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Test Bank for Clinical Nursing
Skills:
A Concept-Based
Approach 4th Edition
Volume III
by Pearson Education
Chapters 1 - 16
Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th
Edition Pearson
1
Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson)
Education Test Bank Chapter 1: Assessment
1) A client on the medical/surgical unit complains of sudden chest pains.
Which action will the nurse implement first?
A) Call the healthcare provider.
B) Administer pain medication.
C) Reassess a new set of vital signs.
D) Turn client from supine to
lateral. ANSWER: C
Explanation: A) The nurse will need to reassess the client first, before
calling the healthcare provider.
B) The nurse will need to reassess the client first, before administering pain
medication.
C) The nurse needs to implement a new set of vital signs first when
there is a change in condition.
D) The nurse will need to reassess the client first, before moving the client,
to avoid making the change in client's condition worse.
Page Ref: 2
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Relationship
Centered Care
2) The nurse is observing the UAP taking the temperature of an unconscious
client. Which route will the nurse question the UAP using?
A) Oral
B) Rectal
C) Scanner
D) Tympa
nic
ANSWER:
A
Explanation: A) The temperature of an unconscious client is never taken
by mouth. The rectal, tympanic, or scanner method is preferred.
B) The rectal, tympanic, or scanner method is preferred.
C) The rectal, tympanic, or scanner method is preferred.
D) The rectal, tympanic, or scanner method
is preferred. Page Ref: 24
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and
Infection Control Standards: Nursing Process: Evaluation | Learning
Outcome: 1.1 | QSEN Competencies: Safety AACN Domains and Comps.:
Domain 5: Quality and Safety
2
NLN Competencies: Quality & Safety
3
3) The nurse is changing a 2-month-old client's diaper and notes the client
feels warm to touch. Which method should the nurse use to check the
baby's temperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
membrane
ANSWER: C
Explanation: A) Oral is used for age 3 or older.
B) The rectal route is the least desirable.
C) The axillary route may not be as accurate as other routes for detecting
fevers in children.
D) The tympanic membrane may be used for 3
months or older. Page Ref: 29
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN
Competencies: Safety AACN Domains and Comps.: Domain 5: Quality and
Safety
NLN Competencies: Quality & Safety
4) A client comes in with exacerbation of chronic obstructive pulmonary
disease (COPD). Which noninvasive diagnostic test will the nurse
implement to know that the client is receiving enough oxygen?
A) Chest x-ray
B) Pulse oximeter
C) Arterial blood gasses
D) Assessment of
respiratory rate ANSWER:
B
Explanation: A) A chest x-ray is not an intervention a nurse completes.
B) A pulse oximeter provides a noninvasive method of measuring
oxygenation, or oxygen saturation, in the blood and provides a pulse
reading, which is especially helpful for the client with a respiratory
illness or disease.
C) Arterial blood gases are an invasive diagnostic test.
D) Assessing a respiratory rate is important for the nurse to implement;
however, it is not a diagnostic test.
Page Ref: 21
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: Nursing Process: Implementation | Learning Outcome: 1.3 |
QSEN Competencies: Informatics
AACN Domains and Comps.: Domain 5: Quality
and Safety NLN Competencies: Quality & Safety
4
5) The nurse is preparing to assess a client's musculoskeletal system. Which
question should the nurse ask before beginning this assessment?
A) "Do you exercise every day?"
B) "Do you have a history of any sports injuries?"
C) "Do you take a hot bath to relax your muscles?"
D) "Do you want pain medication before
I begin?" ANSWER: B
Explanation: A) Knowing if a client exercises is an important question but
knowing if there are any sports injuries to know about first, is most
important before doing a routine musculoskeletal assessment.
B) It is important to note if the client has a history of any sports injuries
first to know what the client will or will not be able to do during a
routine musculoskeletal assessment.
C) Knowing if the client takes a hot bath to relax the muscles is not the
most important thing to ask before performing a routine musculoskeletal
assessment.
D) To know if a client is experiencing any pain is an important question;
however, this question is assuming the client is in pain by asking if the
client wants a pain medication before beginning a routine musculoskeletal
assessment.
Page Ref: 62
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and
Infection Control Standards: Nursing Process: Assessment | Learning
Outcome: 1.5 | QSEN Competencies: Safety
AACN Domains and Comps.: Domain 5: Quality and
Safety NLN Competencies: Quality & Safety
6) An adult child mentions that the client seems to have a decline in mental
status and seems to be forgetting many things in their conversation since
being hospitalized. Which response should the nurse make?
A) "Give your mom time, because it will take her a little longer when
answering questions."
B) "Let me check the cranial nerve function to see if there is a defect in her
mental status."
C) "You do not need to worry. This decline is part of the normal process of
aging."
D) "If you bring some things from her home, it might reduce
the confusion." ANSWER: D
Explanation: A) This is expected to give some older adults time to respond,
but the daughter is concerned about her forgetting, not the length of the
response.
B) Cranial nerve function is an assessment of the cranial nerves and not
the mental status of a client.
C) A decline in mental status is not a normal result of aging, so this response
is not true.
5
D) The stress of being in unfamiliar situations can cause confusion in
some older adults. Page Ref: 75
Cognitive Level: Applying
Client Need/Sub: Psychosocial Integrity
Standards: Nursing Process: Planning | Learning Outcome: 1.6 | QSEN
Competencies: Patient- Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Context and
Environment
7) When assessing breath sounds, the nurse hears moderate-intensity and
moderate-pitch
6
"blowing" sounds between the scapulae and lateral to the sternum at
the first and second intercostal spaces. Which action should the nurse
take?
A) Encourage the client to cough and deep breathe.
B) Notify the healthcare provider of abnormal breath sounds.
C) Document assessment findings as normal breath sounds.
D) Raise the head of the bed to allow maximum
air excursion. ANSWER: C
Explanation: A) There is no reason to encourage the client to take deep
breaths and cough.
B) The nurse would notify the healthcare provider if these were
adventitious lung sounds; however, these are bronchovesicular
sounds.
C) These are bronchovesicular sounds.
D) The nurse would implement this if these were adventitious lung
sounds; however, these are bronchovesicular sounds.
Page Ref: 88
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.7 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Context and
Environment
8) A client seeks medical attention for shortness of breath and a fever.
Which amount of time should the nurse count the peripheral pulse?
A) 15 seconds
B) 30 seconds
C) 1 minute
D) 2
minutes
ANSWER:
C
Explanation: A) Count for a full minute if taking a client's pulse for the
first time.
B) Count for a full minute if taking a client's pulse for the first time.
C) Count for a full minute if taking a client's pulse for the first time.
D) Count for a full minute if taking a client's pulse for
the first time. Page Ref: 19
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.8 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality & Safety
7
9) The nurse is preparing a dose of digoxin for a client. Which
assessment will the nurse complete prior to giving this medication?
A) Temperature
B) Apical pulse
C) Respiratory rate
D) Pain using a pain
scale ANSWER: B
Explanation: A) The temperature does not need to be assessed before giving
digoxin.
B) The nurse should assess the apical pulse before the administration of a
medication that could affect the cardiovascular system, such as before
giving a digitalis preparation.
C) The respiratory rate does not need to be assessed before giving digoxin.
D) Pain level does not need to be assessed before
giving digoxin. Page Ref: 18
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Pharmacological and
Parenteral Therapies Standards: Nursing Process: Assessment |
Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 5: Quality and
Safety NLN Competencies: Quality & Safety
10) The nurse is completing a general assessment of a newborn. Which
technique should the nurse use?
A) Wrap the tape measure around the head below the ears.
B) Wrap the tape measure around the head starting at the nose.
C) Wrap the tape measure around the abdomen at the umbilicus.
D) Wrap the tape measure around the chest below
the nipple line. ANSWER: C
Explanation: A) When measuring the head circumference, wrap the tape
around the head at the supraorbital prominence above the eyebrows,
above the ears, and around the occipital prominence.
B) When measuring the head circumference, wrap the tape around the
head at the supraorbital prominence above the eyebrows, above the ears,
and around the occipital prominence.
C) When measuring the abdomen circumference, wrap the tape around the
abdomen at the level of the umbilicus.
D) When measuring the chest circumference, wrap the tape measure around
the chest, placed just under the axilla and at the nipple line.
Page Ref: 31
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality &
Safety
8
11) The nurse is measuring the blood pressure of an adult client. Which
technique would cause an erroneously low blood pressure?
A) Bladder to cuff ratio too wide
B) Arm unsupported
C) Cuff wrapped too loosely
D) Arm below heart
level ANSWER: A
Explanation: A) The width of the bladder cuff needs to be 40% of the
circumference or 20% wider than the diameter of the midpoint.
B) If the arm is unsupported, it will cause an erroneously high blood
pressure.
C) If the cuff is wrapped too loosely, it will cause an erroneously high blood
pressure.
D) If the arm is below heart level, it will cause an erroneously
high blood pressure. Page Ref: 11
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality & Safety
12) The nurse is reviewing collected data. Which client should the nurse see
first?
A) Infant respirations 38/min
B) 2-year-old pulse 112/min
C) 6-year-old axillary temperature 97.5°F
D) 10-year-old blood pressure
138/88 ANSWER: D
Explanation: A) An infant's respiration range is 20-40/min.
B) A 2-year-old child's pulse range is 70-120/min.
C) A 6-year-old child's temperature range is 98.6°F but axillary is 1°F lower
than oral.
D) A 10-year-old child's blood pressure range is systolic 95-116 and
diastolic 60-70. This is much higher than the range for the age of this
client.
Page Ref: 15
Cognitive Level: Analyzing
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality & Safety
9
13) The nurse is caring for a client with diaphoresis. Which route should
the nurse use to assess the client's temperature? Select all that apply.
A) Oral
B) Rectal
C) Axillary
D) Tympanic
E) Heat
sensitive
ANSWER: A,
B, D
Explanation: A) Oral does not interfere with diaphoresis because the probe
is in the mouth.
B) Rectal does not interfere with diaphoresis because the probe is in the
rectum.
C) Axillary might be wet and cause an error in the reading temperature.
D) Tympanic does not interfere with diaphoresis because the probe is in the
ear. However, do not use if ear is draining or infected.
E) Heat sensitive might have areas of the skin that are wet and cause
an error in reading temperature.
Page Ref: 26, 28
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality &
Safety
14) The nurse is preparing to assess a client's abdomen. Which response
will the nurse make when asked why the stethoscope is warmed up before
placing it on the abdomen?
A) "I might hear a friction rub with a cold stethoscope."
B) "A nice nurse will put a warm stethoscope on your abdomen."
C) "A cold stethoscope may cause your abdominal muscles to contract."
D) "Warming up the stethoscope will help with the
digestion of your food." ANSWER: C
Explanation: A) The nurse might hear a friction rub due to an
inflammation, infection, or abdominal growth, not from a cold
stethoscope.
B) Warming up a stethoscope can be nice for the client's comfort; however,
it is done to decrease the possibility of abdominal muscles contracting;
otherwise the nurse might hear unnecessary contractions.
C) A cold stethoscope may cause the abdominal muscles to contract which
the nurse might hear with a cold stethoscope.
D) Warming up the stethoscope has no effect on the digestion of food. A
warm stethoscope will decrease the possibility of abdominal muscles
1
0
contracting, eliminating the possibility of the nurse hearing any
unnecessary noises.
Page Ref: 31
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality &
Safety
1
1
15) The nurse is preparing a teaching tool about gastrointestinal function.
Which signs and symptoms of colon cancer will the nurse include on the
tool? Select all that apply.
A) Weight gain
B) Rectal bleeding
C) Unusual cough
D) Change in bowel function
E) Decrease medication
absorption ANSWER: B, D
Explanation: A) Weight loss, not gain, is a sign and symptom of colon
cancer.
B) Rectal bleeding is a symptom of colon cancer.
C) Unusual cough is more a sign and symptom of a lung infection or lung
cancer.
D) A change in bowel function is a symptom of colon cancer.
E) A decrease in medication absorption often occurs with aging,
not colon cancer. Page Ref: 34
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality &
Safety
16) The nurse needs to assess the ears of a 2-year-old client. Which technique
will the nurse use?
A) Pull the pinna up and back.
B) Pull the pinna up and forward.
C) Pull the pinna down and back.
D) Pull the pinna down and
forward. ANSWER: C
Explanation: A) Pulling the pinna up and back will straighten the ear canal
for a client greater than 3 years old.
B) Pulling the pinna up and forward will not allow sufficient visualization of
the ear.
C) Pulling the pinna down and back will straighten the ear canal for a client
less than 3 years old.
D) Pulling the pinna down and forward will not allow sufficient
visualization of the ear. Page Ref: 43
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality &
Safety
1
2
17) The nurse is assessing an adolescent. Which finding indicates that the
client is in Tanner's stage 5?
A) There is no pubic hair except for fine body hair.
B) Pubic hair is developing along the labia.
C) Pubic hair distribution extends to umbilicus.
D) Pubic hair appears on the inner aspect
of the thigh. ANSWER: D
Explanation: A) No pubic hair is Tanner Stage 1.
B) Pubic hair developing along the labia is Stage 2.
C) Pubic hair distribution extends to umbilicus is Stage 5 but for men only.
D) Pubic hair appears on the inner aspect of the
thigh for Stage 5. Page Ref: 51
Cognitive Level: Understanding
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality &
Safety
18) The UAP notifies the nurse of these vital signs for a client on the
medical-surgical unit: temperature 97.6°F, respirations 22, pulse 122, and
BP 98/72. mm Hg Which action should the nurse take?
A) Ask the UAP to reassess the client.
B) Inform the UAP to document these vital signs.
C) Reassess the client to validate these vital signs.
D) Notify the healthcare provider of these
vital signs. ANSWER: C
Explanation: A) UAP cannot assess or reassess as evaluation of data.
B) These vital signs are abnormal; the nurse needs to reassess the
client to validate these findings.
C) The nurse needs to reassess the client to validate these findings.
D) The nurse will notify the healthcare provider of these vital signs after the
nurse reassesses the client to validate these findings.
Page Ref: 2
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality &
Safety
10
19) The nurse is assessing the Babinski response of an adult client. Which
finding indicates that the response is negative?
A) All toes turn inward.
B) All toes curve upward.
C) All toes spread outward.
D) All toes bend
downward. ANSWER:
D
Explanation: A) This is not in relation to the Babinski response; it could be
another problem.
B) A positive Babinski response is when the toes spread outward and the
big toe moves upward and backward.
C) A positive Babinski response is when the toes spread outward and the
big toe moves upward and backward.
D) All toes bend downward for a negative Babinski
response on an adult. Page Ref: 70
Cognitive Level: Analyzing
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality &
Safety
20) The nurse is preparing to assess an adult client's blood pressure. Which
action will the nurse take after introducing self?
A) Provide privacy.
B) Perform handwashing.
C) Identify the client with two identifiers.
D) Explain what he or she will be doing
with the client. ANSWER: C
Explanation: A) Need to identify the right client before providing privacy
so the correct room is located.
B) Need to identify the right client before performing handwashing so
the correct room is located.
C) The nurse needs to identify the right client before doing anything else
after introducing self.
D) The nurse needs to identify the right client before explaining the
procedure so the client knows why the nurse is in the room.
Page Ref: 14
Cognitive Level: Understanding
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality &
Safety
11
21) The nurse is completing an assessment on a client who just received
morphine. Which parameter is the highest priority?
A) Pain level
B) Respirations
C) Temperature
D) Blood
pressure
ANSWER: B
Explanation: A) Pain level has already been assessed because the client just
received morphine and it is too early to reassess pain.
B) Respirations are highest priority after administering morphine because
morphine can cause respiratory depression.
C) The temperature of a client is not affected by morphine or pain.
D) Blood pressure can change because of the client's pain; however, the
highest priority for this client is respirations because morphine was just
administered.
Page Ref: 23
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and
Infection Control Standards: Nursing Process: Assessment | Learning
Outcome: 1.4 | QSEN Competencies: Safety
AACN Domains and Comps.: Domain 5: Quality and
Safety NLN Competencies: Quality & Safety
22) The nurse receives information provided during hand-off
communication. Which client will the nurse see first?
A) Kussmaul respirations
B) Blood glucose of 144 mg/dL
C) Pain level 6 out of 10
D) Temperature is
101.8°F ANSWER: A
Explanation: A) This client is probably experiencing diabetic ketoacidosis
or going into shock and needs to be reassessed immediately.
B) The glucose is elevated in this client, but the Kussmaul breathing has a
higher priority.
C) The pain level is moderate pain.
D) The temperature is elevated, but Kussmaul breathing has
a higher priority. Page Ref: 91
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality &
Safety
12
23) The nurse is reviewing the care needs of assigned clients. Which task
can the nurse delegate to the UAP?
A) Administration of medication
B) Recording findings from a sponge bath
C) Teaching a client how to take own vital signs
D) Assessing a client in the medical-surgical unit
for two days ANSWER: B
Explanation: A) Administration of medication requires licensed personnel
to administer.
B) A UAP can record the findings from a sponge bath because the skin is
observed during a UAP's usual care.
C) UAPs cannot teach clients because this is outside their scope of practice.
D) Assessing is outside the UAP's scope
of practice. Page Ref: 79
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Management
of Care Standards: Nursing Process: Assessment | Learning Outcome:
1.4 | QSEN Competencies: Safety
AACN Domains and Comps.: Domain 5: Quality and
Safety NLN Competencies: Quality & Safety
24) The nurse reviews applying a pulse oximeter with UAP. Which statement
indicates teaching was effective?
A) "I will clean the site after applying the sensor."
B) "I will move the adhesive toe or finger sensor once a shift."
C) "I will remove any fingernail polish when using a pulse oximeter."
D) "I will use the side of the finger rather than perpendicular
to the nail bed." ANSWER: D
Explanation: A) The site needs to be cleaned before applying the sensor.
B) The adhesive toe or finger sensor needs to be moved every four hours.
C) The UAP needs to remove dark fingernail polish.
D) The side of the finger is an alternate use if the client has dark
fingernail polish on the fingernail.
Page Ref: 21
Cognitive Level: Analyzing
Client Need/Sub: Safe and Effective Care Environment: Management
of Care Standards: Nursing Process: Assessment | Learning Outcome:
1.4 | QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-
Centered Care NLN Competencies: Quality &
Safety
1
Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson
Education) Test bank Chapter 2: Caring Interventions
1) The nurse is observing a UAP performing a bed bath for a client. Which
action by the UAP requires the nurse to intervene?
