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Based Approach 4th Edition Pearsonii
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,Clinical Nursing Skills: A Concept- z l z l zl z l
Based Approach, 4e (Pearson) Education Test BankiiChapter 1: Assessment
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1) A client on the medical/surgical unit complains of sudden chest pains. Which acti
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on will theiinurse implement first?
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A) Call the healthcare provider. z l z l z l
B) Administer pain medication. z l z l
C) Reassess a new set of vital signs. z l z l z l z l z l z l
D) Turn client from supine to l zl zl zl zl zl
ateral.iiANSWER: C z l
Explanation: A) The nurse will need to reassess the client first, before calling the hea
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lthcareprovider.
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 i
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s a change iniicondition.
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D) The nurse will need to reassess the client first, before moving the client, to av
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oid making theiichange in client's condition worse.
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Page Ref: 2 z l z l
Cognitive Level: Applying z l
Client Need/Sub: z l
Physiological Integrity: Reduction of Risk Potential S z l z l z l zl z l zl
tandards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSE
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N Competencies:Patient-Centered Care
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AACN Domains and Comps.: Domain 2: Person-
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Centered CareiiNLN Competencies: Relationship Centered Car
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e
2) The nurse is observing the UAP taking the temperature of an unconscious clie
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nt. Which routeiiwill the nurse question the UAP using?
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A) Oral
B) Rectal
C) Scanner
D) Tympanic
iiANSWER:
A
Explanation: A) The temperature of an unconscious client is never taken by mouth.
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The rectal,tympanic, 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
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preferred.Page Ref: 24 z l z l
Cognitive Level: Applying z l
Client Need/Sub: z l
Safe and Effective Care Environment: Safety and Infection Control z l z l z l zl z l zl z l z l zl
Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies
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: SafetyAACN 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-
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old client's diaper and notes the client feels warm to touch.Which method should the
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nurse use to check the baby's temperature?
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A) Oral
B) Rectal
C) Axillary
D) Tympanic membra zl
neiiANSWER:
C
Explanation: A) Oral is used for age 3 or older. z l z l z l z l z l z l z l z l
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
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lolder.Page Ref: 29 z l z l
Cognitive Level: Applying z l
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies
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: SafetyAACN 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 (COP
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D). Whichiinoninvasive diagnostic test will the nurse implement to know that the client
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is receiving enough oxygen?
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A) Chest x-ray z l
B) Pulse oximeter z l
C) Arterial blood gasses z l z l
D) Assessment of respiratory zl zl zl
rateiiANSWER: B z l
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 oxyg
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en saturation, in the blood and provides a pulse reading, which is especially helpful for
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the clientiiwith a respiratory illness or disease.
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C) Arterial blood gases are an invasive diagnostic test.
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D) Assessing a respiratory rate is important for the nurse to implement; however,
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lit is not aiidiagnostic test.
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Page Ref: 21 z l z l
Cognitive Level: Applying z l
Client Need/Sub: z l
Physiological Integrity: Reduction of Risk Potential Stand z l z l z l zl z l zl
ards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Co
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mpetencies:Informatics
AACN Domains and Comps.: Domain 5: Quality and Safety
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NLN Competencies: Quality & Safety
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2