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Taylor’s Clinical Nursing Skills A Nursing Process Approach 5th Edition Test Bank

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Taylor’s Clinical Nursing Skills A Nursing Process Approach 5th Edition Test Bank Test Bank Directly From The publisher, 100% Verified Answers. COVERS ALL CHAPTERS. Download Immediately After the Order.

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1. Nurses and other healthcare workers play a key role in reducing the spread of disease,
minimizing complications and reducing adverse outcomes for their patients. Which of
the following statements accurately describe this process? Select all that apply.
A) Nurses limit the spread of microorganisms by completing the chain of infection.
B) Nurses practice asepsis, which includes all activities to prevent infection.
C) Nurses use medical asepsis, which involves procedures and practices that reduce
the number and transfer of microorganisms.
D) Nurses perform surgical asepsis, which includes practices used to render and keep
objects and areas free from microorganisms.
E) Nurses use PPE, which is the most effective way to help prevent the spread of
organisms.
F) Nurses use Standard and Transmission-Based Precautions as an important part of
preventing infection.


2. Nurses use medical asepsis in practice to reduce the number and transfer of pathogens.
Which of the following are principles of this practice? Select all that apply.
A) Carry soiled items close to the body to prevent transfer of pathogens into the
environment.
B) Place soiled bed linen or any other items on the floor, instead of the bed or
furniture.
C) Move equipment close to you when brushing, dusting, or scrubbing articles.
D) Clean the least soiled areas first and then move to the more soiled ones.
E) Use personal grooming habits, such as shampooing hair often, to prevent spreading
microorganisms.
F) Shake out linens and patient clothing before placing them back on the bed.


3. An experienced nurse is teaching a student nurse the proper use of hand hygiene. Which
of the following is an accurate guideline that should be discussed?
A) The use of gloves eliminates the need for hand hygiene.
B) The use of hand hygiene eliminates the need for gloves.
C) Hand hygiene must be performed after contact with inanimate objects near the
patient.
D) Hand lotions should not be used after hand hygiene.


4. When is hand hygiene with an alcohol-based rub appropriate as opposed to using
handwashing?
A) When hands are not visibly soiled
B) Before eating and after using the restroom
C) When hands have been in contact with blood or body fluids
D) When hands have been in contact with blood or body fluids, but there is no visible
soiling




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5. A nurse changing the linens of a patient bed is exposed to urine and performs hand
hygiene. Which of the following is a guideline for performing this skill properly
following this patient encounter?
A) Use an alcohol-based hand rub to decontaminate hands.
B) Remove all jewelry, including wedding bands before handwashing.
C) Keep hands lower than elbows to allow water to flow toward fingertips.
D) Pat dry with a paper towel, beginning with the forearms and moving down to
fingertips.


6. A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter
in a patient. Which of the following is an accurate guideline for using this technique?
A) Hold sterile objects above waist level to prevent accidental contamination.
B) Consider the outside of the sterile package to be sterile.
C) Consider the outer 3-inch edge of a sterile field to be contaminated.
D) Open sterile packages so that the first edge of the wrapper is directed toward you.


7. Which of the following is a recommended guideline for maintaining a sterile field?
A) When a portion of the sterile field becomes contaminated, the nurse should remove
the contaminated objects and continue with the procedure.
B) If a supply is missing, you may leave the sterile field briefly to obtain it.
C) If the patient touches the sterile field, you should discard the supplies and prepare a
new sterile field.
D) If the patient touches the nurse's gloves during the procedure, you may still proceed
with the procedure.


8. A nurse is adding a sterile solution to a sterile field and has just opened the bottle
according to manufacturer's directions. What is the next step?
A) Touch the tip of the bottle to the sterile container to start the flow of the solution
and pour it into the container directly from the top of the container edge.
B) Hold the bottle outside the edge of the sterile field with the label side facing the
palm of the hand and prepare to pour from a height of 4 to 6 inches.
C) “Lip” a new or old bottle of solution before pouring it and hold the solution with
the label facing out from a height of 4 to 6 inches.
D) Hold the bottle inside the 1-inch edges of the sterile field with the label side facing
the palm of the hand and pour from a height of 2 to 4 inches.