A) Washing the client's arms from wrists to shoulders.
B) Washing the client's eyes and face first before the rest of the body.
C) Washing, rinsing, and drying the client's leg from thigh to ankle.
D) Washing the client's back and then the
perineum. ANSWER: C
Explanation: A) The arms should be washed from wrist to shoulder.
B) The eyes and face should be washed before the rest of the body.
C) The correct method in performing a bed bath is washing, rinsing, and
drying the client's leg from ankle to thigh.
D) The back is washed before the
perineum. Page Ref: 98-99
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Basic Care and Comfort
Standards: Nursing Process: Assessment | Learning Outcome: 2.3 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.3 Integrate assessment
skills in practice. NLN Competencies: Relationship
Centered Care
2) The nurse delegates soft contact lens care to a UAP. Which action by
the UAP requires the nurse to intervene?
A) Placing the client in the semi-Fowler's position.
B) Placing the client's removed disposable lenses in the trash.
C) Placing the gloved thumb and forefinger directly on the soft lens on top of
the eyeball.
D) Placing the gloved thumb on the client's lower eyelid and gloved index
finger on the client's upper lid, pressing lightly on the eyeball.
ANSWER: D
Explanation: A) The client should be in the semi-Fowler position.
B) Disposable lens should be placed in the trash.
C) Pressure should not be applied directly on the soft lens covering the
eyeball.
D) Placing the gloved thumb on the client's lower eyelid and gloved index
finger on the client's upper lid, pressing lightly on the eyeball is the
technique to remove rigid contact lenses, not soft lenses.
Page Ref: 110
Cognitive Level: Analyzing
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Intervention | Learning Outcome: 2.3 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 5.2 Contribute to a culture of
2
patient safety. NLN Competencies: Relationship Centered
Care
3
3) The nurse determines some client care tasks can be delegated to the
UAP. Which task should the nurse omit?
A) Performing foot care for a client with diabetes.
B) Changing an occupied bed for a client with multiple intravenous
medications infusing.
C) Performing a bath for a newborn with an unhealed umbilical cord.
D) Oral care for an
unconscious client. ANSWER:
A
Explanation: A) The registered nurse should perform foot care for the
client with diabetes.
B) UAP can change an occupied bed.
C) UAP can provide a bath to a newborn with an unhealed umbilical cord.
D) UAP can provide oral care to an
unconscious client. Page Ref: 111
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Basic Care and Comfort
Standards: Nursing Process: Intervention | Learning Outcome: 2.3 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Relationship Centered
Care
4) When teaching the client about foot care, which statement will the
nurse include in the teaching?
A) "Use creams or lotions on the feet and in between the toes after
showering."
B) "While sitting, cross your legs at the knees instead of the ankles."
C) "Avoid using pumice stones on the feet to decrease callouses."
D) "When your feet are cold, place them on a hot water bottle
to warm them." ANSWER: C
Explanation: A) Lotion or cream should be applied on the feet, avoiding the
toes, after showering.
B) Legs should be crossed at the ankles.
C) The client should avoid using pumice stones on the feet because these can
injure the feet.
D) Feet should not be placed on a hot water bottle as this
could cause a burn. Page Ref: 113
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Intervention | Learning Outcome: 2.3 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.8 Promote self-care
management. NLN Competencies: Relationship
Centered Care
4
5) Prior to delegating hearing aid care to a UAP, what is the nurse's
PRIORITY?
A) Determine the UAP's knowledge of the procedure.
B) Inform the UAP of what to report back to the nurse.
C) Discuss relevant client health information necessary for the task.
D) Provide the UAP with guidance on where to find supplies
necessary for the task. ANSWER: A
Explanation: A) Prior to delegation, the nurse must first determine the
UAP's knowledge of the procedure.
B) Reporting back to the nurse can occur at the end of the procedure.
C) Client information is not essential when delegating hearing aid care.
D) The UAP should be provided with the supplies
for the task. Page Ref: 116
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Basic Care and Comfort
Standards: Nursing Process: Intervention | Learning Outcome: 2.3 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.6 Demonstrate accountability for
care delivery. NLN Competencies: Quality & Safety
6) A client places one hearing aid in the ear and tells the nurse, "I hear a
whistling sound." Which actions will the nurse take in response to the
client's statement? Select all that apply.
A) Turn the volume of the hearing aid up.
B) Check the battery inside the hearing aid.
C) Turn the volume of the hearing aid down.
D) Ensure the ear canal is not blocked with wax.
E) Check that the earmold is attached to
the receiver. ANSWER: C, E
Explanation: A) Turning the volume up will make the whistling worse.
B) The battery does not need to be checked.
C) Turning the volume of the hearing aid down will decrease the client's
distress.
D) Wax in the ear does not cause the hearing aid to whistle.
E) Checking that the earmold is attached to the receiver troubleshoots
the whistling noise. Page Ref: 117
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Basic Care and Comfort
Standards: Nursing Process: Intervention | Learning Outcome: 2.3 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.6 Demonstrate accountability for
care delivery. NLN Competencies: Relationship Centered Care
5
7) The nurse cares for a client who receives new hearing aids for the first
time. Which statements will the nurse include when teaching the client
about the hearing aids? Select all that apply.
A) "Push the earmold slightly backward and pull out to remove it."
B) "Rotate the earmold slightly forward and pull out to remove it."
C) "If the hearing aid is not used for several days, be sure to turn the device
off."
D) "If the earmold is detachable, soak it in isopropyl alcohol weekly to
disinfect it."
E) "Blow any excess moisture through the opening of the earpiece
when cleaning it." ANSWER: B, E
Explanation: A) The hearing aid is not removed by pushing the earmold
backward.
B) The nurse will instruct the client to rotate the earmold slightly
forward and pull it out to remove it.
C) The battery should be removed if the device is not used for several days.
D) The earmold should not be soaked in alcohol.
E) To remove excess moisture, the client can be instructed to blow any
excess moisture through the opening of the earpiece.
Page Ref: 116
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Basic Care and Comfort
Standards: Nursing Process: Intervention | Learning Outcome: 2.3 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.2 Communicate effectively
with individuals. NLN Competencies: Relationship Centered
Care
8) The nurse is performing hearing aid care for a client and notes the
hearing aid has "TM" near its on/off switch. What is the nurse's
understanding of the meaning of "TM"?
A) Transmitting mode
B) Tympanic membrane
C) Telephone/microphone
D) Tympanic/microp
hone ANSWER: C
Explanation: A) TM does not mean transmitting mode.
B) TM does not mean tympanic membrane.
C) "T/M" on the hearing aid stands for telephone/microphone, not tympanic
membrane.
D) TM does not mean tympanic
microphone. Page Ref: 116
Cognitive Level: Remembering
Client Need/Sub: Physiological Integrity: Basic Care and Comfort
Standards: Nursing Process: Assessment | Learning Outcome: 2.3 |
QSEN Competencies: Patient-Centered Care
6
AACN Domains and Comps.: 2.2 Communicate effectively with
individuals. NLN Competencies: Quality & Safety
7
9) A nurse is providing oral care to an older adult. What findings does the
nurse recognize are normal findings in this client? Select all that apply.
A) Dry mouth
B) Gingivitis
C) Jaw bone loss
D) Receding gums
E) Tooth root
decay
ANSWER: A, D,
E
Explanation: A) Dryness of the oral mucosa is a common finding among
many older adults.
B) Gingivitis is not a common finding in an older adult.
C) Jaw bone loss is not a common finding in an older adult.
D) Receding gums is a common finding among many older adults.
E) Tooth root decay is common in some older adults, often due
to receding gums. Page Ref: 122
Cognitive Level: Remembering
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 2.3 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.3 Integrate assessment skills
in practice. NLN Competencies: Knowledge and Science
10) The nurse is making an occupied bed. In which order should the
nurse perform when removing the top linens and adding the bath
blanket?
A) Spread the bath blanket over the top sheet.
B) Remove the spread and the blanket.
C) Reach under the bath blanket, grasp top edge of sheet.
D) Ask the client to hold the top edge of the bath blanket.
E) Pull the sheet from under the
bath blanket. ANSWER: B, A, D, C,
E
Explanation: A) Spreading the bath blanket over the top sheet happens
after the nurse removes the spread and blanket (top linens).
B) Removing the spread and blanket is the first step in the procedure.
C) After removing the spread and the blanket, spreading the bath blanket on
the top sheet, asking the client to hold the top edge of the bath blanket, the
nurse will reach under the bath blanket and grasp the top edge of the sheet.
D) After removing the spread and the blanket, spreading the bath
blanket on the top sheet, thenurse will ask the client to hold the top
edge of the bath blanket.
E) After removing the spread and the blanket, spreading the bath blanket on
the top sheet, asking the client to hold the top edge of the bath blanket, the
8
nurse will reach under the bath blanket and grasp the top edge of the sheet.
Finally, the nurse will pull the sheet from under the bath blanket. Page Ref:
104
Cognitive Level: Analyzing
Client Need/Sub: Safe and Effective Care Environment: Safety and
Infection Control Standards: Nursing Process: Intervention |
Learning Outcome: 2.1 | QSEN Competencies: Safety
AACN Domains and Comps.: 2.6 Demonstrate accountability for
care delivery. NLN Competencies: Quality & Safety
9
11) The nurse prepares to make an unoccupied bed. Place the steps in
correct order of how the nurse will remove the soiled linens.
A) Detach the call bell and any drainage tubes from the bed linens.
B) Loosen all the bedding systematically.
C) Roll all soiled linens inside the bottom sheet.
D) Remove the incontinent pad and discard.
E) Remove the pillowcases and fold
reusable linens. ANSWER: A, B, E, D, C
Explanation: A) The first step to make an unoccupied bed is to detach the
call bell and any drainage tubes from the bed linens.
B) The second step when making an unoccupied bed is loosening all the
bedding systematically.
C) The final step when making an unoccupied bed is rolling all soiled
linens inside the bottom sheet.
D) Removing the incontinent pad and discarding it occurs after detaching
the call bell, loosening the bedding, and removing the pillowcases.
E) Removing the pillowcases occurs after detaching the call bell and
loosening all bedding systematically.
Page Ref: 105
Cognitive Level: Analyzing
Client Need/Sub: Safe and Effective Care Environment: Safety and
Infection Control Standards: Nursing Process: Intervention | Learning
Outcome: 2.1 | QSEN Competencies: Safety
AACN Domains and Comps.: 2.6 Demonstrate accountability for
care delivery. NLN Competencies: Quality & Safety
1
0
12) The nurse prepares to perform oral care for a client with dentures.
Place the steps in correct order for how the nurse will remove the client's
dentures.
A) Use gauze to grasp upper plate at the front teeth with the thumb and
second finger.
B) Lift the lower plate and remove without stretching the lip.
C) Move the denture up and down slightly.
D) Don gloves.
E) Place the upper plate in the denture cup.
F) Place the lower plate in the
denture cup. ANSWER: D, A, C, E,
B, F
Explanation: A) The correct steps to remove the client's dentures is as
follows: Don gloves, use gauze to grasp the upper plate at the front teeth
with the thumb and second finger, move the denture up and down slightly,
place the upper plate in the denture cup. Next, lift the lower plate and
remove it without stretching the lip. Finally, place the lower plate in the
denture cup.
B) The correct steps to remove the client's dentures is as follows: Don
gloves, use gauze to grasp the upper plate at the front teeth with the thumb
and second finger, move the denture up and down slightly, place the upper
plate in the denture cup. Next, lift the lower plate and remove it without
stretching the lip. Finally, place the lower plate in the denture cup.
C) The correct steps to remove the client's dentures is as follows: Don
gloves, use gauze to grasp the upper plate at the front teeth with the thumb
and second finger, move the denture up and down slightly, place the upper
plate in the denture cup. Next, lift the lower plate and remove it without
stretching the lip. Finally, place the lower plate in the denture cup.
D) The correct steps to remove the client's dentures is as follows: Don
gloves, use gauze to grasp the upper plate at the front teeth with the thumb
and second finger, move the denture up and down slightly, place the upper
plate in the denture cup. Next, lift the lower plate and remove it without
stretching the lip. Finally, place the lower plate in the denture cup.
E) The correct steps to remove the client's dentures is as follows: Don
gloves, use gauze to grasp the upper plate at the front teeth with the thumb
and second finger, move the denture up and down slightly, place the upper
plate in the denture cup. Next, lift the lower plate and remove it without
stretching the lip. Finally, place the lower plate in the denture cup.
F) The correct steps to remove the client's dentures is as follows: Don
gloves, use gauze to grasp the upper plate at the front teeth with the thumb
and second finger, move the denture up and down slightly, place the upper
plate in the denture cup. Next, lift the lower plate and remove it without
stretching the lip. Finally, place the lower plate in the denture cup.
Page Ref: 119
Cognitive Level: Analyzing
1
1
Client Need/Sub: Safe and Effective Care Environment: Safety and
Infection Control Standards: Nursing Process: Intervention | Learning
Outcome: 2.2 | QSEN Competencies: Safety
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
1
2
13) The nurse prepares to mix two medications (vial A and B) in one
syringe. Place the steps in correct order for how the nurse will perform
the procedure.
A) Inject a volume of air equal to the volume of medication to be withdrawn
into vial A.
B) Withdraw the required amount of medication from vial B.
C) Draw up a volume of air equal to the volume of medications to be
withdrawn from both vials A and B.
D) Withdraw the needle from vial A and inject the remaining air into vial B.
E) Withdraw the required amount of medication
from vial A. ANSWER: C, A, D, B, E
Explanation: A) Mixing two medications from two vials in one syringe has
the following steps: After performing appropriate hand hygiene, draw up a
volume of air equal to the volume of medications to be withdrawn from
both vials A and B. Inject a volume of air equal to the volume of medication
to be withdrawn into vial A. Next withdraw the needle from vial A and
inject the remaining air into vial B. Withdraw the required amount of
medication from vial B. Finally, withdraw the required amount of
medication from vial A.
B) Mixing two medications from two vials in one syringe has the following
steps: After performing appropriate hand hygiene, draw up a volume of air
equal to the volume of medications to be withdrawn from both vials A and
B. Inject a volume of air equal to the volume of medication to be withdrawn
into vial A. Next withdraw the needle from vial A and inject the remaining
air into vial B. Withdraw the required amount of medication from vial B.
Finally, withdraw the required amount of medication from vial A.
C) Mixing two medications from two vials in one syringe has the following
steps: After performing appropriate hand hygiene, draw up a volume of air
equal to the volume of medications to be withdrawn from both vials A and
B. Inject a volume of air equal to the volume of medication to be withdrawn
into vial A. Next withdraw the needle from vial A and inject the remaining
air into vial B. Withdraw the required amount of medication from vial B.
Finally, withdraw the required amount of medication from vial A.
D) Mixing two medications from two vials in one syringe has the following
steps: After performing appropriate hand hygiene, draw up a volume of air
equal to the volume of medications to be withdrawn from both vials A and
B. Inject a volume of air equal to the volume of medication to be withdrawn
into vial A. Next withdraw the needle from vial A and inject the remaining
air into vial B. Withdraw the required amount of medication from vial B.
Finally, withdraw the required amount of medication from vial A.
E) Mixing two medications from two vials in one syringe has the following
steps: After performing appropriate hand hygiene, draw up a volume of air
equal to the volume of medications to be withdrawn from both vials A and
B. Inject a volume of air equal to the volume of medication to be withdrawn
1
3
into vial A. Next withdraw the needle from vial A and inject the remaining
air into vial B. Withdraw the required amount of medication from vial B.
Finally, withdraw the required amount of medication from vial A.
Page Ref: 134
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Pharmacological and
Parenteral Therapies Standards: Nursing Process: Intervention |
Learning Outcome: 2.7 | QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.6 Demonstrate accountability for
care delivery. NLN Competencies: Quality & Safety
1
4
14) The nurse delegates oral care of an unconscious client on supplemental
oxygen to the UAP. Which action by the UAP requires the nurse to
intervene?
A) Placing a bite block in the client's mouth.
B) Applying petroleum-based moisturizer to the client's lips.
C) Positioning the client in side-lying position with head of bed lowered.
D) Using a separate moistened swab for the inside
of each cheek. ANSWER: B
Explanation: A) A bite block should be used.
B) Applying petroleum-based moisturizer to the client's lips will require
nursing intervention because these products may increase the risk of
fire for clients with oxygen. Water-based moisturizers should be used
instead.
C) The client should be in the side-lying position with the head of the bed
lowered.
D) A separate moistened swab should be used for the inside
of each cheek. Page Ref: 117
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: Nursing Process: Intervention | Learning Outcome: 2.2 |
QSEN Competencies: Safety
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
15) The nurse understands that, in addition to the five client rights of
medication administration, there are now more rights for safe medication
administration. Which rights are the new rights for safe medication
administration? Select all that apply.
A) Right documentation
B) Right dose
C) Right time
D) Right route
E) Right
reason
ANSWER: A,
E
Explanation: A) Right documentation is a new right for safe medication
administration.
B) Right dose has been a right for safe medication administration.
C) Right time has been a right for safe medication administration.
D) Right route has been a right for safe medication administration.
E) Right reason is a new right for safe medication
administration. Page Ref: 128
Cognitive Level: Understanding
Client Need/Sub: Physiological Integrity: Pharmacological and
1
5
Parenteral Therapies Standards: Nursing Process: Intervention |
Learning Outcome: 2.4 | QSEN Competencies: Safety
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
10
16) The nurse is acting as preceptor for a novice nurse. Which action
by the novice nurse requires the nurse preceptor to intervene?
A) Labeling medications placed in a medication cup.
B) Removing prepackaged medication and placing in a medication cup.
C) Keeping narcotics separated from other medications that need to be
administered.
D) Breaking scored tablets as needed for
correct dosage. ANSWER: B
Explanation: A) Medications placed in a cup should be labeled.
B) The nurse should leave prepackaged medications in their original
package to ensure proper labeling and to maintain sanitary approaches.
C) Narcotics should be kept separate from other medications.
D) Scored tablets should be broken for the
correct dosage. Page Ref: 151
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Pharmacological and
Parenteral Therapies Standards: Nursing Process: Intervention |
Learning Outcome: 2.4 | QSEN Competencies: Safety
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
17) The nurse performs a skin assessment while bathing an older adult
client. Which lifespan considerations regarding skin characteristics are
more common in the older adult? Select all that apply.
