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TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER

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TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER MULTIPLE RESPONSE 1. The nurse is going to measure the patient’s oxygen saturation. The nurse knows pulse oximetry readings can be influenced by which of the following factors. (Select all that apply.) a. Nail polish b. Respiratory treatments c. Poor circulation to the site d. Tremors e. Hemoglobin levels f. Latex allergy ANS: A, B, C, D, E There are many factors that can influence pulse oximetry readings, including nail polish on the fingers where the reading is taken, poor circulation to the extremities, tremors, respiratory treatments, and hemoglobin or hematocrit levels. It is important to select the correct site to take the reading to get the best accuracy. Latex allergy would not affect the reading but would preclude the use of disposable sensors. N DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation N Chapter 08: Health Assessment Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse admits the patient with mild chest pain from the emergency department. Which should the nurse implement first to gain patient cooperation during a physical assessment? a. Explain the procedure and its purpose. b. Perform assessment in stages over the day. c. Complete assessment within 3–5 minutes. d. Assess painful areas before nontender areas. ANS: A First and foremost, the nurse should explain the procedure and its purpose. The patient is more likely to cooperate during a physical assessment if he or she knows what to expect and what the purpose of the procedure is. The nurse explains how the information is used to plan individualized nursing care. The nurse completes the assessment in as few stages as possible because he or she needs the assessment data to plan care. The nurse will assess painful and tender areas last. DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation 2. The nurse assesses a patient with light skin and observes normally shaped nail beds exhibiting pallor and a slight bluish color. Which would the nurse implement first? a. Provide a warm heating pad. b. Collaborate with the health care provider. c. Assess the patient’s oxygen saturation. d. Check for restricted venous return. ANS: C Nail beds in a patient with light skin are a view of the patient’s capillary bed at the periphery. Pallor and a bluish color in the capillary bed indicate inadequate oxygenation because oxygenated blood is dark red resulting in pink nail beds. The nurse would assess the oxygenation more thoroughly and intervene if needed. A heating pad is not warranted. The nurse will collaborate with the provider, but needs more data first. Since this is a problem in the arterial blood flow, checking venous return is not indicated. DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment 3. The nurse is performing a neurological assessment. Which patient behaviors demonstrate a level of consciousness within normal limits? a. States name, age, and date but not location. b. Is lethargic; responds logically to questions. c. Responds verbally, but words are unintelligible. d. Responds to questions spontaneously; is alert and oriented. ANS: D The patient who responds to questions spontaneously and is alert and oriented exhibits neurological findings that are within normal limits. The patient is conscious, responds to the environment, and has congruent thought processes. The patient who does not know the location is disoriented to place. Lethargy is not a normal finding despite correct responses. Unintelligible speech is abnormal. DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment 4. How often should the nurse perform a general assessment of the patient? a. At least every 4 hours b. As often as it is needed c. When the patient requests it d. At the rate set by agency policy ANS: B The nurse performs a general assessment at the beginning of the shift and as often as needed afterward; however, the nurse frequently performs a focused assessment to make clinical judgments and problem solve. Every 4 hours is time consuming unless indicated by patient condition. Patients do not determine when to perform an assessment, but the nurse is responsive to patient concerns and resolves the problem to the patient’s satisfaction. Agency policy sets the minimum standard for patients at different levels of acuity, but the nurse always uses judgment to determine when to assess the patient. DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning 5. The nurse is assessing a patientNwith a cast extending from just below the left knee to the toes. Which assessment contains a desirable patient outcome? a. The toes are pink bilaterally. b. The cast is warm at the ankle. c. Paresthesia is present in the left foot. d. The cast is snug at the knee. ANS: A Bilateral pink toes indicate adequate oxygenation to the periphery and support the outcome, “Patient has pink and warm toes bilaterally while wearing cast.” This also implies that the cast fits properly without areas of constriction. An area of warmth on a cast potentially indicates an infection. Paresthesia indicates nerve compression or irritation; when this occurs with a cast in place on the affected extremity, it usually indicates swelling of the extremity, potentially leading to impaired perfusion. A tight cast potentially restricts blood flow and compresses nerves, leading to tissue damage and paresthesias.

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TEST BANK FOR NURSING INTERVENTIONS AND
CLINICAL SKILLS 7TH EDITION BY POTTER

,Chapter 01: Using Evidence in Nursing Practice
Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition


MULTIPLE CHOICE

1. A nursing educator is explaining how the best clinical practices are determined. Which
statement best explains the purpose of evidence-based practice?
a. It ensures that all patients receive holistic care.
b. It provides a definite reason for providing care in a specific manner.
c. It prevents errors when care is being delivered.
d. It guarantees that care delivered is based on research.
ANS: B
Evidence-based practice is the use of the current best evidence in making patient care
decisions. It applies to all types of health care professionals. Currently there is no method that
can ensure that all patients receive holistic care, that all errors can be prevented, or that a
guarantee exists that care given is based on research.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment
TOP: Nursing Process: Implementation