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9. Place the following steps for putting the first hand into a sterile glove in the order in
which they would be performed.
A) Carefully open the inner package. Fold open the top flap, then the bottom and
sides.
B) Place the inner package on the work surface with the side labeled 'cuff end' closest
to the body.
C) With the thumb and forefinger of the nondominant hand, grasp the folded cuff of
the glove for dominant hand, touching only the exposed inside of glove.
D) Keeping the hands above the waistline, lift and hold the glove up and off the inner
package with fingers down.
E) Place sterile glove package on clean, dry surface at or above your waist.
F) Carefully insert dominant hand palm up into glove and pull on glove.
G) Open the outside wrapper by carefully peeling the top layer back and remove inner
package, handling only the outside of it.


10. Place the following steps for putting on PPE in the order in which they would be
performed.
A) Put on goggles and place over eyes and adjust to fit.
B) Put on the mask or respirator over your nose, mouth, and chin.
C) Put on the gown, with the opening in the back. Tie gown securely at neck and
waist.
D) Perform hand hygiene.
E) Put on clean, disposable gloves and extend gloves to cover the cuffs of the gown.
F) Provide instruction about precautions to patient, family members, and visitors.


11. Which of the following is an accurate guideline for removing soiled gloves after patient
care?
A) Use the nondominant hand to grasp the opposite glove near the cuffed end on the
outside exposed area.
B) Remove the glove on the nondominant hand by pulling it straight off, keeping the
contaminated area on the outside.
C) After removing the glove on the nondominant hand, hold the removed glove in the
remaining gloved hand.
D) After removing the first glove, slide the fingers of the ungloved hand between the
remaining glove and the wrist and pull the glove straight off with the contaminated
area on the outside.




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12. Which of the following pieces of personal protective equipment should be removed
first?
A) Gloves
B) Respirator
C) Gown
D) Goggles


13. A nurse is performing a venipuncture on a patient and notices that there is a hole in one
of the sterile gloves. What would be the appropriate action to take to maintain a sterile
field?
A) Finish the procedure and perform handwashing immediately afterward.
B) Finish the procedure, remove damaged gloves, and open new sterile gloves.
C) Stop the procedure, remove damaged gloves, and open new sterile gloves.
D) Stop the procedure, remove damaged gloves, perform handwashing, and open new
sterile gloves.


14. For which of the following patients would the use of Standard Precautions alone be
appropriate?
A) A patient with diphtheria who needs pm care
B) A patient with TB who needs medications administered
C) An incontinent patient in a nursing home who has diarrhea
D) A child with chickenpox who is treated in the ER


15. A nurse is in charge of patient care for a patient who has MRSA. Which of the
following is an accurate guideline for using Transmission-Based Precautions when
caring for this patient?
A) Place the patient in a private room that has monitored negative air pressure.
B) Keep visitors 3 feet from the patient.
C) Use respiratory protection when entering the room.
D) Wear gloves whenever entering the patient's room.


16. A nurse is caring for a child who is hospitalized for diphtheria. Which one of the
following guidelines would be appropriate when caring for this patient?
A) Use a private room with the door closed.
B) Wear PPE when entering the room for all interactions that may involve contact
with the patient.
C) Place patient in private room that has monitored negative air pressure.
D) Use respiratory protection when entering the room of patient with known or
suspected diphtheria.




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17. Which of the following is an accurate guideline for the use of PPE?
A) Put on PPE after entering the patient's room.
B) Substitute personal glasses for protective eyewear, if desired.
C) Replace gloves if they are visibly soiled.
D) When wearing gloves, work from “dirty” areas to ”clean” ones.


18. Which of the following would be appropriate nursing diagnoses related to the use of
PPE? Select all that apply.
A) Risk for infection
B) Deficient knowledge
C) Ineffective protection
D) Bowel incontinence
E) Self-care deficit
F) Risk for falls




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Answer Key

1. B, C, D, F
2. D, E
3. C
4. A
5. C
6. A
7. C
8. B
9. E, G, B, A, C, D, F
10. D, F, C, B, A, E
11. C
12. A
13. D
14. C
15. D
16. B
17. C
18. A, B, C, D




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1. A nurse is attempting to obtain vital signs from a restless toddler who is clinging to his
mother's legs and asking to go home. Which of the following would be the best nursing
intervention to accomplish this task?
A) Perform the blood pressure assessment first because it is the most frightening
procedure for a child.
B) Perform as many of the assessments as possible with the child seated on the
parent's lap.
C) Do not allow the child to see the instruments until they are ready to be used.
D) Remove any distractions (e.g., toys/dolls from the room to improve concentration).