A) Dry skin
B) Itchy skin
C) Poor healing
D) Increased risk of water retention
E) Increased risk of
trauma ANSWER: A,
B, C, E
Explanation: A) The older adult client is at increased risk for dry skin due to
a decrease in endocrine secretion and decreased elastin.
B) The older adult client is at increased risk for itchy skin due to a
decrease in endocrine secretion and decreased elastin.
C) The older adult client is at increased risk for poor healing due to
inadequate nutrition, compromised immunity, poor hydration, and
decreased mobility, among other factors.
D) The older adult client is not at risk for water retention.
E) The older adult client is at increased risk of trauma due to fall,
immobility, and decreased ability to heal, among others.
Page Ref: 102
Cognitive Level: Understanding
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 2.3 |
10
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.3 Integrate assessment skills
in practice. NLN Competencies: Relationship Centered Care
11
18) The nurse prepares to administer an intermittent intravenous
solution using a secondary administration set. Place the steps of
assembling the secondary infusion in correct order.
A) Insert the secondary tubing needleless cannula into the distal primary
tubing port located above the infusion pump.
B) Hang the secondary container above the level of the primary bag.
C) Attach the appropriate label to the secondary tubing.
D) Lower medication bag to clear tubing and back-prime tubing.
E) Close the clamp on the secondary infusion tubing and spike the
medication infusion bag. ANSWER: E, A, B, D, C
Explanation: A) The correct steps of assembling the secondary infusion is
as follows: Close the clamp on the secondary infusion tubing and spike the
medication infusion bag; insert the secondary tubing needleless cannula
into the distal primary tubing port located above the infusion pump; hang
the secondary container above the level of the primary bag; lower
medication bag to clear tubing and back-prime tubing; attach the
appropriate label to the secondary tubing.
B) The correct steps of assembling the secondary infusion is as follows:
Close the clamp on the secondary infusion tubing and spike the medication
infusion bag; insert the secondary tubing needleless cannula into the distal
primary tubing port located above the infusion pump; hang the secondary
container above the level of the primary bag; lower medication bag to clear
tubing and back-prime tubing; attach the appropriate label to the secondary
tubing.
C) The correct steps of assembling the secondary infusion is as follows:
Close the clamp on the secondary infusion tubing and spike the medication
infusion bag; insert the secondary tubing needleless cannula into the distal
primary tubing port located above the infusion pump; hang the secondary
container above the level of the primary bag; lower medication bag to clear
tubing and back-prime tubing; attach the appropriate label to the secondary
tubing.
D) The correct steps of assembling the secondary infusion is as follows:
Close the clamp on the secondary infusion tubing and spike the medication
infusion bag; insert the secondary tubing needleless cannula into the distal
primary tubing port located above the infusion pump; hang the secondary
container above the level of the primary bag; lower medication bag to clear
tubing and back-prime tubing; attach the appropriate label to the secondary
tubing.
E) The correct steps of assembling the secondary infusion is as follows:
Close the clamp on the secondary infusion tubing and spike the medication
infusion bag; insert the secondary tubing needleless cannula into the distal
primary tubing port located above the infusion pump; hang the secondary
container above the level of the primary bag; lower medication bag to clear
tubing and back-prime tubing; attach the appropriate label to the secondary
12
tubing.
Page Ref: 179-180
Cognitive Level:
Analyzing
Client Need/Sub: Physiological Integrity: Pharmacological and
Parenteral Therapies Standards: Nursing Process: Intervention |
Learning Outcome: 2.8 | QSEN Competencies: Safety
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
13
19) A novice nurse instructs a client on the use of sublingual nitroglycerin.
Which statement by the novice nurse requires intervention by the nurse
preceptor?
A) "Be sure to take the medication prior to the start of your pain."
B) "Do not chew or swallow the tablet."
C) "The tablet may cause burning or tingling as it dissolves."
D) "Be sure to sit down when you decide to take the
medication." ANSWER: A
Explanation: A) Nitroglycerin is taken at the onset of the client's
symptoms, not prior to.
B) A sublingual medication is not to be chewed or swallowed whole.
C) Nitroglycerin may cause burning or tingling as it dissolves.
D) The client should sit when taking the
medication. Page Ref: 155
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Pharmacological and
Parenteral Therapies Standards: Nursing Process: Intervention |
Learning Outcome: 2.5 | QSEN Competencies: Safety
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
20) A nurse mixes two insulins in one syringe for a client with diabetes.
Which action by the nurse is incorrect?
A) Injecting a volume of air equal to the volume of medication to be
withdrawn into the first vial.
B) Drawing up air in the syringe equal to the dose of both insulins.
C) Gently shaking the vials in order to ensure medication has dissolved.
D) Withdrawing the needle from the first vial and injecting the
remaining air into the second vial.
ANSWER: C
Explanation: A) The volume of air equal to the volume of medication to be
withdrawn should be injected into the first vial.
B) Air should be drawn up into the syringe equal to the dose of both
insulins.
C) Shaking the insulins is not recommended because it will cause the
medication to become frothy and difficult to measure. Instead, the nurse
should gently roll the insulins in order to mix them.
D) The needle should be withdrawn from the first vial and the remaining
air should be injected into the second vial.
Page Ref: 134-135
Cognitive Level:
Applying
Client Need/Sub: Physiological Integrity: Pharmacological and
Parenteral Therapies Standards: Nursing Process: Intervention |
Learning Outcome: 2.7 | QSEN Competencies: Evidence-Based
Practice
14
AACN Domains and Comps.: 2.6 Demonstrate accountability for
care delivery. NLN Competencies: Quality & Safety
15
21) While giving the client a bath, the nurse notes the client has facial acne.
What statement will the nurse omit when teaching the client about this
condition?
A) "Use cool water when cleansing your face to close the pores."
B) "Wash your face frequently to remove oil and dirt."
C) "Avoid using oil-based creams on your face."
D) "Do not squeeze the lesions on
your face." ANSWER: A
Explanation: A) The nurse should instruct the client to use soap and warm
water to cleanse the face.
B) The face should be washed frequently.
C) Oil-based creams should not be applied to the face.
D) Lesions should not be
squeezed. Page Ref: 102
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Intervention | Learning Outcome: 2.3 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.6 Demonstrate accountability for
care delivery. NLN Competencies: Relationship Centered Care
22) The nurse is caring for an older adult client and performs a bed bath and
linen change. Which action by the nurse poses an increase of injury in the
client?
A) Washing the client with a washcloth.
B) Pulling linens underneath the client.
C) Assisting the client to turn in bed.
D) Covering the client with
warm linens. ANSWER: B
Explanation: A) The client should be washed with a washcloth.
B) The nurse should be most cautious when pulling linens underneath an
older adult client. This increases the risk of skin impairment because some
older adults can be more prone to injury of the skin.
C) The client should be assisted to turn in bed.
D) The client should be covered with
warm linens. Page Ref: 109
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and
Infection Control Standards: Nursing Process: Intervention | Learning
Outcome: 2.3 | QSEN Competencies: Safety
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
16
23) The nurse cares for a client who wears soft contact lenses for vision
correction. Which statement will the nurse include when teaching the
client about care of the lenses?
A) "If you do not have saline solution, saliva works to cleanse the lenses."
B) "If you wear disposable lenses, it is acceptable to cleanse them and wear
them again."
C) "If you are removing the lens, place your thumb and forefinger directly on
the lens."
D) "If you wear disposable lenses, be sure to cleanse the lens
container daily." ANSWER: C
Explanation: A) Saliva should not be used to cleanse the lenses.
B) Disposable lenses are not to be cleansed and reused.
C) When instructing the client to remove the soft lens, the nurse should tell
the client to place the thumb and forefinger directly on the lens and
squeeze gently.
D) A lens container is not used for
disposable lenses. Page Ref: 110
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Intervention | Learning Outcome: 2.3 |
QSEN Competencies: Safety
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
17
24) The nurse prepares to perform a z-track injection to a client. Place the
steps of the procedure in correct order.
A) Maintain displacement and insert needle at a 90-degree angle.
B) Inject medication slowly, keeping skin taut.
C) Pull skin 2.5–3.8 cm (1–1.5 in.) laterally away from the injection site.
D) Withdraw needle.
E) Release retracted
skin. ANSWER: C,
A, B, D, E
Explanation: A) The injection technique of a z-track injection include the
following steps: Pull skin 2.5–3.8 cm (1–1.5 in.) laterally away from the
injection site; maintain displacement and insert needle at a 90-degree
angle; inject medication slowly, keeping skin taut; withdraw the needle;
release the retracted skin.
B) The injection technique of a z-track injection include the following steps:
Pull skin 2.5–3.8 cm (1–1.5 in.) laterally away from the injection site;
maintain displacement and insert needle at a 90-degree angle; inject
medication slowly, keeping skin taut; withdraw the needle; release the
retracted skin.
C) The injection technique of a z-track injection include the following steps:
Pull skin 2.5–3.8 cm (1–1.5 in.) laterally away from the injection site;
maintain displacement and insert needle at a 90-degree angle; inject
medication slowly, keeping skin taut; withdraw the needle; release the
retracted skin.
D) The injection technique of a z-track injection include the following steps:
Pull skin 2.5–3.8 cm (1–1.5 in.) laterally away from the injection site;
maintain displacement and insert needle at a 90-degree angle; inject
medication slowly, keeping skin taut; withdraw the needle; release the
retracted skin.
E) The injection technique of a z-track injection include the following steps:
Pull skin 2.5–3.8 cm (1–1.5 in.) laterally away from the injection site;
maintain displacement and insert needle at a 90-degree angle; inject
medication slowly, keeping skin taut; withdraw the needle; release the
retracted skin.
Page Ref: 171
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Pharmacological and
Parenteral Therapies Standards: Nursing Process: Intervention |
Learning Outcome: 2.4 | QSEN Competencies: Evidence-Based
Practice
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
1
Clinical Nursing Skills: A Concept-Based Approach, 4e
(Pearson) Chapter 3 Comfort
1) The nurse cares for a neonate who appears in pain. The neonate has tight
facial muscles, loud and shrill cry, rapid breathing, tense extremities and
is thrashing about. Using the NIPS pain scale, which number will the nurse
give the neonate?
A) 5
B) 6
C) 7
D) 8
ANSWE
R: C
Explanation: A) This is the incorrect use of NIPS.
B) This is the incorrect use of NIPS.
C) The Neonatal Infant Pain Scale (NIPS) is a standardized pain scale used
for assessing pain in neonates up to 6 weeks of age. The scale is based on
facial expressions, cry, breathing patterns, arm and leg movements, and
state of arousal. Tight facial muscles (1 point), loud and shrill cry (2
points), rapid breathing (1 point), tense extremities (2 points), and
increased movement (1 point) equal 7 points.
D) This is the incorrect use
of NIPS. Page Ref: 192
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: Nursing Process: Assessment | Learning Outcome: 2.3 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.3 Integrate assessment
skills in practice. NLN Competencies: Relationship
Centered Care
2
2) The nurse sets up a PCA pump for a postoperative client. Which safety
parameters will the nurse use? Select all that apply.
A) Dose volume limits
B) Partial dose settings
C) Dosage limits
D) Lockout interval
E) Re-programming alarm
settings ANSWER: A, C, D
Explanation: A) Dose volume limit parameters limit the amount of drug that
the client can receive when the client pushes the control button. This is an
important safety parameter the nurse will use.
B) There are no partial dose settings on a PCA pump.
C) Dosage limits set the dosage limits as specified on the order. This is
an important safety parameter the nurse will use.
D) The lockout interval is set in order to ensure that doses are not
administered too frequently. This is an important safety parameter the
nurse will use.
E) Alarm settings should not be re-
programmed. Page Ref: 204-205
Cognitive Level: Understanding
Client Need/Sub: Safe and Effective Care Environment: Safety and
Infection Control Standards: Nursing Process: Intervention |
Learning Outcome: 3.5 | QSEN Competencies: Safety
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
3
3) The nurse cares for a client who requires a PCA for pain control. The
healthcare provider has ordered a loading dose for the client. Place the
steps in order for the nurse to provide the loading dose by PCA pump.
A) Set the safety parameters.
B) Press the loading dose control button.
C) Set the volume to be delivered.
D) Set the pump for a lockout time of
zero minutes. ANSWER: D, C, B, A
Explanation: A) When providing the loading dose by PCA pump, the nurse
must first set the pump for a lockout time of zero minutes. Next, the nurse
will set the volume to be delivered and press the loading dose control
button. Finally, the nurse will set the safety parameters.
B) When providing the loading dose by PCA pump, the nurse must first set
the pump for a lockout time of zero minutes. Next, the nurse will set the
volume to be delivered and press the loading dose control button. Finally,
the nurse will set the safety parameters.
C) When providing the loading dose by PCA pump, the nurse must first set
the pump for a lockout time of zero minutes. Next, the nurse will set the
volume to be delivered and press the loading dose control button. Finally,
the nurse will set the safety parameters.
D) When providing the loading dose by PCA pump, the nurse must first set
the pump for a lockout time of zero minutes. Next, the nurse will set the
volume to be delivered and press the loading dose control button. Finally,
the nurse will set the safety parameters.
Page Ref: 204
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Pharmacological and
Parenteral Therapies Standards: Nursing Process: Intervention |
Learning Outcome: 3.5 | QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
4) The nurse is caring for a client in acute pain. When assessing the
client's quality of pain, which statement will the nurse use?
A) "How long have you been having pain?"
B) "Is the pain better or worse at certain times of the day or night?"
C) "What words would you use to describe your pain?"
D) "Have you noticed any time during the day or night that the pain
is better or worse?" ANSWER: C
Explanation: A) Asking how long the pain has been present assesses
duration.
B) Asking if the pain changes during the day assesses recurrence.
C) Quality of pain may be assessed by asking the client, "What words would
you use to describe your pain?"
D) Asking if the pain is different during the day assesses
for recurrence. Page Ref: 194
4
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Basic Care and Comfort
Standards: Nursing Process: Assessment | Learning Outcome: 3.1 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.3 Integrate assessment skills
in practice. NLN Competencies: Relationship Centered Care
5
5) A nurse assesses a client who is experiencing acute pain. Which
aspects of the pain assessment are gathered first before the
detailed assessment? Select all that apply.
A) Location
B) Provocation
C) Intensity
D) Quality
E) Radiation
ANSWER: A,
C, D
Explanation: A) For clients experiencing acute or severe pain, the nurse may
focus on determining location, intensity, and quality–and quickly follow
with an intervention. Clients with less severe or chronic pain can usually
provide a more detailed description, and the nurse can obtain a
comprehensive pain assessment.
B) Precipitating factors can be assessed during the detailed assessment.
C) For clients experiencing acute or severe pain, the nurse may focus on
determining location, intensity, and quality–and quickly follow with an
intervention. Clients with less severe or chronic pain can usually provide
a more detailed description, and the nurse can obtain a comprehensive
pain assessment.
D) For clients experiencing acute or severe pain, the nurse may focus on
determining location, intensity, and quality–and quickly follow with an
intervention. Clients with less severe or chronic pain can usually provide
a more detailed description, and the nurse can obtain a comprehensive
pain assessment.
E) Radiation would be assessed during the
detailed assessment. Page Ref: 194
Cognitive Level: Remembering
Client Need/Sub: Physiological Integrity: Basic Care and Comfort
Standards: Nursing Process: Intervention | Learning Outcome: 3.1 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.3 Integrate assessment skills
in practice. NLN Competencies: Relationship Centered
Care
6
6) The nurse is caring for a client who is using a TENS unit for pain
management. Which statements will the nurse use when teaching the
client about this therapy? Select all that apply.
A) "Make sure and cover the unit while showering or bathing."
B) "When turning the unit on, make sure the amplitude control is set to 5."
C) "With the unit off, plug the lead wires into the battery-operated unit at
one end, leaving the electrodes at the other end."
D) "Increase the amplitude until you feel discomfort and then decrease the
amplitude until you feel comfortable."
E) "Wash, rinse, and dry the area where you would like to
apply the electrodes." ANSWER: C, D, E
Explanation: A) The TENS unit is not to be used in the shower or bathing.
B) The amplitude control should be set at level 0.
C) The nurse should instruct the client that, with the TENS unit off, plug
the lead wires into the battery-operated unit at one end, leaving
electrodes at the other end.
D) The client should be instructed to slowly increase the intensity of the
stimulus (amplitude) until a slight increase in discomfort is noted.
E) The area should be washed, rinsed, and dried before
applying the electrodes. Page Ref: 201
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Basic Care and Comfort
Standards: Nursing Process: Intervention | Learning Outcome: 3.6 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.2 Communicate effectively
with individuals. NLN Competencies: Relationship Centered
Care
7
7) The nurse cares for a client who wants to try biofeedback for relief of
chronic pain. What advantages to this therapy does the nurse
recognize? Select all that apply.
A) Increases circulation and endorphins
B) Completely controlled by the client
C) Rapid pain relief
D) Redirects energy flow through pressure on meridian points
E) Promotes stress reduction as well as
pain relief ANSWER: B, E
Explanation: A) Massage increases circulation and endorphins.
B) Biofeedback is an electric monitoring device that feeds back effect of
behavior so the client can control internal processes (such as the heart
rate). Advantages to biofeedback include the fact that it is completely
controlled by the client.
C) Ice therapy promotes rapid pain relief.
D) Acupressure redirects energy flow through pressure on meridian points.
E) Advantages to biofeedback include the fact that it promotes stress
reduction as well as pain relief.
Page Ref: 203
Cognitive Level: Understanding
Client Need/Sub: Physiological Integrity: Basic Care and Comfort
Standards: Nursing Process: Assessment | Learning Outcome: 3.6 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 1.3 Demonstrate clinical judgment
founded on a broad knowledge base.
NLN Competencies: Knowledge and Science
8
8) The nurse cares for a client with chronic pain who asks the nurse about
using acupressure for pain relief. Which statements will the nurse include
in the teaching regarding how this treatment works for pain relief? Select
all that apply.
A) "The pressure compresses and splints irritated nerve endings."
B) "It redirects energy flow through pressure on meridian points."
C) "The therapy restores structural integrity and balance."
D) "The therapy reduces pain and increases endorphins."
E) "It manipulates muscles and realigns spinal column
nerve function." ANSWER: B, D
Explanation: A) Acupressure does not compress nerve endings.
B) Acupressure is a therapy based on the traditional Chinese method of
acupuncture. This method involves using specific points located on
meridians at various places on the body.
C) Chiropractic care restores structural integrity and balance.