2. Which question is a problem-focused trigger for initiating the evidence-based practice method
in nursing care?
a. What is known about reduction of urinary tract infections in the older adult with
diabetes?
b. How can chronic pain best be described when the patient is nonverbal?
N
c. How long can an IV catheter remain in place in a patient with obesity?
d. What measures can the nurse take to reduce the rising incidence of urinary tract
infections on the older adult care unit?
ANS: D
Evidence-based practice (EBP) questions tend to arise from two sources: recurrent problems
or new knowledge. In the correct option, the increase in urinary tract infections indicates a
trend or recurring problem in a specific group of patients. The other questions are general
information questions, not based on what is happening in a specific area or to a group of
specific patients in an area or relating to an observed trend.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment
TOP: Nursing Process: Implementation

3. What does the “I” indicate in a “PICO” question?
a. Intervention of interest
b. Incorporation of concepts
c. Implementation by nursing
d. Interest of personnel
ANS: A
The “I” stands for intervention of interest, meaning what the nurse hopes to use in practice
and believes is worthwhile or valuable. This could be a treatment for a specific type of wound
or an approach on how to teach food preparation for a patient with impaired sight.

, DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment
TOP: Nursing Process: Implementation

4. Who will the clinical research nurse contact to search relevant databases in preparation for an
upcoming study?
a. The physician whose patients may be involved in the study
b. The medical librarian
c. The nurse manager of the unit where the study will be conducted
d. The director of nursing of the facility
ANS: B
The medical librarian is most knowledgeable regarding databases relevant to a study. The
other individuals do not have the knowledge regarding relevant databases.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment
TOP: Nursing Process: Implementation

5. Which database contains summaries of clinical guidelines and their development?
a. MEDLINE
b. CINAHL
c. Cochrane Database of Systematic Reviews
d. The National Guideline Clearinghouse
ANS: D
The National Guideline Clearinghouse is a database supported by the Agency for Healthcare
Research and Quality. It contains summaries of clinical guidelines for practice. MEDLINE is
a database for studies in medicN ine, nursing, dentistry, psychiatry, veterinary medicine, and
allied health. CINAHL (Cumulative Index of Nursing and Allied Health Literature) includes
studies in nursing, allied health, and biomedicine. The Cochrane Database Full text of
regularly updated systematic reviews prepared by the Cochrane Collaboration includes
completed reviews and protocols.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment
TOP: Nursing Process: Implementation

6. Which does the nurse researcher identify as the strongest type of research?
a. Randomized controlled trials
b. A qualitative study
c. A descriptive study
d. A case controlled study
ANS: A
Individual randomized controlled trials are close to the top of the research pyramid. Only
systematic reviews and meta-analyses are higher. This type of study tests an intervention
against the usual standard of care. The other types of studies are useful but do not give the
same type of information as a randomized controlled trial provides.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment
TOP: Nursing Process: Assessment

, 7. What is the nurse attempting to determine when critiquing the evidence related to a PICOT
question?
a. The ethical conduct of the research the nurse read
b. The strength of the evidence found in the literature
c. If there are any experts in the clinical question needing to be researched
d. If the study demonstrates cost-effectiveness if a change in practice occurs
ANS: B
Once a literature search is complete and data are gathered about the question, it is time to
critique the evidence. Critiquing the evidence involves a systematic approach to looking at the
strength of the work reviewed and its relevance. The other questions are not applicable to
critiquing the evidence.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment
TOP: Nursing Process: Implementation

8. A nurse finds a cohort study comparing one group taking hormone treatment with another
group not taking hormone treatment to determine the incidence of changes in bone density of
the lower spine. What can the nurse imply from this study?
a. Low level of strength makes the study limited in value.
b. Moderate level of strength makes the study probably useful.
c. Opinions of the individuals in the cohort are not research.
d. This could be the basis for a Quality Improvement project.
ANS: B
A cohort study is Level 4 evidence as it is a single, non-experimental study. This moderate
level of evidence makes the study probably useful but the nurse should strive to find stronger
evidence. N
DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment
TOP: Nursing Process: Evaluation

9. Which question would be the best example of a knowledge-focused trigger for conducting an
evidence-based practice project?
a. What is the best method for treatment of leg swelling when a patient is taking
gabapentin (Neurontin)?
b. How can we decrease the incidence of skin cancer in adults over the age of 65?
c. What is the current evidence for improving oral intake for cancer patients with
stomatitis?
d. What is the maximal length of time our hospital allows irrigation kits to be used?
ANS: C
Evidence-based practice (EBP) questions tend to arise from two sources: recurrent problems
or new knowledge. In this example, the new knowledge that drives the question is the one
looking at current evidence. The other questions do not look at the newest knowledge to form
a question to research.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Safe and Effective Care Environment
TOP: Nursing Process: Implementation


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