2. A nurse assesses the rectal temperature of a patient who is postoperative following oral
surgery. What patient assessment needs to be made before taking this temperature?
A) Pain assessment
B) Pulse rate
C) Platelet count
D) Fecal occult blood test


3. A patient informs the nurse that she still uses a mercury thermometer to take the
temperature of her children when they are sick. Which of the following is a
recommended teaching guideline for patients using these types of thermometers?
A) Teach patient safety related to accidental breakage of the thermometer.
B) Tell patients using mercury thermometers to throw them in the trash and buy a new
type of instrument.
C) Encourage patients to use alternative devices to assess temperature in their home.
D) Tell patients that mercury thermometers should be used only in a hospital setting
with appropriate safeguards.


4. A nurse is obtaining vital signs from patients using the tympanic method for measuring
temperature. Which of the following guidelines should be followed when taking a
tympanic temperature?
A) Do not take a tympanic temperature if the patient has an earache.
B) Do not take a tympanic temperature if there is noticeable earwax present.
C) Do not take a tympanic temperature if the patient has an ear infection.
D) If the patient has been sleeping with head to one side, take the temperature in the
ear facing down.




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5. Which of the following statements accurately describe the types of equipment that are
used to assess temperature? Select all that apply.
A) Nonmercury glass thermometers used for oral readings commonly have blunt bulbs
to prevent injury.
B) Axillary temperatures are generally about one degree less than oral temperatures.
C) Rectal temperatures are generally about one degree higher than other temperatures.
D) The nurse should wait 5 minutes before taking an oral temperature on a patient who
was drinking iced tea.
E) Nasal oxygen is not thought to affect oral temperature readings, but oxygen by
mask does.
F) A dirty probe lens and cone on the temporal artery thermometer can cause a falsely
high reading.


6. A nurse teaching a student nurse how to take temperatures with a nonmercury glass
thermometer would be correct in stating the following:
A) If the thermometer is stored in a chemical solution, wipe the thermometer dry with
a soft tissue, using a firm, twisting motion from the fingers to the bulb.
B) Grasp the thermometer firmly with the thumb and the forefinger and, using strong
wrist movements, shake it until the chemical line reaches at least 92ºF.
C) Read the thermometer by holding it horizontally at eye level, and rotate it between
your fingers until you can see the chemical line.
D) Leave the thermometer in place for 3 minutes for oral, rectal, and axillary routes or
according to agency protocol.


7. Which of the following patients would be an appropriate candidate for the use of a
radiant heater?
A) An older adult suffering from hypothermia
B) A premature infant
C) An infant with jaundice
D) A child recovering from a near-drowning incident


8. A nurse responds to an order to place an infant in an overhead radiant heater. Which of
the following are recommended guidelines the nurse should follow?
A) Attach the probe to the infant's skin over a bony area.
B) Allow the blankets to warm before placing the infant under the warmer.
C) Make sure nothing is covering the probe to allow it to register an accurate
temperature.
D) Keep the setting of the warmer on manual and adjust it at 15-minute intervals
according to the temperature registered.




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9. A nurse is using a cooling blanket on an adult patient with an uncontrolled fever. Which
of the following statements accurately describes a recommended guideline for using this
type of equipment?
A) Position the blanket under the patient so that the top edge of the pad is aligned with
the patient's neck.
B) For patients who are comatose or anesthetized, use a rectal probe to monitor core
body temperature.
C) Cover the hypothermia blanket with a thick blanket or mattress pad.
D) Do not apply lanolin to the patient's skin where it will be in contact with the
blanket.


10. A nurse records a pulse rate of 170 beats/minute on a patient's flow chart. For which of
the following age groups would this be considered a normal reading?
A) Newborn
B) Ten-year-old
C) Adolescent
D) Adult


11. A nurse palpates the pulse of a patient and documents the following: 6/6/12 pulse 85
and regular, 3+, and equal in radial, popliteal, and dorsalis pedis. What does the number
3+ represent?
A) Pulse rate
B) Pulse quality (amplitude)
C) Pulse rhythm
D) Pulse deficit


12. On assessment, a nurse notes that a patient's pulse is weak and applying light pressure
causes it to disappear. What pulse amplitude would the nurse document on the flow
chart?
A) 1+
B) 2+
C) 3+
D) 4+


13. A patient is taking medications to treat a heart arrhythmia. Which site should be used to
assess pulse in this patient?
A) Brachial
B) Radial
C) Dorsalis pedis
D) Apical




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