D) This therapy reduces pain and increases endorphins.
E) Chiropractic care manipulates muscles and realigns spinal
column nerve function. Page Ref: 203
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Basic Care and Comfort
Standards: Nursing Process: Intervention | Learning Outcome: 3.6 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 1.3 Demonstrate clinical judgment
founded on a broad knowledge base.
NLN Competencies: Knowledge and Science
9
9) The nurse prepares to apply dry heat to a client's extremity in an effort
to reduce pain. Which variables are recognized by the nurse to affect
physiological tolerance to heat and cold? Select all that apply.
A) Body part location
B) Size of the exposed body part
C) Individual tolerance
D) Intactness of skin
E) Gender
ANSWER: A, B, C, D
Explanation: A) Body part location affects the physiological tolerance to
heat and cold. For example, the back of the hand and foot are not very
temperature sensitive. In contrast, the inner aspect of the wrist and
forearm, the neck, and the perineal area are temperature sensitive.
B) The size of the exposed body part affects the physiological tolerance to
heat and cold. The larger the area exposed to heat and cold is, the lower
is the tolerance.
C) Individual tolerance affects the physiological tolerance to heat and cold.
The very young and the very old have the least physiological tolerance.
D) Injured areas of the skin are more susceptible to temperature variations
versus intact skin.
E) Gender does not affect tolerance to heat or
cold application. Page Ref: 207
Cognitive Level: Understanding
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: Nursing Process: Assessment | Learning Outcome: 3.1 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 1.3 Demonstrate clinical judgment
founded on a broad knowledge base.
NLN Competencies: Knowledge and Science
1
0
10) The nurse is caring for five clients with acute pain. When considering
the use of heat and cold therapy, which medical conditions will the
nurse determine require special precautions? Select all that apply.
A) Diabetes
B) Venous insufficiency
C) Asthma
D) Congestive heart failure
E) Arterial
disease
ANSWER: A, B,
D, E
Explanation: A) Clients with diabetes require special precautions during
heat and cold therapy because these clients lack the normal ability to
dissipate heat via the blood circulation, which puts them at risk for tissue
damage with heat applications. Cold applications are contraindicated for
these clients.
B) Clients with peripheral vascular disease (peripheral arterial disease and
venous insufficiency) require special precautions during heat and cold
therapy because these clients lack the normal ability to dissipate heat via
the blood circulation, which puts them at risk for tissue damage with heat
applications. Cold applications are contraindicated for these clients.
C) Clients with asthma do not require special precautions.
D) Clients with congestive heart failure and those with diabetes require
special precautions during heat and cold therapy because these clients lack
the normal ability to dissipate heat via the blood circulation, which puts
them at risk for tissue damage with heat applications. Cold applications are
contraindicated for these clients.
E) Clients with peripheral vascular disease (peripheral arterial disease and
venous insufficiency) require special precautions during heat and cold
therapy because these clients lack the normal ability to dissipate heat via
the blood circulation, which puts them at risk for tissue damage with heat
applications. Cold applications are contraindicated for these clients.
Page Ref: 208
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: Nursing Process: Assessment | Learning Outcome: 3.1 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 1.3 Demonstrate clinical judgment
founded on a broad knowledge base.
NLN Competencies: Knowledge and Science
10
11) A nurse cares for a 13-year-old adolescent with a terminal illness.
Which client statement does the nurse expect to hear from this client
regarding death and dying?
A) "I will go to sleep for a long time and then wake up."
B) "I know that people die with my disease but I won't die."
C) "I wonder what happens to people after death."
D) "I know people die but I will defy my
own death." ANSWER: D
Explanation: A) Children up to age 5 believe death is being asleep.
B) Children ages 5 to 9 years believe own death can be avoided.
C) Children ages 9 to 12 years express an interest in the afterlife.
D) An adolescent client fears a lingering death, often fantasizing that
death may be defied by acting in reckless behavior (e.g., substance
abuse, dangerous driving).
Page Ref: 223
Cognitive Level: Analyzing
Client Need/Sub: Psychosocial Integrity
Standards: Nursing Process: Assessment | Learning Outcome: 3.7 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.3 Integrate assessment skills
in practice. NLN Competencies: Relationship Centered Care
12) The nurse cares for a client who needs a PCA pump for control of
postoperative pain. Which task can the nurse delegate to the unlicensed
assistive personnel (UAP)?
A) Pushing the client button if the client is unable.
B) Silencing the pump alarm while waiting for the nurse.
C) Reporting specific client observations.
D) Asking the client about level
of pain. ANSWER: C
Explanation: A) Pushing the client's PCA button is administering an
intravenous medication and is a task for the nurse only.
B) The UAP should not silence the PCA pump.
C) The nurse may delegate the UAP to report specific client observations
(such as reporting inadequate pain control).
D) The UAP should not determine the client's pain level because it
involves assessment of the client's clinical situation and assessment
should not be performed by unlicensed personnel. Page Ref: 204
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Management of Care
Standards: Nursing Process: Intervention | Learning Outcome: 3.5 | QSEN
Competencies: Teamwork and Collaboration
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Teamwork
11
13) The nurse cares for an older adult client who will have heat and cold
therapy to assist with pain. Which lifespan considerations does the nurse
consider when using this treatment for the client? Select all that apply.
A) Skin cells proliferate quicker as one ages.
B) Sensitivity to pain decreases as one ages.
C) Skin becomes thinner as one ages.
D) Moisture in the skin decreases as one ages.
E) Skin burns easier as
one ages. ANSWER: B, C,
D, E
Explanation: A) Skin cells do not proliferate quicker with aging.
B) Older adults have a reduced sensitivity to pain, and therefore may not
feel untoward effects of heat and cold treatment.
C) Older adults have thinner skin.
D) Temperature should be reduced when using heat therapy because
older adult patient's skin burns more easily.
E) Because skin is thinner, skin burns easier
as one ages. Page Ref: 218
Cognitive Level: Analyzing
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 3.4 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.3 Integrate assessment skills
in practice. NLN Competencies: Knowledge and Science
14) The nurse is caring for a client with acute pain and uses the FLACC pain
assessment. Which clinical scenario does the nurse recognize as LEAST
appropriate for use of the FLACC pain assessment?
A) Situations where clients self-report pain.
B) Situations requiring rapid pain assessment.
C) Clients who are asleep.
D) Clients who are
children. ANSWER: B
Explanation: A) The FLACC pain assessment is not used for clients who can
self-report pain.
B) The FLACC pain assessment requires observation of the client for at least
5 minutes before a determination regarding the pain can be made.
C) It is used for clients who are asleep.
D) It is used for
children. Page Ref:
192
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 3.3 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.3 Integrate assessment skills
in practice. NLN Competencies: Relationship Centered Care
12
15) The nurse is preparing to use a disposable hot pack on the client for pain
relief. Which action will the nurse prioritize as an appropriate task for the
UAP?
A) Observing the site of application and reporting abnormal findings.
B) Assessing the client's level of pain.
C) Determining if the client requires additional therapy.
D) Documenting the client's response
to therapy. ANSWER: A
Explanation: A) The UAP may observe the site of the application and report
abnormal findings.
B) The nurse assesses the level of pain.
C) The nurse determines if the client needs additional therapy.
D) The nurse documents the client's
response to therapy. Page Ref: 212
Cognitive Level: Analyzing
Client Need/Sub: Safe and Effective Care Environment: Management of Care
Standards: Nursing Process: Intervention | Learning Outcome: 3.4 | QSEN
Competencies: Teamwork and Collaboration
AACN Domains and Comps.: 6.4 Work with other professions to maintain a
climate of mutual learning, respect, and shared values.
NLN Competencies: Teamwork
16) The nurse assesses a toddler for pain using the FLACC scale. The nurse
notes the client is crying steadily with a quivering chin, is kicking, is
shifting back and forth, and is difficult to console. What number does the
nurse document for the client's pain, based on the FLACC scale?
A) 8
B) 9
C) 10
D) 11
ANSWE
R: B
Explanation: A) The assessment tool was not used correctly.
B) The FLACC behavioral pain assessment may be used to help the nurse
determine the client's level of pain. Assessment is based on findings of the
face, legs, activity, cry, and consolability. A steady cry (2) with quivering
chin (2), kicking (2), shifting back and forth (1), and difficult to console (2)
results in a FLACC score of 9.
C) The assessment tool was not used correctly.
D) The maximum score on the FLACC
tool is 10. Page Ref: 192
Cognitive Level: Analyzing
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 3.2 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.3 Integrate assessment skills
13
in practice. NLN Competencies: Relationship Centered Care
14
17) The nurse is caring for a client in acute pain and plans to use a pain scale
tool for assessment. What is the major advantage in using this tool?
A) It allows organization in the assessment process.
B) It works with the same efficacy among the entire population.
C) It allows for variation among various cultures.
D) It can always be performed
quickly. ANSWER: A
Explanation: A) The major advantage of a standardized pain scale tool for
assessment of the client's pain is that it allows the nurse to stay organized
in the assessment process.
B) While efficient in assessing a client's pain, the tool does not factor in
cultural variances and perceptions of pain.
C) Pain scales do not factor in cultural variances.
D) The idea that most tools may be performed quickly is not
universally true. Page Ref: 195
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 3.2 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.3 Integrate assessment skills
in practice. NLN Competencies: Relationship Centered
Care
18) The nurse is caring for a client who is dying. When prioritizing care,
which intervention will the nurse provide to meet the client's physiological
needs?
A) Encourage frequent ambulation and deep breathing.
B) Initiate total nutrition intravenously.
C) Administer curative medications.
D) Encourage favorite foods as
tolerated. ANSWER: D
Explanation: A) The client's tolerance should be supported. The client
may not have the strength to ambulate or take deep breaths.
B) Intravenous nutrition is determined according to the client's preference.
C) Curative medications are not prescribed for a client who is dying.
D) Encouraging favorite foods as tolerated is an important nursing
intervention the nurse will perform for the dying client.
Page Ref: 220
Cognitive Level: Applying
Client Need/Sub: Psychosocial Integrity
Standards: Nursing Process: Intervention | Learning Outcome: 3.8 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.1 Engage with the individual in establishing
a caring relationship.
NLN Competencies: Relationship Centered Care
15
19) The nurse prepares to perform a pain assessment and chooses to use
a standardized pain assessment tool. Place the steps in order for the use
of the standardized pain assessment tool.
A) Assess the client's physiological response to pain.
B) Assess the client's perception of pain.
C) Perform a focused assessment.
D) Document the
findings. ANSWER:
B, A, C, D
Explanation: A) The steps to performing a pain assessment using a
standardized pain assessment tool is as follows: Assess the client's
perception of pain (including location, intensity, and quality), assess the
client's physiological response to pain (i.e., changes in vital signs),
perform a focused assessment, and document the findings.
B) The steps to performing a pain assessment using a standardized pain
assessment tool is as follows: Assess the client's perception of pain
(including location, intensity, and quality), assess the client's
physiological response to pain (i.e., changes in vital signs), perform a
focused assessment, and document the findings.
C) The steps to performing a pain assessment using a standardized pain
assessment tool is as follows: Assess the client's perception of pain
(including location, intensity, and quality), assess the client's
physiological response to pain (i.e., changes in vital signs), perform a
focused assessment, and document the findings.
D) The steps to performing a pain assessment using a standardized pain
assessment tool is as follows: Assess the client's perception of pain
(including location, intensity, and quality), assess the client's
physiological response to pain (i.e., changes in vital signs), perform a
focused assessment, and document the findings.
Page Ref: 194
Cognitive Level: Analyzing
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 3.1 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.3 Integrate assessment skills
in practice. NLN Competencies: Relationship Centered Care
16
20) The nurse prepares to apply a TENS unit on a client who is
experiencing pain. Place the steps of this procedure in the correct
order.
A) With the unit off, plug the lead wires into the unit.
B) Insert the battery and test for functioning.
C) Turn the unit on and ensure the amplitude is set to zero.
D) Apply the electrodes to the client.
E) Increase the amplitude until the client notes discomfort.
F) Slowly decrease the amplitude until the client notes a
pleasant sensation. ANSWER: B, A, D, C, E, F
Explanation: A) Application of the TENS unit is as follows: Insert the battery
and test for functioning; with the unit off, plug the lead wires into the unit;
apply the electrodes to the client; turn the unit on and ensure the amplitude
is set to zero; increase the amplitude until the client notes discomfort;
slowly decrease the amplitude until the client notes a pleasant sensation.
B) Application of the TENS unit is as follows: Insert the battery and test
for functioning; with the unit off, plug the lead wires into the unit; apply
the electrodes to the client; turn the unit on and ensure the amplitude is
set to zero; increase the amplitude until the client notes discomfort;
slowly decrease the amplitude until the client notes a pleasant sensation.
C) Application of the TENS unit is as follows: Insert the battery and test for
functioning; with the unit off, plug the lead wires into the unit; apply the
electrodes to the client; turn the unit on and ensure the amplitude is set to
zero; increase the amplitude until the client notes discomfort; slowly
decrease the amplitude until the client notes a pleasant sensation.
D) Application of the TENS unit is as follows: Insert the battery and test
for functioning; with the unit off, plug the lead wires into the unit; apply
the electrodes to the client; turn the unit on and ensure the amplitude is
set to zero; increase the amplitude until the client notes discomfort;
slowly decrease the amplitude until the client notes a pleasant sensation.
E) Application of the TENS unit is as follows: Insert the battery and test for
functioning; with the unit off, plug the lead wires into the unit; apply the
electrodes to the client; turn the unit on and ensure the amplitude is set to
zero; increase the amplitude until the client notes discomfort; slowly
decrease the amplitude until the client notes a pleasant sensation.
F) Application of the TENS unit is as follows: Insert the battery and test for
functioning; with the unit off, plug the lead wires into the unit; apply the
electrodes to the client; turn the unit on and ensure the amplitude is set to
zero; increase the amplitude until the client notes discomfort; slowly
decrease the amplitude until the client notes a pleasant sensation.
Page Ref: 201
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Basic Care and Comfort
Standards: Nursing Process: Intervention | Learning Outcome: 3.6 |
QSEN Competencies: Patient-Centered Care
17
AACN Domains and Comps.: 2.6 Demonstrate accountability for
care delivery. NLN Competencies: Relationship Centered Care
1
Clinical Nursing Skills: A Concept-Based Approach,
4e (Pearson) Chapter 4 Elimination
1) The nurse prepares to obtain a urine sample from a client's closed
drainage system. Place the procedure steps in the correct order.
A) Disinfect the needle insertion site.
B) Insert the needle at a 30-to 40-degree angle.
C) Unclamp the catheter.
D) Transfer the urine to the specimen container.
E) Withdraw the required amount of urine.
F) Clamp the drainage tubing at least 8 cm (3 in.) below the sampling
port for 30 minutes. ANSWER: F, A, B, E, C, D
Explanation: A) The procedure for obtaining a urine sample from a closed
drainage system is as follows: clamp the drainage tubing at least 8 cm (3
in.) below the sampling port for 30 minutes; disinfect the needle insertion
site; insert the needle at a 30- to 40-degree angle; withdraw the required
amount of urine; unclamp the catheter; transfer the urine to the specimen
container.
B) The procedure for obtaining a urine sample from a closed drainage
system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below
the sampling port for 30 minutes; disinfect the needle insertion site;
insert the needle at a 30- to 40-degree angle; withdraw the required
amount of urine; unclamp the catheter; transfer the urine to the specimen
container.
C) The procedure for obtaining a urine sample from a closed drainage
system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below
the sampling port for 30 minutes; disinfect the needle insertion site;
insert the needle at a 30- to 40-degree angle; withdraw the required
amount of urine; unclamp the catheter; transfer the urine to the specimen
container.
D) The procedure for obtaining a urine sample from a closed drainage
system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below
the sampling port for 30 minutes; disinfect the needle insertion site;
insert the needle at a 30- to 40-degree angle; withdraw the required
amount of urine; unclamp the catheter; transfer the urine to the specimen
container.
E) The procedure for obtaining a urine sample from a closed drainage
system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below
the sampling port for 30 minutes; disinfect the needle insertion site;
insert the needle at a 30- to 40-degree angle; withdraw the required
amount of urine; unclamp the catheter; transfer the urine to the specimen
container.
F) The procedure for obtaining a urine sample from a closed drainage
system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below
the sampling port for 30 minutes; disinfect the needle insertion site; insert
2
the needle at a 30- to 40-degree angle; withdraw the required amount of
urine; unclamp the catheter; transfer the urine to the specimen container.
Page Ref: 234
Cognitive Level: Analyzing
Client Need/Sub: Safe and Effective Care Environment: Safety and
Infection Control Standards: Nursing Process: Intervention | Learning
Outcome: 4.1 | QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
3
2) The nurse prepares to obtain a urine specimen from a client's indwelling
catheter. What is the nurse's understanding of the purpose of clamping
the indwelling catheter prior to collection of urine?
A) Decreases client discomfort
B) Increases urine production
C) Promotes sterile collection
D) Eases technique of
procedure ANSWER: C
Explanation: A) Clamping is not done to decrease the client's discomfort.
B) Clamping is not done to increase urine production.
C) Clamping the client's indwelling catheter promotes the sterile
collection of urine because sterile urine collects in the tube, allowing
for sterile collection.
D) Clamping is not done to ease technique of
the procedure. Page Ref: 247
Cognitive Level: Understanding
Client Need/Sub: Safe and Effective Care Environment: Safety and
Infection Control Standards: Nursing Process: Intervention | Learning
Outcome: 4.1 | QSEN Competencies: Safety
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
4
3) A nurse prepares to administer a warm water enema to a client.
Place the steps of the procedure in correct order.
A) Raise the solution container.
B) Open the clamp.
C) Encourage the client to retain the solution.
D) Lift the upper buttock, insert the tube slowly.
E) Assist the client to the left lateral position with right leg flexed.
F) Allow the solution to run through the tubing
to remove air. ANSWER: F, E, D, A, B, C
Explanation: A) The steps of the warm water enema administration is as
follows: Allow the solution to run through the tubing to remove air; assist
the client to the left lateral position with the right leg flexed; lift the upper
buttock and insert the tube slowly; raise the solution container and open
the clamp; encourage the client to retain the solution.
B) The steps of the warm water enema administration is as follows: Allow
the solution to run through the tubing to remove air; assist the client to the
left lateral position with the right leg flexed; lift the upper buttock and
insert the tube slowly; raise the solution container and open the clamp;
encourage the client to retain the solution.
