
4th Edition Volume III
m m m
by Pearson Education Chapters 1 - 16
m m m m m m
,TestmBankmformClinicalmNursingmSkills:mAmConcept-
BasedmApproachm4thmEditionmPearsonm
,ClinicalmNursingmSkills:mAmConcept-
BasedmApproach,m4em(Pearson)mEducationmTestmBankmChapterm1:mAssessment
1) Amclientmonmthemmedical/surgicalmunitmcomplainsmofmsuddenmchestmpains.mWhichmaction
mwillmthemnursemimplementmfirst?
A) Callmthemhealthcaremprovider.
B) Administermpainmmedication.
C) Reassessmamnewmsetmofmvitalmsigns.
D) Turnmclientmfrommsupinemtomlate
ral.mANSWER:m C
Explanation:mA)mThemnursemwillmneedmtomreassessmthemclientmfirst,mbeforemcallingmthemh
ealthcaremprovider.
B) Themnursemwillmneedmtomreassessmthemclientmfirst,mbeforemadministeringmpainmmedication.
C) Themnursemneedsmtomimplementmamnewmsetmofmvitalmsignsmfirstmwhenmtheremisma
mchangeminmcondition.
D) Themnursemwillmneedmtomreassessmthemclientmfirst,mbeforemmovingmthemclient,mtomavoidm
makingmthemchangeminmclient'smconditionmworse.
PagemRef:m2
CognitivemLevel:m Applying
ClientmNeed/Sub:m PhysiologicalmIntegrity:mReductionmofmRiskmPotential
Standards:mNursingmProcess:mAssessmentm|mLearningmOutcome:m1.1m|mQSENmCompete
ncies:mPatient-CenteredmCare
AACNmDomainsmandmComps.:mDomainm2:mPerson-
CenteredmCaremNLNmCompetencies:m RelationshipmCenteredmCar
e
2) ThemnursemismobservingmthemUAPmtakingmthemtemperaturemofmanmunconsciousmclient.mWh
ichmroutemwillmthemnursemquestionmthemUAPmusing?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
mANSWER:m A
Explanation:mA)mThemtemperaturemofmanmunconsciousmclientmismnevermtakenmbymmouth.mThe
mrectal,mtympanic,mormscannermmethodmismpreferred.
B) Themrectal,mtympanic,mormscannermmethodmismpreferred.
C) Themrectal,mtympanic,mormscannermmethodmismpreferred.
D) Themrectal,mtympanic,mormscannermmethodmismpref
erred.mPagemRef:m24
CognitivemLevel:m Applying
ClientmNeed/Sub:mmm SafemandmEffectivemCaremEnvironment:mSafetymandmInfectionmControlmSt
andards:m NursingmProcess:mEvaluationm|mLearningmOutcome:m1.1m|mQSENmCompetencies:mSa
fetymAACNmDomainsmandmComps.:m Domainm5:mQualitymandmSafety
NLNmCompetencies:m Qualitym&mSafety
1
, 3) Themnursemismchangingmam2-month-
oldmclient'smdiapermandmnotesmthemclientmfeelsmwarmmtomtouch.mWhichmmethodmshouldmthe
mnursemusemtomcheckmthembaby'smtemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanicmmembran
emANSWER:m C
Explanation:m A)mOralmismusedmformagem3mormolder.
B) Themrectalmroutemismthemleastmdesirable.
C) Themaxillarymroutemmaymnotmbemasmaccuratemasmothermroutesmformdetectingmfeversminmchildren.
D) Themtympanicmmembranemmaymbemusedmform3mmonthsmor
molder.mPagemRef:m29
CognitivemLevel:m Applying
ClientmNeed/Sub:m PhysiologicalmIntegrity:mReductionmofmRiskmPotential
Standards:m NursingmProcess:mEvaluatingm|mLearningmOutcome:m1.2m|mQSENmCompetencies:m
SafetymAACNmDomainsmandmComps.:m Domainm5:mQualitymandmSafety
NLNmCompetencies:m Qualitym&mSafety
4) Amclientmcomesminmwithmexacerbationmofmchronicmobstructivempulmonarymdiseasem(COPD).m
Whichmnoninvasivemdiagnosticmtestmwillmthemnursemimplementmtomknowmthatmthemclientmismre
ceivingmenoughmoxygen?
A) Chestmx-ray
B) Pulsemoximeter
C) Arterialmbloodmgasses
D) Assessmentmofmrespiratorymr
atemANSWER:m B
Explanation:m A)mAmchestmx-raymismnotmanminterventionmamnursemcompletes.
B) Ampulsemoximetermprovidesmamnoninvasivemmethodmofmmeasuringmoxygenation,mormoxy
genmsaturation,minmthembloodmandmprovidesmampulsemreading,mwhichmismespeciallymhelpful
mformthemclientmwithmamrespiratorymillnessmormdisease.
C) Arterialmbloodmgasesmaremanminvasivemdiagnosticmtest.
D) Assessingmamrespiratorymratemismimportantmformthemnursemtomimplement;mhowever,m
itmismnotmamdiagnosticmtest.
PagemRef:m21
CognitivemLevel:m Applying
ClientmNeed/Sub:m PhysiologicalmIntegrity:mReductionmofmRiskmPotential
Standards:mNursingmProcess:mImplementationm|mLearningmOutcome:m1.3m|mQSENmCompeten
cies:mInformatics
AACNmDomainsmandmComps.:m Domainm5:mQualitymandmSafetym
NLNmCompetencies:m Qualitym&mSafety
2