C) The steps of the warm water enema administration is as follows: Allow
the solution to run through the tubing to remove air; assist the client to the
left lateral position with the right leg flexed; lift the upper buttock and
insert the tube slowly; raise the solution container and open the clamp;
encourage the client to retain the solution.
D) The steps of the warm water enema administration is as follows: Allow
the solution to run through the tubing to remove air; assist the client to the
left lateral position with the right leg flexed; lift the upper buttock and
insert the tube slowly; raise the solution container and open the clamp;
encourage the client to retain the solution.
E) The steps of the warm water enema administration is as follows: Allow
the solution to run through the tubing to remove air; assist the client to the
left lateral position with the right leg flexed; lift the upper buttock and
insert the tube slowly; raise the solution container and open the clamp;
encourage the client to retain the solution.
F) The steps of the warm water enema administration is as follows: Allow
the solution to run through the tubing to remove air; assist the client to the
left lateral position with the right leg flexed; lift the upper buttock and
insert the tube slowly; raise the solution container and open the clamp;
encourage the client to retain the solution.
Page Ref: 269
Cognitive Level: Analyzing
Client Need/Sub: Safe and Effective Care Environment: Safety and
Infection Control Standards: Nursing Process: Intervention | Learning
Outcome: 4.3 | QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.6 Demonstrate accountability for
5
care delivery. NLN Competencies: Relationship Centered Care
6
4) The registered nurse acts as preceptor to a novice nurse who is placing
an indwelling urinary catheter for a client. Which action by the novice
nurse requires intervention by the preceptor?
A) Removing and discarding clean gloves after opening the drainage
package.
B) Cleansing the urethral meatus before removing the catheter from the
protective sleeve.
C) Donning sterile gloves prior to attaching the catheter to the drainage
system.
D) Lubricating the tip of the catheter before inserting the tip of the
prefilled syringe into the catheter side arm.
ANSWER: B
Explanation: A) Clean gloves should be removed and discarded after
opening the drainage package.
B) The nurse should remove the catheter from the protective sleeve
prior to cleansing the urethral meatus. This action will require
intervention by the nurse preceptor.
C) Sterile gloves should be applied before attaching the catheter to the
drainage system.
D) The tip of the catheter should be lubricated before inserting the tip of
the prefilled syringe into the catheter side arm.
Page Ref: 250
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and
Infection Control Standards: Nursing Process: Intervention | Learning
Outcome: 4.8 | QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 5.2 Contribute to a culture of
patient safety. NLN Competencies: Quality & Safety
5) When placing the client on a bedpan, which position will the nurse place
the client?
A) High-Fowler
B) Semi-Fowler
C) Upright
D) Supin
e
ANSWE
R: B
Explanation: A) The high-Fowler position is not the best to use for a
bedpan.
B) The semi-Fowler position alleviates back strain and permits a more
normal position for elimination.
C) The upright position is not the best to use for a bedpan.
D) The supine position is not the best to use
for a bedpan. Page Ref: 240
Cognitive Level: Remembering
Client Need/Sub: Physiological Integrity: Basic Care and Comfort
7
Standards: Nursing Process: Intervention | Learning Outcome: 4.2 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.6 Demonstrate accountability for
care delivery. NLN Competencies: Relationship Centered Care
8
6) The nurse attempts to obtain a urine sample from a client's ileal conduit.
After correct sterile catheterization, no urine output is noted. Which
action should the nurse take?
A) Contact the healthcare provider.
B) Reinsert the catheter.
C) Ask the client to drink water.
D) Advance the catheter further in
the stoma. ANSWER: C
Explanation: A) The healthcare provider does not need to be contacted.
B) The catheter does not need to be reinserted.
C) After correct sterile catheterization of an ileal conduit, if no urine is
obtained, the nurse should ask the client to drink water in order to
produce urine.
D) The catheter does not need to be advanced further
into the stoma. Page Ref: 235
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and
Infection Control Standards: Nursing Process: Intervention | Learning
Outcome: 4.8 | QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.6 Demonstrate accountability for
care delivery. NLN Competencies: Relationship Centered Care
7) When auscultating a client's AV fistula, the nurse notes a whooshing
sound. What term is used to describe this finding?
A) Bruit
B) Murmur
C) Gallop
D) Click
ANSWE
R: A
Explanation: A) The whooshing sound heard on auscultation of a patent AV
fistula is called bruit.
B) Murmur is used to describe an abnormal heart sound.
C) Gallop is used to describe an abnormal heart sound.
D) Click is used to describe an abnormal
heart sound. Page Ref: 286
Cognitive Level: Remembering
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 4.7 |
QSEN Competencies: Patient-Centered Care
AACN Domains and Comps.: 2.3 Integrate assessment skills
in practice. NLN Competencies: Relationship Centered
Care
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Test bank clinical nursing skills a concept based approach 4e pearson education (1).docx

  • 1. Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Volume III by Pearson Education Chapters 1 - 16
  • 2. Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Pearson
  • 3. 1 Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Education Test Bank Chapter 1: Assessment 1) A client on the medical/surgical unit complains of sudden chest pains. Which action will the nurse implement first? A) Call the healthcare provider. B) Administer pain medication. C) Reassess a new set of vital signs. D) Turn client from supine to lateral. ANSWER: C Explanation: A) The nurse will need to reassess the client first, before calling the healthcare provider. B) The nurse will need to reassess the client first, before administering pain medication. C) The nurse needs to implement a new set of vital signs first when there is a change in condition. D) The nurse will need to reassess the client first, before moving the client, to avoid making the change in client's condition worse. Page Ref: 2 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Relationship Centered Care 2) The nurse is observing the UAP taking the temperature of an unconscious client. Which route will the nurse question the UAP using? A) Oral B) Rectal C) Scanner D) Tympa nic ANSWER: A Explanation: A) The temperature of an unconscious client is never taken by mouth. The rectal, tympanic, or scanner method is preferred. B) The rectal, tympanic, or scanner method is preferred. C) The rectal, tympanic, or scanner method is preferred. D) The rectal, tympanic, or scanner method is preferred. Page Ref: 24 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: Safety AACN Domains and Comps.: Domain 5: Quality and Safety
  • 5. 3 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch. Which method should the nurse use to check the baby's temperature? A) Oral B) Rectal C) Axillary D) Tympanic membrane ANSWER: C Explanation: A) Oral is used for age 3 or older. B) The rectal route is the least desirable. C) The axillary route may not be as accurate as other routes for detecting fevers in children. D) The tympanic membrane may be used for 3 months or older. Page Ref: 29 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies: Safety AACN Domains and Comps.: Domain 5: Quality and Safety NLN Competencies: Quality & Safety 4) A client comes in with exacerbation of chronic obstructive pulmonary disease (COPD). Which noninvasive diagnostic test will the nurse implement to know that the client is receiving enough oxygen? A) Chest x-ray B) Pulse oximeter C) Arterial blood gasses D) Assessment of respiratory rate ANSWER: B Explanation: A) A chest x-ray is not an intervention a nurse completes. B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen saturation, in the blood and provides a pulse reading, which is especially helpful for the client with a respiratory illness or disease. C) Arterial blood gases are an invasive diagnostic test. D) Assessing a respiratory rate is important for the nurse to implement; however, it is not a diagnostic test. Page Ref: 21 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Competencies: Informatics AACN Domains and Comps.: Domain 5: Quality and Safety NLN Competencies: Quality & Safety
  • 6. 4 5) The nurse is preparing to assess a client's musculoskeletal system. Which question should the nurse ask before beginning this assessment? A) "Do you exercise every day?" B) "Do you have a history of any sports injuries?" C) "Do you take a hot bath to relax your muscles?" D) "Do you want pain medication before I begin?" ANSWER: B Explanation: A) Knowing if a client exercises is an important question but knowing if there are any sports injuries to know about first, is most important before doing a routine musculoskeletal assessment. B) It is important to note if the client has a history of any sports injuries first to know what the client will or will not be able to do during a routine musculoskeletal assessment. C) Knowing if the client takes a hot bath to relax the muscles is not the most important thing to ask before performing a routine musculoskeletal assessment. D) To know if a client is experiencing any pain is an important question; however, this question is assuming the client is in pain by asking if the client wants a pain medication before beginning a routine musculoskeletal assessment. Page Ref: 62 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 1.5 | QSEN Competencies: Safety AACN Domains and Comps.: Domain 5: Quality and Safety NLN Competencies: Quality & Safety 6) An adult child mentions that the client seems to have a decline in mental status and seems to be forgetting many things in their conversation since being hospitalized. Which response should the nurse make? A) "Give your mom time, because it will take her a little longer when answering questions." B) "Let me check the cranial nerve function to see if there is a defect in her mental status." C) "You do not need to worry. This decline is part of the normal process of aging." D) "If you bring some things from her home, it might reduce the confusion." ANSWER: D Explanation: A) This is expected to give some older adults time to respond, but the daughter is concerned about her forgetting, not the length of the response. B) Cranial nerve function is an assessment of the cranial nerves and not the mental status of a client. C) A decline in mental status is not a normal result of aging, so this response is not true.
  • 7. 5 D) The stress of being in unfamiliar situations can cause confusion in some older adults. Page Ref: 75 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: Nursing Process: Planning | Learning Outcome: 1.6 | QSEN Competencies: Patient- Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Context and Environment 7) When assessing breath sounds, the nurse hears moderate-intensity and moderate-pitch
  • 8. 6 "blowing" sounds between the scapulae and lateral to the sternum at the first and second intercostal spaces. Which action should the nurse take? A) Encourage the client to cough and deep breathe. B) Notify the healthcare provider of abnormal breath sounds. C) Document assessment findings as normal breath sounds. D) Raise the head of the bed to allow maximum air excursion. ANSWER: C Explanation: A) There is no reason to encourage the client to take deep breaths and cough. B) The nurse would notify the healthcare provider if these were adventitious lung sounds; however, these are bronchovesicular sounds. C) These are bronchovesicular sounds. D) The nurse would implement this if these were adventitious lung sounds; however, these are bronchovesicular sounds. Page Ref: 88 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.7 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Context and Environment 8) A client seeks medical attention for shortness of breath and a fever. Which amount of time should the nurse count the peripheral pulse? A) 15 seconds B) 30 seconds C) 1 minute D) 2 minutes ANSWER: C Explanation: A) Count for a full minute if taking a client's pulse for the first time. B) Count for a full minute if taking a client's pulse for the first time. C) Count for a full minute if taking a client's pulse for the first time. D) Count for a full minute if taking a client's pulse for the first time. Page Ref: 19 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.8 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety
  • 9. 7 9) The nurse is preparing a dose of digoxin for a client. Which assessment will the nurse complete prior to giving this medication? A) Temperature B) Apical pulse C) Respiratory rate D) Pain using a pain scale ANSWER: B Explanation: A) The temperature does not need to be assessed before giving digoxin. B) The nurse should assess the apical pulse before the administration of a medication that could affect the cardiovascular system, such as before giving a digitalis preparation. C) The respiratory rate does not need to be assessed before giving digoxin. D) Pain level does not need to be assessed before giving digoxin. Page Ref: 18 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 5: Quality and Safety NLN Competencies: Quality & Safety 10) The nurse is completing a general assessment of a newborn. Which technique should the nurse use? A) Wrap the tape measure around the head below the ears. B) Wrap the tape measure around the head starting at the nose. C) Wrap the tape measure around the abdomen at the umbilicus. D) Wrap the tape measure around the chest below the nipple line. ANSWER: C Explanation: A) When measuring the head circumference, wrap the tape around the head at the supraorbital prominence above the eyebrows, above the ears, and around the occipital prominence. B) When measuring the head circumference, wrap the tape around the head at the supraorbital prominence above the eyebrows, above the ears, and around the occipital prominence. C) When measuring the abdomen circumference, wrap the tape around the abdomen at the level of the umbilicus. D) When measuring the chest circumference, wrap the tape measure around the chest, placed just under the axilla and at the nipple line. Page Ref: 31 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety
  • 10. 8 11) The nurse is measuring the blood pressure of an adult client. Which technique would cause an erroneously low blood pressure? A) Bladder to cuff ratio too wide B) Arm unsupported C) Cuff wrapped too loosely D) Arm below heart level ANSWER: A Explanation: A) The width of the bladder cuff needs to be 40% of the circumference or 20% wider than the diameter of the midpoint. B) If the arm is unsupported, it will cause an erroneously high blood pressure. C) If the cuff is wrapped too loosely, it will cause an erroneously high blood pressure. D) If the arm is below heart level, it will cause an erroneously high blood pressure. Page Ref: 11 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety 12) The nurse is reviewing collected data. Which client should the nurse see first? A) Infant respirations 38/min B) 2-year-old pulse 112/min C) 6-year-old axillary temperature 97.5°F D) 10-year-old blood pressure 138/88 ANSWER: D Explanation: A) An infant's respiration range is 20-40/min. B) A 2-year-old child's pulse range is 70-120/min. C) A 6-year-old child's temperature range is 98.6°F but axillary is 1°F lower than oral. D) A 10-year-old child's blood pressure range is systolic 95-116 and diastolic 60-70. This is much higher than the range for the age of this client. Page Ref: 15 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety
  • 11. 9 13) The nurse is caring for a client with diaphoresis. Which route should the nurse use to assess the client's temperature? Select all that apply. A) Oral B) Rectal C) Axillary D) Tympanic E) Heat sensitive ANSWER: A, B, D Explanation: A) Oral does not interfere with diaphoresis because the probe is in the mouth. B) Rectal does not interfere with diaphoresis because the probe is in the rectum. C) Axillary might be wet and cause an error in the reading temperature. D) Tympanic does not interfere with diaphoresis because the probe is in the ear. However, do not use if ear is draining or infected. E) Heat sensitive might have areas of the skin that are wet and cause an error in reading temperature. Page Ref: 26, 28 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety 14) The nurse is preparing to assess a client's abdomen. Which response will the nurse make when asked why the stethoscope is warmed up before placing it on the abdomen? A) "I might hear a friction rub with a cold stethoscope." B) "A nice nurse will put a warm stethoscope on your abdomen." C) "A cold stethoscope may cause your abdominal muscles to contract." D) "Warming up the stethoscope will help with the digestion of your food." ANSWER: C Explanation: A) The nurse might hear a friction rub due to an inflammation, infection, or abdominal growth, not from a cold stethoscope. B) Warming up a stethoscope can be nice for the client's comfort; however, it is done to decrease the possibility of abdominal muscles contracting; otherwise the nurse might hear unnecessary contractions. C) A cold stethoscope may cause the abdominal muscles to contract which the nurse might hear with a cold stethoscope. D) Warming up the stethoscope has no effect on the digestion of food. A warm stethoscope will decrease the possibility of abdominal muscles
  • 12. 1 0 contracting, eliminating the possibility of the nurse hearing any unnecessary noises. Page Ref: 31 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety
  • 13. 1 1 15) The nurse is preparing a teaching tool about gastrointestinal function. Which signs and symptoms of colon cancer will the nurse include on the tool? Select all that apply. A) Weight gain B) Rectal bleeding C) Unusual cough D) Change in bowel function E) Decrease medication absorption ANSWER: B, D Explanation: A) Weight loss, not gain, is a sign and symptom of colon cancer. B) Rectal bleeding is a symptom of colon cancer. C) Unusual cough is more a sign and symptom of a lung infection or lung cancer. D) A change in bowel function is a symptom of colon cancer. E) A decrease in medication absorption often occurs with aging, not colon cancer. Page Ref: 34 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety 16) The nurse needs to assess the ears of a 2-year-old client. Which technique will the nurse use? A) Pull the pinna up and back. B) Pull the pinna up and forward. C) Pull the pinna down and back. D) Pull the pinna down and forward. ANSWER: C Explanation: A) Pulling the pinna up and back will straighten the ear canal for a client greater than 3 years old. B) Pulling the pinna up and forward will not allow sufficient visualization of the ear. C) Pulling the pinna down and back will straighten the ear canal for a client less than 3 years old. D) Pulling the pinna down and forward will not allow sufficient visualization of the ear. Page Ref: 43 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety
  • 14. 1 2 17) The nurse is assessing an adolescent. Which finding indicates that the client is in Tanner's stage 5? A) There is no pubic hair except for fine body hair. B) Pubic hair is developing along the labia. C) Pubic hair distribution extends to umbilicus. D) Pubic hair appears on the inner aspect of the thigh. ANSWER: D Explanation: A) No pubic hair is Tanner Stage 1. B) Pubic hair developing along the labia is Stage 2. C) Pubic hair distribution extends to umbilicus is Stage 5 but for men only. D) Pubic hair appears on the inner aspect of the thigh for Stage 5. Page Ref: 51 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety 18) The UAP notifies the nurse of these vital signs for a client on the medical-surgical unit: temperature 97.6°F, respirations 22, pulse 122, and BP 98/72. mm Hg Which action should the nurse take? A) Ask the UAP to reassess the client. B) Inform the UAP to document these vital signs. C) Reassess the client to validate these vital signs. D) Notify the healthcare provider of these vital signs. ANSWER: C Explanation: A) UAP cannot assess or reassess as evaluation of data. B) These vital signs are abnormal; the nurse needs to reassess the client to validate these findings. C) The nurse needs to reassess the client to validate these findings. D) The nurse will notify the healthcare provider of these vital signs after the nurse reassesses the client to validate these findings. Page Ref: 2 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety
  • 15. 10 19) The nurse is assessing the Babinski response of an adult client. Which finding indicates that the response is negative? A) All toes turn inward. B) All toes curve upward. C) All toes spread outward. D) All toes bend downward. ANSWER: D Explanation: A) This is not in relation to the Babinski response; it could be another problem. B) A positive Babinski response is when the toes spread outward and the big toe moves upward and backward. C) A positive Babinski response is when the toes spread outward and the big toe moves upward and backward. D) All toes bend downward for a negative Babinski response on an adult. Page Ref: 70 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety 20) The nurse is preparing to assess an adult client's blood pressure. Which action will the nurse take after introducing self? A) Provide privacy. B) Perform handwashing. C) Identify the client with two identifiers. D) Explain what he or she will be doing with the client. ANSWER: C Explanation: A) Need to identify the right client before providing privacy so the correct room is located. B) Need to identify the right client before performing handwashing so the correct room is located. C) The nurse needs to identify the right client before doing anything else after introducing self. D) The nurse needs to identify the right client before explaining the procedure so the client knows why the nurse is in the room. Page Ref: 14 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety
  • 16. 11 21) The nurse is completing an assessment on a client who just received morphine. Which parameter is the highest priority? A) Pain level B) Respirations C) Temperature D) Blood pressure ANSWER: B Explanation: A) Pain level has already been assessed because the client just received morphine and it is too early to reassess pain. B) Respirations are highest priority after administering morphine because morphine can cause respiratory depression. C) The temperature of a client is not affected by morphine or pain. D) Blood pressure can change because of the client's pain; however, the highest priority for this client is respirations because morphine was just administered. Page Ref: 23 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Safety AACN Domains and Comps.: Domain 5: Quality and Safety NLN Competencies: Quality & Safety 22) The nurse receives information provided during hand-off communication. Which client will the nurse see first? A) Kussmaul respirations B) Blood glucose of 144 mg/dL C) Pain level 6 out of 10 D) Temperature is 101.8°F ANSWER: A Explanation: A) This client is probably experiencing diabetic ketoacidosis or going into shock and needs to be reassessed immediately. B) The glucose is elevated in this client, but the Kussmaul breathing has a higher priority. C) The pain level is moderate pain. D) The temperature is elevated, but Kussmaul breathing has a higher priority. Page Ref: 91 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety
  • 17. 12 23) The nurse is reviewing the care needs of assigned clients. Which task can the nurse delegate to the UAP? A) Administration of medication B) Recording findings from a sponge bath C) Teaching a client how to take own vital signs D) Assessing a client in the medical-surgical unit for two days ANSWER: B Explanation: A) Administration of medication requires licensed personnel to administer. B) A UAP can record the findings from a sponge bath because the skin is observed during a UAP's usual care. C) UAPs cannot teach clients because this is outside their scope of practice. D) Assessing is outside the UAP's scope of practice. Page Ref: 79 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Safety AACN Domains and Comps.: Domain 5: Quality and Safety NLN Competencies: Quality & Safety 24) The nurse reviews applying a pulse oximeter with UAP. Which statement indicates teaching was effective? A) "I will clean the site after applying the sensor." B) "I will move the adhesive toe or finger sensor once a shift." C) "I will remove any fingernail polish when using a pulse oximeter." D) "I will use the side of the finger rather than perpendicular to the nail bed." ANSWER: D Explanation: A) The site needs to be cleaned before applying the sensor. B) The adhesive toe or finger sensor needs to be moved every four hours. C) The UAP needs to remove dark fingernail polish. D) The side of the finger is an alternate use if the client has dark fingernail polish on the fingernail. Page Ref: 21 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person- Centered Care NLN Competencies: Quality & Safety
  • 18. 1 Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson Education) Test bank Chapter 2: Caring Interventions 1) The nurse is observing a UAP performing a bed bath for a client. Which action by the UAP requires the nurse to intervene? A) Washing the client's arms from wrists to shoulders. B) Washing the client's eyes and face first before the rest of the body. C) Washing, rinsing, and drying the client's leg from thigh to ankle. D) Washing the client's back and then the perineum. ANSWER: C Explanation: A) The arms should be washed from wrist to shoulder. B) The eyes and face should be washed before the rest of the body. C) The correct method in performing a bed bath is washing, rinsing, and drying the client's leg from ankle to thigh. D) The back is washed before the perineum. Page Ref: 98-99 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.3 Integrate assessment skills in practice. NLN Competencies: Relationship Centered Care 2) The nurse delegates soft contact lens care to a UAP. Which action by the UAP requires the nurse to intervene? A) Placing the client in the semi-Fowler's position. B) Placing the client's removed disposable lenses in the trash. C) Placing the gloved thumb and forefinger directly on the soft lens on top of the eyeball. D) Placing the gloved thumb on the client's lower eyelid and gloved index finger on the client's upper lid, pressing lightly on the eyeball. ANSWER: D Explanation: A) The client should be in the semi-Fowler position. B) Disposable lens should be placed in the trash. C) Pressure should not be applied directly on the soft lens covering the eyeball. D) Placing the gloved thumb on the client's lower eyelid and gloved index finger on the client's upper lid, pressing lightly on the eyeball is the technique to remove rigid contact lenses, not soft lenses. Page Ref: 110 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 5.2 Contribute to a culture of
  • 19. 2 patient safety. NLN Competencies: Relationship Centered Care
  • 20. 3 3) The nurse determines some client care tasks can be delegated to the UAP. Which task should the nurse omit? A) Performing foot care for a client with diabetes. B) Changing an occupied bed for a client with multiple intravenous medications infusing. C) Performing a bath for a newborn with an unhealed umbilical cord. D) Oral care for an unconscious client. ANSWER: A Explanation: A) The registered nurse should perform foot care for the client with diabetes. B) UAP can change an occupied bed. C) UAP can provide a bath to a newborn with an unhealed umbilical cord. D) UAP can provide oral care to an unconscious client. Page Ref: 111 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Relationship Centered Care 4) When teaching the client about foot care, which statement will the nurse include in the teaching? A) "Use creams or lotions on the feet and in between the toes after showering." B) "While sitting, cross your legs at the knees instead of the ankles." C) "Avoid using pumice stones on the feet to decrease callouses." D) "When your feet are cold, place them on a hot water bottle to warm them." ANSWER: C Explanation: A) Lotion or cream should be applied on the feet, avoiding the toes, after showering. B) Legs should be crossed at the ankles. C) The client should avoid using pumice stones on the feet because these can injure the feet. D) Feet should not be placed on a hot water bottle as this could cause a burn. Page Ref: 113 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.8 Promote self-care management. NLN Competencies: Relationship Centered Care
  • 21. 4 5) Prior to delegating hearing aid care to a UAP, what is the nurse's PRIORITY? A) Determine the UAP's knowledge of the procedure. B) Inform the UAP of what to report back to the nurse. C) Discuss relevant client health information necessary for the task. D) Provide the UAP with guidance on where to find supplies necessary for the task. ANSWER: A Explanation: A) Prior to delegation, the nurse must first determine the UAP's knowledge of the procedure. B) Reporting back to the nurse can occur at the end of the procedure. C) Client information is not essential when delegating hearing aid care. D) The UAP should be provided with the supplies for the task. Page Ref: 116 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.6 Demonstrate accountability for care delivery. NLN Competencies: Quality & Safety 6) A client places one hearing aid in the ear and tells the nurse, "I hear a whistling sound." Which actions will the nurse take in response to the client's statement? Select all that apply. A) Turn the volume of the hearing aid up. B) Check the battery inside the hearing aid. C) Turn the volume of the hearing aid down. D) Ensure the ear canal is not blocked with wax. E) Check that the earmold is attached to the receiver. ANSWER: C, E Explanation: A) Turning the volume up will make the whistling worse. B) The battery does not need to be checked. C) Turning the volume of the hearing aid down will decrease the client's distress. D) Wax in the ear does not cause the hearing aid to whistle. E) Checking that the earmold is attached to the receiver troubleshoots the whistling noise. Page Ref: 117 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.6 Demonstrate accountability for care delivery. NLN Competencies: Relationship Centered Care
  • 22. 5 7) The nurse cares for a client who receives new hearing aids for the first time. Which statements will the nurse include when teaching the client about the hearing aids? Select all that apply. A) "Push the earmold slightly backward and pull out to remove it." B) "Rotate the earmold slightly forward and pull out to remove it." C) "If the hearing aid is not used for several days, be sure to turn the device off." D) "If the earmold is detachable, soak it in isopropyl alcohol weekly to disinfect it." E) "Blow any excess moisture through the opening of the earpiece when cleaning it." ANSWER: B, E Explanation: A) The hearing aid is not removed by pushing the earmold backward. B) The nurse will instruct the client to rotate the earmold slightly forward and pull it out to remove it. C) The battery should be removed if the device is not used for several days. D) The earmold should not be soaked in alcohol. E) To remove excess moisture, the client can be instructed to blow any excess moisture through the opening of the earpiece. Page Ref: 116 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.2 Communicate effectively with individuals. NLN Competencies: Relationship Centered Care 8) The nurse is performing hearing aid care for a client and notes the hearing aid has "TM" near its on/off switch. What is the nurse's understanding of the meaning of "TM"? A) Transmitting mode B) Tympanic membrane C) Telephone/microphone D) Tympanic/microp hone ANSWER: C Explanation: A) TM does not mean transmitting mode. B) TM does not mean tympanic membrane. C) "T/M" on the hearing aid stands for telephone/microphone, not tympanic membrane. D) TM does not mean tympanic microphone. Page Ref: 116 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care
  • 23. 6 AACN Domains and Comps.: 2.2 Communicate effectively with individuals. NLN Competencies: Quality & Safety
  • 24. 7 9) A nurse is providing oral care to an older adult. What findings does the nurse recognize are normal findings in this client? Select all that apply. A) Dry mouth B) Gingivitis C) Jaw bone loss D) Receding gums E) Tooth root decay ANSWER: A, D, E Explanation: A) Dryness of the oral mucosa is a common finding among many older adults. B) Gingivitis is not a common finding in an older adult. C) Jaw bone loss is not a common finding in an older adult. D) Receding gums is a common finding among many older adults. E) Tooth root decay is common in some older adults, often due to receding gums. Page Ref: 122 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.3 Integrate assessment skills in practice. NLN Competencies: Knowledge and Science 10) The nurse is making an occupied bed. In which order should the nurse perform when removing the top linens and adding the bath blanket? A) Spread the bath blanket over the top sheet. B) Remove the spread and the blanket. C) Reach under the bath blanket, grasp top edge of sheet. D) Ask the client to hold the top edge of the bath blanket. E) Pull the sheet from under the bath blanket. ANSWER: B, A, D, C, E Explanation: A) Spreading the bath blanket over the top sheet happens after the nurse removes the spread and blanket (top linens). B) Removing the spread and blanket is the first step in the procedure. C) After removing the spread and the blanket, spreading the bath blanket on the top sheet, asking the client to hold the top edge of the bath blanket, the nurse will reach under the bath blanket and grasp the top edge of the sheet. D) After removing the spread and the blanket, spreading the bath blanket on the top sheet, thenurse will ask the client to hold the top edge of the bath blanket. E) After removing the spread and the blanket, spreading the bath blanket on the top sheet, asking the client to hold the top edge of the bath blanket, the
  • 25. 8 nurse will reach under the bath blanket and grasp the top edge of the sheet. Finally, the nurse will pull the sheet from under the bath blanket. Page Ref: 104 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 2.1 | QSEN Competencies: Safety AACN Domains and Comps.: 2.6 Demonstrate accountability for care delivery. NLN Competencies: Quality & Safety
  • 26. 9 11) The nurse prepares to make an unoccupied bed. Place the steps in correct order of how the nurse will remove the soiled linens. A) Detach the call bell and any drainage tubes from the bed linens. B) Loosen all the bedding systematically. C) Roll all soiled linens inside the bottom sheet. D) Remove the incontinent pad and discard. E) Remove the pillowcases and fold reusable linens. ANSWER: A, B, E, D, C Explanation: A) The first step to make an unoccupied bed is to detach the call bell and any drainage tubes from the bed linens. B) The second step when making an unoccupied bed is loosening all the bedding systematically. C) The final step when making an unoccupied bed is rolling all soiled linens inside the bottom sheet. D) Removing the incontinent pad and discarding it occurs after detaching the call bell, loosening the bedding, and removing the pillowcases. E) Removing the pillowcases occurs after detaching the call bell and loosening all bedding systematically. Page Ref: 105 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 2.1 | QSEN Competencies: Safety AACN Domains and Comps.: 2.6 Demonstrate accountability for care delivery. NLN Competencies: Quality & Safety
  • 27. 1 0 12) The nurse prepares to perform oral care for a client with dentures. Place the steps in correct order for how the nurse will remove the client's dentures. A) Use gauze to grasp upper plate at the front teeth with the thumb and second finger. B) Lift the lower plate and remove without stretching the lip. C) Move the denture up and down slightly. D) Don gloves. E) Place the upper plate in the denture cup. F) Place the lower plate in the denture cup. ANSWER: D, A, C, E, B, F Explanation: A) The correct steps to remove the client's dentures is as follows: Don gloves, use gauze to grasp the upper plate at the front teeth with the thumb and second finger, move the denture up and down slightly, place the upper plate in the denture cup. Next, lift the lower plate and remove it without stretching the lip. Finally, place the lower plate in the denture cup. B) The correct steps to remove the client's dentures is as follows: Don gloves, use gauze to grasp the upper plate at the front teeth with the thumb and second finger, move the denture up and down slightly, place the upper plate in the denture cup. Next, lift the lower plate and remove it without stretching the lip. Finally, place the lower plate in the denture cup. C) The correct steps to remove the client's dentures is as follows: Don gloves, use gauze to grasp the upper plate at the front teeth with the thumb and second finger, move the denture up and down slightly, place the upper plate in the denture cup. Next, lift the lower plate and remove it without stretching the lip. Finally, place the lower plate in the denture cup. D) The correct steps to remove the client's dentures is as follows: Don gloves, use gauze to grasp the upper plate at the front teeth with the thumb and second finger, move the denture up and down slightly, place the upper plate in the denture cup. Next, lift the lower plate and remove it without stretching the lip. Finally, place the lower plate in the denture cup. E) The correct steps to remove the client's dentures is as follows: Don gloves, use gauze to grasp the upper plate at the front teeth with the thumb and second finger, move the denture up and down slightly, place the upper plate in the denture cup. Next, lift the lower plate and remove it without stretching the lip. Finally, place the lower plate in the denture cup. F) The correct steps to remove the client's dentures is as follows: Don gloves, use gauze to grasp the upper plate at the front teeth with the thumb and second finger, move the denture up and down slightly, place the upper plate in the denture cup. Next, lift the lower plate and remove it without stretching the lip. Finally, place the lower plate in the denture cup. Page Ref: 119 Cognitive Level: Analyzing
  • 28. 1 1 Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 2.2 | QSEN Competencies: Safety AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety
  • 29. 1 2 13) The nurse prepares to mix two medications (vial A and B) in one syringe. Place the steps in correct order for how the nurse will perform the procedure. A) Inject a volume of air equal to the volume of medication to be withdrawn into vial A. B) Withdraw the required amount of medication from vial B. C) Draw up a volume of air equal to the volume of medications to be withdrawn from both vials A and B. D) Withdraw the needle from vial A and inject the remaining air into vial B. E) Withdraw the required amount of medication from vial A. ANSWER: C, A, D, B, E Explanation: A) Mixing two medications from two vials in one syringe has the following steps: After performing appropriate hand hygiene, draw up a volume of air equal to the volume of medications to be withdrawn from both vials A and B. Inject a volume of air equal to the volume of medication to be withdrawn into vial A. Next withdraw the needle from vial A and inject the remaining air into vial B. Withdraw the required amount of medication from vial B. Finally, withdraw the required amount of medication from vial A. B) Mixing two medications from two vials in one syringe has the following steps: After performing appropriate hand hygiene, draw up a volume of air equal to the volume of medications to be withdrawn from both vials A and B. Inject a volume of air equal to the volume of medication to be withdrawn into vial A. Next withdraw the needle from vial A and inject the remaining air into vial B. Withdraw the required amount of medication from vial B. Finally, withdraw the required amount of medication from vial A. C) Mixing two medications from two vials in one syringe has the following steps: After performing appropriate hand hygiene, draw up a volume of air equal to the volume of medications to be withdrawn from both vials A and B. Inject a volume of air equal to the volume of medication to be withdrawn into vial A. Next withdraw the needle from vial A and inject the remaining air into vial B. Withdraw the required amount of medication from vial B. Finally, withdraw the required amount of medication from vial A. D) Mixing two medications from two vials in one syringe has the following steps: After performing appropriate hand hygiene, draw up a volume of air equal to the volume of medications to be withdrawn from both vials A and B. Inject a volume of air equal to the volume of medication to be withdrawn into vial A. Next withdraw the needle from vial A and inject the remaining air into vial B. Withdraw the required amount of medication from vial B. Finally, withdraw the required amount of medication from vial A. E) Mixing two medications from two vials in one syringe has the following steps: After performing appropriate hand hygiene, draw up a volume of air equal to the volume of medications to be withdrawn from both vials A and B. Inject a volume of air equal to the volume of medication to be withdrawn
  • 30. 1 3 into vial A. Next withdraw the needle from vial A and inject the remaining air into vial B. Withdraw the required amount of medication from vial B. Finally, withdraw the required amount of medication from vial A. Page Ref: 134 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Intervention | Learning Outcome: 2.7 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.6 Demonstrate accountability for care delivery. NLN Competencies: Quality & Safety
  • 31. 1 4 14) The nurse delegates oral care of an unconscious client on supplemental oxygen to the UAP. Which action by the UAP requires the nurse to intervene? A) Placing a bite block in the client's mouth. B) Applying petroleum-based moisturizer to the client's lips. C) Positioning the client in side-lying position with head of bed lowered. D) Using a separate moistened swab for the inside of each cheek. ANSWER: B Explanation: A) A bite block should be used. B) Applying petroleum-based moisturizer to the client's lips will require nursing intervention because these products may increase the risk of fire for clients with oxygen. Water-based moisturizers should be used instead. C) The client should be in the side-lying position with the head of the bed lowered. D) A separate moistened swab should be used for the inside of each cheek. Page Ref: 117 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Intervention | Learning Outcome: 2.2 | QSEN Competencies: Safety AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety 15) The nurse understands that, in addition to the five client rights of medication administration, there are now more rights for safe medication administration. Which rights are the new rights for safe medication administration? Select all that apply. A) Right documentation B) Right dose C) Right time D) Right route E) Right reason ANSWER: A, E Explanation: A) Right documentation is a new right for safe medication administration. B) Right dose has been a right for safe medication administration. C) Right time has been a right for safe medication administration. D) Right route has been a right for safe medication administration. E) Right reason is a new right for safe medication administration. Page Ref: 128 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Pharmacological and
  • 32. 1 5 Parenteral Therapies Standards: Nursing Process: Intervention | Learning Outcome: 2.4 | QSEN Competencies: Safety AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety
  • 33. 10 16) The nurse is acting as preceptor for a novice nurse. Which action by the novice nurse requires the nurse preceptor to intervene? A) Labeling medications placed in a medication cup. B) Removing prepackaged medication and placing in a medication cup. C) Keeping narcotics separated from other medications that need to be administered. D) Breaking scored tablets as needed for correct dosage. ANSWER: B Explanation: A) Medications placed in a cup should be labeled. B) The nurse should leave prepackaged medications in their original package to ensure proper labeling and to maintain sanitary approaches. C) Narcotics should be kept separate from other medications. D) Scored tablets should be broken for the correct dosage. Page Ref: 151 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Intervention | Learning Outcome: 2.4 | QSEN Competencies: Safety AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety 17) The nurse performs a skin assessment while bathing an older adult client. Which lifespan considerations regarding skin characteristics are more common in the older adult? Select all that apply. A) Dry skin B) Itchy skin C) Poor healing D) Increased risk of water retention E) Increased risk of trauma ANSWER: A, B, C, E Explanation: A) The older adult client is at increased risk for dry skin due to a decrease in endocrine secretion and decreased elastin. B) The older adult client is at increased risk for itchy skin due to a decrease in endocrine secretion and decreased elastin. C) The older adult client is at increased risk for poor healing due to inadequate nutrition, compromised immunity, poor hydration, and decreased mobility, among other factors. D) The older adult client is not at risk for water retention. E) The older adult client is at increased risk of trauma due to fall, immobility, and decreased ability to heal, among others. Page Ref: 102 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 2.3 |
  • 34. 10 QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.3 Integrate assessment skills in practice. NLN Competencies: Relationship Centered Care
  • 35. 11 18) The nurse prepares to administer an intermittent intravenous solution using a secondary administration set. Place the steps of assembling the secondary infusion in correct order. A) Insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump. B) Hang the secondary container above the level of the primary bag. C) Attach the appropriate label to the secondary tubing. D) Lower medication bag to clear tubing and back-prime tubing. E) Close the clamp on the secondary infusion tubing and spike the medication infusion bag. ANSWER: E, A, B, D, C Explanation: A) The correct steps of assembling the secondary infusion is as follows: Close the clamp on the secondary infusion tubing and spike the medication infusion bag; insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump; hang the secondary container above the level of the primary bag; lower medication bag to clear tubing and back-prime tubing; attach the appropriate label to the secondary tubing. B) The correct steps of assembling the secondary infusion is as follows: Close the clamp on the secondary infusion tubing and spike the medication infusion bag; insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump; hang the secondary container above the level of the primary bag; lower medication bag to clear tubing and back-prime tubing; attach the appropriate label to the secondary tubing. C) The correct steps of assembling the secondary infusion is as follows: Close the clamp on the secondary infusion tubing and spike the medication infusion bag; insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump; hang the secondary container above the level of the primary bag; lower medication bag to clear tubing and back-prime tubing; attach the appropriate label to the secondary tubing. D) The correct steps of assembling the secondary infusion is as follows: Close the clamp on the secondary infusion tubing and spike the medication infusion bag; insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump; hang the secondary container above the level of the primary bag; lower medication bag to clear tubing and back-prime tubing; attach the appropriate label to the secondary tubing. E) The correct steps of assembling the secondary infusion is as follows: Close the clamp on the secondary infusion tubing and spike the medication infusion bag; insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump; hang the secondary container above the level of the primary bag; lower medication bag to clear tubing and back-prime tubing; attach the appropriate label to the secondary
  • 36. 12 tubing. Page Ref: 179-180 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Intervention | Learning Outcome: 2.8 | QSEN Competencies: Safety AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety
  • 37. 13 19) A novice nurse instructs a client on the use of sublingual nitroglycerin. Which statement by the novice nurse requires intervention by the nurse preceptor? A) "Be sure to take the medication prior to the start of your pain." B) "Do not chew or swallow the tablet." C) "The tablet may cause burning or tingling as it dissolves." D) "Be sure to sit down when you decide to take the medication." ANSWER: A Explanation: A) Nitroglycerin is taken at the onset of the client's symptoms, not prior to. B) A sublingual medication is not to be chewed or swallowed whole. C) Nitroglycerin may cause burning or tingling as it dissolves. D) The client should sit when taking the medication. Page Ref: 155 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Intervention | Learning Outcome: 2.5 | QSEN Competencies: Safety AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety 20) A nurse mixes two insulins in one syringe for a client with diabetes. Which action by the nurse is incorrect? A) Injecting a volume of air equal to the volume of medication to be withdrawn into the first vial. B) Drawing up air in the syringe equal to the dose of both insulins. C) Gently shaking the vials in order to ensure medication has dissolved. D) Withdrawing the needle from the first vial and injecting the remaining air into the second vial. ANSWER: C Explanation: A) The volume of air equal to the volume of medication to be withdrawn should be injected into the first vial. B) Air should be drawn up into the syringe equal to the dose of both insulins. C) Shaking the insulins is not recommended because it will cause the medication to become frothy and difficult to measure. Instead, the nurse should gently roll the insulins in order to mix them. D) The needle should be withdrawn from the first vial and the remaining air should be injected into the second vial. Page Ref: 134-135 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Intervention | Learning Outcome: 2.7 | QSEN Competencies: Evidence-Based Practice
  • 38. 14 AACN Domains and Comps.: 2.6 Demonstrate accountability for care delivery. NLN Competencies: Quality & Safety
  • 39. 15 21) While giving the client a bath, the nurse notes the client has facial acne. What statement will the nurse omit when teaching the client about this condition? A) "Use cool water when cleansing your face to close the pores." B) "Wash your face frequently to remove oil and dirt." C) "Avoid using oil-based creams on your face." D) "Do not squeeze the lesions on your face." ANSWER: A Explanation: A) The nurse should instruct the client to use soap and warm water to cleanse the face. B) The face should be washed frequently. C) Oil-based creams should not be applied to the face. D) Lesions should not be squeezed. Page Ref: 102 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.6 Demonstrate accountability for care delivery. NLN Competencies: Relationship Centered Care 22) The nurse is caring for an older adult client and performs a bed bath and linen change. Which action by the nurse poses an increase of injury in the client? A) Washing the client with a washcloth. B) Pulling linens underneath the client. C) Assisting the client to turn in bed. D) Covering the client with warm linens. ANSWER: B Explanation: A) The client should be washed with a washcloth. B) The nurse should be most cautious when pulling linens underneath an older adult client. This increases the risk of skin impairment because some older adults can be more prone to injury of the skin. C) The client should be assisted to turn in bed. D) The client should be covered with warm linens. Page Ref: 109 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Safety AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety
  • 40. 16 23) The nurse cares for a client who wears soft contact lenses for vision correction. Which statement will the nurse include when teaching the client about care of the lenses? A) "If you do not have saline solution, saliva works to cleanse the lenses." B) "If you wear disposable lenses, it is acceptable to cleanse them and wear them again." C) "If you are removing the lens, place your thumb and forefinger directly on the lens." D) "If you wear disposable lenses, be sure to cleanse the lens container daily." ANSWER: C Explanation: A) Saliva should not be used to cleanse the lenses. B) Disposable lenses are not to be cleansed and reused. C) When instructing the client to remove the soft lens, the nurse should tell the client to place the thumb and forefinger directly on the lens and squeeze gently. D) A lens container is not used for disposable lenses. Page Ref: 110 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Intervention | Learning Outcome: 2.3 | QSEN Competencies: Safety AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety
  • 41. 17 24) The nurse prepares to perform a z-track injection to a client. Place the steps of the procedure in correct order. A) Maintain displacement and insert needle at a 90-degree angle. B) Inject medication slowly, keeping skin taut. C) Pull skin 2.5–3.8 cm (1–1.5 in.) laterally away from the injection site. D) Withdraw needle. E) Release retracted skin. ANSWER: C, A, B, D, E Explanation: A) The injection technique of a z-track injection include the following steps: Pull skin 2.5–3.8 cm (1–1.5 in.) laterally away from the injection site; maintain displacement and insert needle at a 90-degree angle; inject medication slowly, keeping skin taut; withdraw the needle; release the retracted skin. B) The injection technique of a z-track injection include the following steps: Pull skin 2.5–3.8 cm (1–1.5 in.) laterally away from the injection site; maintain displacement and insert needle at a 90-degree angle; inject medication slowly, keeping skin taut; withdraw the needle; release the retracted skin. C) The injection technique of a z-track injection include the following steps: Pull skin 2.5–3.8 cm (1–1.5 in.) laterally away from the injection site; maintain displacement and insert needle at a 90-degree angle; inject medication slowly, keeping skin taut; withdraw the needle; release the retracted skin. D) The injection technique of a z-track injection include the following steps: Pull skin 2.5–3.8 cm (1–1.5 in.) laterally away from the injection site; maintain displacement and insert needle at a 90-degree angle; inject medication slowly, keeping skin taut; withdraw the needle; release the retracted skin. E) The injection technique of a z-track injection include the following steps: Pull skin 2.5–3.8 cm (1–1.5 in.) laterally away from the injection site; maintain displacement and insert needle at a 90-degree angle; inject medication slowly, keeping skin taut; withdraw the needle; release the retracted skin. Page Ref: 171 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Intervention | Learning Outcome: 2.4 | QSEN Competencies: Evidence-Based Practice AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety
  • 42. 1 Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Chapter 3 Comfort 1) The nurse cares for a neonate who appears in pain. The neonate has tight facial muscles, loud and shrill cry, rapid breathing, tense extremities and is thrashing about. Using the NIPS pain scale, which number will the nurse give the neonate? A) 5 B) 6 C) 7 D) 8 ANSWE R: C Explanation: A) This is the incorrect use of NIPS. B) This is the incorrect use of NIPS. C) The Neonatal Infant Pain Scale (NIPS) is a standardized pain scale used for assessing pain in neonates up to 6 weeks of age. The scale is based on facial expressions, cry, breathing patterns, arm and leg movements, and state of arousal. Tight facial muscles (1 point), loud and shrill cry (2 points), rapid breathing (1 point), tense extremities (2 points), and increased movement (1 point) equal 7 points. D) This is the incorrect use of NIPS. Page Ref: 192 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 2.3 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.3 Integrate assessment skills in practice. NLN Competencies: Relationship Centered Care
  • 43. 2 2) The nurse sets up a PCA pump for a postoperative client. Which safety parameters will the nurse use? Select all that apply. A) Dose volume limits B) Partial dose settings C) Dosage limits D) Lockout interval E) Re-programming alarm settings ANSWER: A, C, D Explanation: A) Dose volume limit parameters limit the amount of drug that the client can receive when the client pushes the control button. This is an important safety parameter the nurse will use. B) There are no partial dose settings on a PCA pump. C) Dosage limits set the dosage limits as specified on the order. This is an important safety parameter the nurse will use. D) The lockout interval is set in order to ensure that doses are not administered too frequently. This is an important safety parameter the nurse will use. E) Alarm settings should not be re- programmed. Page Ref: 204-205 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 3.5 | QSEN Competencies: Safety AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety
  • 44. 3 3) The nurse cares for a client who requires a PCA for pain control. The healthcare provider has ordered a loading dose for the client. Place the steps in order for the nurse to provide the loading dose by PCA pump. A) Set the safety parameters. B) Press the loading dose control button. C) Set the volume to be delivered. D) Set the pump for a lockout time of zero minutes. ANSWER: D, C, B, A Explanation: A) When providing the loading dose by PCA pump, the nurse must first set the pump for a lockout time of zero minutes. Next, the nurse will set the volume to be delivered and press the loading dose control button. Finally, the nurse will set the safety parameters. B) When providing the loading dose by PCA pump, the nurse must first set the pump for a lockout time of zero minutes. Next, the nurse will set the volume to be delivered and press the loading dose control button. Finally, the nurse will set the safety parameters. C) When providing the loading dose by PCA pump, the nurse must first set the pump for a lockout time of zero minutes. Next, the nurse will set the volume to be delivered and press the loading dose control button. Finally, the nurse will set the safety parameters. D) When providing the loading dose by PCA pump, the nurse must first set the pump for a lockout time of zero minutes. Next, the nurse will set the volume to be delivered and press the loading dose control button. Finally, the nurse will set the safety parameters. Page Ref: 204 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Intervention | Learning Outcome: 3.5 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety 4) The nurse is caring for a client in acute pain. When assessing the client's quality of pain, which statement will the nurse use? A) "How long have you been having pain?" B) "Is the pain better or worse at certain times of the day or night?" C) "What words would you use to describe your pain?" D) "Have you noticed any time during the day or night that the pain is better or worse?" ANSWER: C Explanation: A) Asking how long the pain has been present assesses duration. B) Asking if the pain changes during the day assesses recurrence. C) Quality of pain may be assessed by asking the client, "What words would you use to describe your pain?" D) Asking if the pain is different during the day assesses for recurrence. Page Ref: 194
  • 45. 4 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 3.1 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.3 Integrate assessment skills in practice. NLN Competencies: Relationship Centered Care
  • 46. 5 5) A nurse assesses a client who is experiencing acute pain. Which aspects of the pain assessment are gathered first before the detailed assessment? Select all that apply. A) Location B) Provocation C) Intensity D) Quality E) Radiation ANSWER: A, C, D Explanation: A) For clients experiencing acute or severe pain, the nurse may focus on determining location, intensity, and quality–and quickly follow with an intervention. Clients with less severe or chronic pain can usually provide a more detailed description, and the nurse can obtain a comprehensive pain assessment. B) Precipitating factors can be assessed during the detailed assessment. C) For clients experiencing acute or severe pain, the nurse may focus on determining location, intensity, and quality–and quickly follow with an intervention. Clients with less severe or chronic pain can usually provide a more detailed description, and the nurse can obtain a comprehensive pain assessment. D) For clients experiencing acute or severe pain, the nurse may focus on determining location, intensity, and quality–and quickly follow with an intervention. Clients with less severe or chronic pain can usually provide a more detailed description, and the nurse can obtain a comprehensive pain assessment. E) Radiation would be assessed during the detailed assessment. Page Ref: 194 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 3.1 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.3 Integrate assessment skills in practice. NLN Competencies: Relationship Centered Care
  • 47. 6 6) The nurse is caring for a client who is using a TENS unit for pain management. Which statements will the nurse use when teaching the client about this therapy? Select all that apply. A) "Make sure and cover the unit while showering or bathing." B) "When turning the unit on, make sure the amplitude control is set to 5." C) "With the unit off, plug the lead wires into the battery-operated unit at one end, leaving the electrodes at the other end." D) "Increase the amplitude until you feel discomfort and then decrease the amplitude until you feel comfortable." E) "Wash, rinse, and dry the area where you would like to apply the electrodes." ANSWER: C, D, E Explanation: A) The TENS unit is not to be used in the shower or bathing. B) The amplitude control should be set at level 0. C) The nurse should instruct the client that, with the TENS unit off, plug the lead wires into the battery-operated unit at one end, leaving electrodes at the other end. D) The client should be instructed to slowly increase the intensity of the stimulus (amplitude) until a slight increase in discomfort is noted. E) The area should be washed, rinsed, and dried before applying the electrodes. Page Ref: 201 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 3.6 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.2 Communicate effectively with individuals. NLN Competencies: Relationship Centered Care
  • 48. 7 7) The nurse cares for a client who wants to try biofeedback for relief of chronic pain. What advantages to this therapy does the nurse recognize? Select all that apply. A) Increases circulation and endorphins B) Completely controlled by the client C) Rapid pain relief D) Redirects energy flow through pressure on meridian points E) Promotes stress reduction as well as pain relief ANSWER: B, E Explanation: A) Massage increases circulation and endorphins. B) Biofeedback is an electric monitoring device that feeds back effect of behavior so the client can control internal processes (such as the heart rate). Advantages to biofeedback include the fact that it is completely controlled by the client. C) Ice therapy promotes rapid pain relief. D) Acupressure redirects energy flow through pressure on meridian points. E) Advantages to biofeedback include the fact that it promotes stress reduction as well as pain relief. Page Ref: 203 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 3.6 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 1.3 Demonstrate clinical judgment founded on a broad knowledge base. NLN Competencies: Knowledge and Science
  • 49. 8 8) The nurse cares for a client with chronic pain who asks the nurse about using acupressure for pain relief. Which statements will the nurse include in the teaching regarding how this treatment works for pain relief? Select all that apply. A) "The pressure compresses and splints irritated nerve endings." B) "It redirects energy flow through pressure on meridian points." C) "The therapy restores structural integrity and balance." D) "The therapy reduces pain and increases endorphins." E) "It manipulates muscles and realigns spinal column nerve function." ANSWER: B, D Explanation: A) Acupressure does not compress nerve endings. B) Acupressure is a therapy based on the traditional Chinese method of acupuncture. This method involves using specific points located on meridians at various places on the body. C) Chiropractic care restores structural integrity and balance. D) This therapy reduces pain and increases endorphins. E) Chiropractic care manipulates muscles and realigns spinal column nerve function. Page Ref: 203 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 3.6 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 1.3 Demonstrate clinical judgment founded on a broad knowledge base. NLN Competencies: Knowledge and Science
  • 50. 9 9) The nurse prepares to apply dry heat to a client's extremity in an effort to reduce pain. Which variables are recognized by the nurse to affect physiological tolerance to heat and cold? Select all that apply. A) Body part location B) Size of the exposed body part C) Individual tolerance D) Intactness of skin E) Gender ANSWER: A, B, C, D Explanation: A) Body part location affects the physiological tolerance to heat and cold. For example, the back of the hand and foot are not very temperature sensitive. In contrast, the inner aspect of the wrist and forearm, the neck, and the perineal area are temperature sensitive. B) The size of the exposed body part affects the physiological tolerance to heat and cold. The larger the area exposed to heat and cold is, the lower is the tolerance. C) Individual tolerance affects the physiological tolerance to heat and cold. The very young and the very old have the least physiological tolerance. D) Injured areas of the skin are more susceptible to temperature variations versus intact skin. E) Gender does not affect tolerance to heat or cold application. Page Ref: 207 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 3.1 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 1.3 Demonstrate clinical judgment founded on a broad knowledge base. NLN Competencies: Knowledge and Science
  • 51. 1 0 10) The nurse is caring for five clients with acute pain. When considering the use of heat and cold therapy, which medical conditions will the nurse determine require special precautions? Select all that apply. A) Diabetes B) Venous insufficiency C) Asthma D) Congestive heart failure E) Arterial disease ANSWER: A, B, D, E Explanation: A) Clients with diabetes require special precautions during heat and cold therapy because these clients lack the normal ability to dissipate heat via the blood circulation, which puts them at risk for tissue damage with heat applications. Cold applications are contraindicated for these clients. B) Clients with peripheral vascular disease (peripheral arterial disease and venous insufficiency) require special precautions during heat and cold therapy because these clients lack the normal ability to dissipate heat via the blood circulation, which puts them at risk for tissue damage with heat applications. Cold applications are contraindicated for these clients. C) Clients with asthma do not require special precautions. D) Clients with congestive heart failure and those with diabetes require special precautions during heat and cold therapy because these clients lack the normal ability to dissipate heat via the blood circulation, which puts them at risk for tissue damage with heat applications. Cold applications are contraindicated for these clients. E) Clients with peripheral vascular disease (peripheral arterial disease and venous insufficiency) require special precautions during heat and cold therapy because these clients lack the normal ability to dissipate heat via the blood circulation, which puts them at risk for tissue damage with heat applications. Cold applications are contraindicated for these clients. Page Ref: 208 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 3.1 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 1.3 Demonstrate clinical judgment founded on a broad knowledge base. NLN Competencies: Knowledge and Science
  • 52. 10 11) A nurse cares for a 13-year-old adolescent with a terminal illness. Which client statement does the nurse expect to hear from this client regarding death and dying? A) "I will go to sleep for a long time and then wake up." B) "I know that people die with my disease but I won't die." C) "I wonder what happens to people after death." D) "I know people die but I will defy my own death." ANSWER: D Explanation: A) Children up to age 5 believe death is being asleep. B) Children ages 5 to 9 years believe own death can be avoided. C) Children ages 9 to 12 years express an interest in the afterlife. D) An adolescent client fears a lingering death, often fantasizing that death may be defied by acting in reckless behavior (e.g., substance abuse, dangerous driving). Page Ref: 223 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 3.7 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.3 Integrate assessment skills in practice. NLN Competencies: Relationship Centered Care 12) The nurse cares for a client who needs a PCA pump for control of postoperative pain. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)? A) Pushing the client button if the client is unable. B) Silencing the pump alarm while waiting for the nurse. C) Reporting specific client observations. D) Asking the client about level of pain. ANSWER: C Explanation: A) Pushing the client's PCA button is administering an intravenous medication and is a task for the nurse only. B) The UAP should not silence the PCA pump. C) The nurse may delegate the UAP to report specific client observations (such as reporting inadequate pain control). D) The UAP should not determine the client's pain level because it involves assessment of the client's clinical situation and assessment should not be performed by unlicensed personnel. Page Ref: 204 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: Nursing Process: Intervention | Learning Outcome: 3.5 | QSEN Competencies: Teamwork and Collaboration AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Teamwork
  • 53. 11 13) The nurse cares for an older adult client who will have heat and cold therapy to assist with pain. Which lifespan considerations does the nurse consider when using this treatment for the client? Select all that apply. A) Skin cells proliferate quicker as one ages. B) Sensitivity to pain decreases as one ages. C) Skin becomes thinner as one ages. D) Moisture in the skin decreases as one ages. E) Skin burns easier as one ages. ANSWER: B, C, D, E Explanation: A) Skin cells do not proliferate quicker with aging. B) Older adults have a reduced sensitivity to pain, and therefore may not feel untoward effects of heat and cold treatment. C) Older adults have thinner skin. D) Temperature should be reduced when using heat therapy because older adult patient's skin burns more easily. E) Because skin is thinner, skin burns easier as one ages. Page Ref: 218 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 3.4 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.3 Integrate assessment skills in practice. NLN Competencies: Knowledge and Science 14) The nurse is caring for a client with acute pain and uses the FLACC pain assessment. Which clinical scenario does the nurse recognize as LEAST appropriate for use of the FLACC pain assessment? A) Situations where clients self-report pain. B) Situations requiring rapid pain assessment. C) Clients who are asleep. D) Clients who are children. ANSWER: B Explanation: A) The FLACC pain assessment is not used for clients who can self-report pain. B) The FLACC pain assessment requires observation of the client for at least 5 minutes before a determination regarding the pain can be made. C) It is used for clients who are asleep. D) It is used for children. Page Ref: 192 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 3.3 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.3 Integrate assessment skills in practice. NLN Competencies: Relationship Centered Care
  • 54. 12 15) The nurse is preparing to use a disposable hot pack on the client for pain relief. Which action will the nurse prioritize as an appropriate task for the UAP? A) Observing the site of application and reporting abnormal findings. B) Assessing the client's level of pain. C) Determining if the client requires additional therapy. D) Documenting the client's response to therapy. ANSWER: A Explanation: A) The UAP may observe the site of the application and report abnormal findings. B) The nurse assesses the level of pain. C) The nurse determines if the client needs additional therapy. D) The nurse documents the client's response to therapy. Page Ref: 212 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: Nursing Process: Intervention | Learning Outcome: 3.4 | QSEN Competencies: Teamwork and Collaboration AACN Domains and Comps.: 6.4 Work with other professions to maintain a climate of mutual learning, respect, and shared values. NLN Competencies: Teamwork 16) The nurse assesses a toddler for pain using the FLACC scale. The nurse notes the client is crying steadily with a quivering chin, is kicking, is shifting back and forth, and is difficult to console. What number does the nurse document for the client's pain, based on the FLACC scale? A) 8 B) 9 C) 10 D) 11 ANSWE R: B Explanation: A) The assessment tool was not used correctly. B) The FLACC behavioral pain assessment may be used to help the nurse determine the client's level of pain. Assessment is based on findings of the face, legs, activity, cry, and consolability. A steady cry (2) with quivering chin (2), kicking (2), shifting back and forth (1), and difficult to console (2) results in a FLACC score of 9. C) The assessment tool was not used correctly. D) The maximum score on the FLACC tool is 10. Page Ref: 192 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 3.2 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.3 Integrate assessment skills
  • 55. 13 in practice. NLN Competencies: Relationship Centered Care
  • 56. 14 17) The nurse is caring for a client in acute pain and plans to use a pain scale tool for assessment. What is the major advantage in using this tool? A) It allows organization in the assessment process. B) It works with the same efficacy among the entire population. C) It allows for variation among various cultures. D) It can always be performed quickly. ANSWER: A Explanation: A) The major advantage of a standardized pain scale tool for assessment of the client's pain is that it allows the nurse to stay organized in the assessment process. B) While efficient in assessing a client's pain, the tool does not factor in cultural variances and perceptions of pain. C) Pain scales do not factor in cultural variances. D) The idea that most tools may be performed quickly is not universally true. Page Ref: 195 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 3.2 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.3 Integrate assessment skills in practice. NLN Competencies: Relationship Centered Care 18) The nurse is caring for a client who is dying. When prioritizing care, which intervention will the nurse provide to meet the client's physiological needs? A) Encourage frequent ambulation and deep breathing. B) Initiate total nutrition intravenously. C) Administer curative medications. D) Encourage favorite foods as tolerated. ANSWER: D Explanation: A) The client's tolerance should be supported. The client may not have the strength to ambulate or take deep breaths. B) Intravenous nutrition is determined according to the client's preference. C) Curative medications are not prescribed for a client who is dying. D) Encouraging favorite foods as tolerated is an important nursing intervention the nurse will perform for the dying client. Page Ref: 220 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: Nursing Process: Intervention | Learning Outcome: 3.8 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.1 Engage with the individual in establishing a caring relationship. NLN Competencies: Relationship Centered Care
  • 57. 15 19) The nurse prepares to perform a pain assessment and chooses to use a standardized pain assessment tool. Place the steps in order for the use of the standardized pain assessment tool. A) Assess the client's physiological response to pain. B) Assess the client's perception of pain. C) Perform a focused assessment. D) Document the findings. ANSWER: B, A, C, D Explanation: A) The steps to performing a pain assessment using a standardized pain assessment tool is as follows: Assess the client's perception of pain (including location, intensity, and quality), assess the client's physiological response to pain (i.e., changes in vital signs), perform a focused assessment, and document the findings. B) The steps to performing a pain assessment using a standardized pain assessment tool is as follows: Assess the client's perception of pain (including location, intensity, and quality), assess the client's physiological response to pain (i.e., changes in vital signs), perform a focused assessment, and document the findings. C) The steps to performing a pain assessment using a standardized pain assessment tool is as follows: Assess the client's perception of pain (including location, intensity, and quality), assess the client's physiological response to pain (i.e., changes in vital signs), perform a focused assessment, and document the findings. D) The steps to performing a pain assessment using a standardized pain assessment tool is as follows: Assess the client's perception of pain (including location, intensity, and quality), assess the client's physiological response to pain (i.e., changes in vital signs), perform a focused assessment, and document the findings. Page Ref: 194 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 3.1 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.3 Integrate assessment skills in practice. NLN Competencies: Relationship Centered Care
  • 58. 16 20) The nurse prepares to apply a TENS unit on a client who is experiencing pain. Place the steps of this procedure in the correct order. A) With the unit off, plug the lead wires into the unit. B) Insert the battery and test for functioning. C) Turn the unit on and ensure the amplitude is set to zero. D) Apply the electrodes to the client. E) Increase the amplitude until the client notes discomfort. F) Slowly decrease the amplitude until the client notes a pleasant sensation. ANSWER: B, A, D, C, E, F Explanation: A) Application of the TENS unit is as follows: Insert the battery and test for functioning; with the unit off, plug the lead wires into the unit; apply the electrodes to the client; turn the unit on and ensure the amplitude is set to zero; increase the amplitude until the client notes discomfort; slowly decrease the amplitude until the client notes a pleasant sensation. B) Application of the TENS unit is as follows: Insert the battery and test for functioning; with the unit off, plug the lead wires into the unit; apply the electrodes to the client; turn the unit on and ensure the amplitude is set to zero; increase the amplitude until the client notes discomfort; slowly decrease the amplitude until the client notes a pleasant sensation. C) Application of the TENS unit is as follows: Insert the battery and test for functioning; with the unit off, plug the lead wires into the unit; apply the electrodes to the client; turn the unit on and ensure the amplitude is set to zero; increase the amplitude until the client notes discomfort; slowly decrease the amplitude until the client notes a pleasant sensation. D) Application of the TENS unit is as follows: Insert the battery and test for functioning; with the unit off, plug the lead wires into the unit; apply the electrodes to the client; turn the unit on and ensure the amplitude is set to zero; increase the amplitude until the client notes discomfort; slowly decrease the amplitude until the client notes a pleasant sensation. E) Application of the TENS unit is as follows: Insert the battery and test for functioning; with the unit off, plug the lead wires into the unit; apply the electrodes to the client; turn the unit on and ensure the amplitude is set to zero; increase the amplitude until the client notes discomfort; slowly decrease the amplitude until the client notes a pleasant sensation. F) Application of the TENS unit is as follows: Insert the battery and test for functioning; with the unit off, plug the lead wires into the unit; apply the electrodes to the client; turn the unit on and ensure the amplitude is set to zero; increase the amplitude until the client notes discomfort; slowly decrease the amplitude until the client notes a pleasant sensation. Page Ref: 201 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Intervention | Learning Outcome: 3.6 | QSEN Competencies: Patient-Centered Care
  • 59. 17 AACN Domains and Comps.: 2.6 Demonstrate accountability for care delivery. NLN Competencies: Relationship Centered Care
  • 60. 1 Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Chapter 4 Elimination 1) The nurse prepares to obtain a urine sample from a client's closed drainage system. Place the procedure steps in the correct order. A) Disinfect the needle insertion site. B) Insert the needle at a 30-to 40-degree angle. C) Unclamp the catheter. D) Transfer the urine to the specimen container. E) Withdraw the required amount of urine. F) Clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes. ANSWER: F, A, B, E, C, D Explanation: A) The procedure for obtaining a urine sample from a closed drainage system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes; disinfect the needle insertion site; insert the needle at a 30- to 40-degree angle; withdraw the required amount of urine; unclamp the catheter; transfer the urine to the specimen container. B) The procedure for obtaining a urine sample from a closed drainage system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes; disinfect the needle insertion site; insert the needle at a 30- to 40-degree angle; withdraw the required amount of urine; unclamp the catheter; transfer the urine to the specimen container. C) The procedure for obtaining a urine sample from a closed drainage system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes; disinfect the needle insertion site; insert the needle at a 30- to 40-degree angle; withdraw the required amount of urine; unclamp the catheter; transfer the urine to the specimen container. D) The procedure for obtaining a urine sample from a closed drainage system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes; disinfect the needle insertion site; insert the needle at a 30- to 40-degree angle; withdraw the required amount of urine; unclamp the catheter; transfer the urine to the specimen container. E) The procedure for obtaining a urine sample from a closed drainage system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes; disinfect the needle insertion site; insert the needle at a 30- to 40-degree angle; withdraw the required amount of urine; unclamp the catheter; transfer the urine to the specimen container. F) The procedure for obtaining a urine sample from a closed drainage system is as follows: clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes; disinfect the needle insertion site; insert
  • 61. 2 the needle at a 30- to 40-degree angle; withdraw the required amount of urine; unclamp the catheter; transfer the urine to the specimen container. Page Ref: 234 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 4.1 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety
  • 62. 3 2) The nurse prepares to obtain a urine specimen from a client's indwelling catheter. What is the nurse's understanding of the purpose of clamping the indwelling catheter prior to collection of urine? A) Decreases client discomfort B) Increases urine production C) Promotes sterile collection D) Eases technique of procedure ANSWER: C Explanation: A) Clamping is not done to decrease the client's discomfort. B) Clamping is not done to increase urine production. C) Clamping the client's indwelling catheter promotes the sterile collection of urine because sterile urine collects in the tube, allowing for sterile collection. D) Clamping is not done to ease technique of the procedure. Page Ref: 247 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 4.1 | QSEN Competencies: Safety AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety
  • 63. 4 3) A nurse prepares to administer a warm water enema to a client. Place the steps of the procedure in correct order. A) Raise the solution container. B) Open the clamp. C) Encourage the client to retain the solution. D) Lift the upper buttock, insert the tube slowly. E) Assist the client to the left lateral position with right leg flexed. F) Allow the solution to run through the tubing to remove air. ANSWER: F, E, D, A, B, C Explanation: A) The steps of the warm water enema administration is as follows: Allow the solution to run through the tubing to remove air; assist the client to the left lateral position with the right leg flexed; lift the upper buttock and insert the tube slowly; raise the solution container and open the clamp; encourage the client to retain the solution. B) The steps of the warm water enema administration is as follows: Allow the solution to run through the tubing to remove air; assist the client to the left lateral position with the right leg flexed; lift the upper buttock and insert the tube slowly; raise the solution container and open the clamp; encourage the client to retain the solution. C) The steps of the warm water enema administration is as follows: Allow the solution to run through the tubing to remove air; assist the client to the left lateral position with the right leg flexed; lift the upper buttock and insert the tube slowly; raise the solution container and open the clamp; encourage the client to retain the solution. D) The steps of the warm water enema administration is as follows: Allow the solution to run through the tubing to remove air; assist the client to the left lateral position with the right leg flexed; lift the upper buttock and insert the tube slowly; raise the solution container and open the clamp; encourage the client to retain the solution. E) The steps of the warm water enema administration is as follows: Allow the solution to run through the tubing to remove air; assist the client to the left lateral position with the right leg flexed; lift the upper buttock and insert the tube slowly; raise the solution container and open the clamp; encourage the client to retain the solution. F) The steps of the warm water enema administration is as follows: Allow the solution to run through the tubing to remove air; assist the client to the left lateral position with the right leg flexed; lift the upper buttock and insert the tube slowly; raise the solution container and open the clamp; encourage the client to retain the solution. Page Ref: 269 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 4.3 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.6 Demonstrate accountability for
  • 64. 5 care delivery. NLN Competencies: Relationship Centered Care
  • 65. 6 4) The registered nurse acts as preceptor to a novice nurse who is placing an indwelling urinary catheter for a client. Which action by the novice nurse requires intervention by the preceptor? A) Removing and discarding clean gloves after opening the drainage package. B) Cleansing the urethral meatus before removing the catheter from the protective sleeve. C) Donning sterile gloves prior to attaching the catheter to the drainage system. D) Lubricating the tip of the catheter before inserting the tip of the prefilled syringe into the catheter side arm. ANSWER: B Explanation: A) Clean gloves should be removed and discarded after opening the drainage package. B) The nurse should remove the catheter from the protective sleeve prior to cleansing the urethral meatus. This action will require intervention by the nurse preceptor. C) Sterile gloves should be applied before attaching the catheter to the drainage system. D) The tip of the catheter should be lubricated before inserting the tip of the prefilled syringe into the catheter side arm. Page Ref: 250 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 4.8 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 5.2 Contribute to a culture of patient safety. NLN Competencies: Quality & Safety 5) When placing the client on a bedpan, which position will the nurse place the client? A) High-Fowler B) Semi-Fowler C) Upright D) Supin e ANSWE R: B Explanation: A) The high-Fowler position is not the best to use for a bedpan. B) The semi-Fowler position alleviates back strain and permits a more normal position for elimination. C) The upright position is not the best to use for a bedpan. D) The supine position is not the best to use for a bedpan. Page Ref: 240 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Basic Care and Comfort
  • 66. 7 Standards: Nursing Process: Intervention | Learning Outcome: 4.2 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.6 Demonstrate accountability for care delivery. NLN Competencies: Relationship Centered Care
  • 67. 8 6) The nurse attempts to obtain a urine sample from a client's ileal conduit. After correct sterile catheterization, no urine output is noted. Which action should the nurse take? A) Contact the healthcare provider. B) Reinsert the catheter. C) Ask the client to drink water. D) Advance the catheter further in the stoma. ANSWER: C Explanation: A) The healthcare provider does not need to be contacted. B) The catheter does not need to be reinserted. C) After correct sterile catheterization of an ileal conduit, if no urine is obtained, the nurse should ask the client to drink water in order to produce urine. D) The catheter does not need to be advanced further into the stoma. Page Ref: 235 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Intervention | Learning Outcome: 4.8 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.6 Demonstrate accountability for care delivery. NLN Competencies: Relationship Centered Care 7) When auscultating a client's AV fistula, the nurse notes a whooshing sound. What term is used to describe this finding? A) Bruit B) Murmur C) Gallop D) Click ANSWE R: A Explanation: A) The whooshing sound heard on auscultation of a patent AV fistula is called bruit. B) Murmur is used to describe an abnormal heart sound. C) Gallop is used to describe an abnormal heart sound. D) Click is used to describe an abnormal heart sound. Page Ref: 286 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 4.7 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: 2.3 Integrate assessment skills in practice. NLN Competencies: Relationship Centered Care