Chapter 04 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

Chapter 04 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.
1) The physician performs a specimen collection by inserting a needle into the abdomen to collect 1) fluid. The nurse documents the performance of a:
A) Paracentesis. B) Thoracentesis.
C) Lumbar puncture. D) Venogram.
Answer: A
Explanation: A) A paracentesis is insertion of a needle to remove or collect fluid accumulating in the peritoneal cavity. A thoracentesis removes fluid from the thoracic cavity. A lumbar puncture is the insertion of a needle into the lumbar spine. A venogram is an imaging test that allows visualization of veins using an injected contrast media.
Cognitive Level: Knowledge
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
B) A paracentesis is insertion of a needle to remove or collect fluid accumulating in the peritoneal cavity. A thoracentesis removes fluid from the thoracic cavity. A lumbar puncture is the insertion of a needle into the lumbar spine. A venogram is an imaging test that allows visualization of veins using an injected contrast media.
Cognitive Level: Knowledge
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
C) A paracentesis is insertion of a needle to remove or collect fluid accumulating in the peritoneal cavity. A thoracentesis removes fluid from the thoracic cavity. A lumbar puncture is the insertion of a needle into the lumbar spine. A venogram is an imaging test that allows visualization of veins using an injected contrast media.
Cognitive Level: Knowledge
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
D) A paracentesis is insertion of a needle to remove or collect fluid accumulating in the peritoneal cavity. A thoracentesis removes fluid from the thoracic cavity. A lumbar puncture is the insertion of a needle into the lumbar spine. A venogram is an imaging test that allows visualization of veins using an injected contrast media.
Cognitive Level: Knowledge
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
Objective: Learning Outcome 4-1: Define the key terms used in the skills of diagnostic testing, aspiration/biopsy procedures, and care of clients receiving contrast media.

2) The nurse assesses the client’s wound drainage and sees that it is a combination of pus and blood, 2) and documents the drainage as:
A) Serosanguinous. B) Sanguineous.
C) Purulent. D) Purosanguineous.
Answer: D
Explanation: A) Purosanguineous drainage is a combination of pus and blood often seen in a recent wound that is infected. Serosanguineous drainage is clear fluid combined with blood often seen in surgical incisions. Sanguineous drainage is blood ranging from bright to dark red. Purulent drainage is thick blue, green, or yellow drainage, depending on the infective agent.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
B) Purosanguineous drainage is a combination of pus and blood often seen in a recent wound that is infected. Serosanguineous drainage is clear fluid combined with blood often seen in surgical incisions. Sanguineous drainage is blood ranging from bright to dark red. Purulent drainage is thick blue, green, or yellow drainage, depending on the infective agent.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
C) Purosanguineous drainage is a combination of pus and blood often seen in a recent wound that is infected. Serosanguineous drainage is clear fluid combined with blood often seen in surgical incisions. Sanguineous drainage is blood ranging from bright to dark red. Purulent drainage is thick blue, green, or yellow drainage, depending on the infective agent.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
D) Purosanguineous drainage is a combination of pus and blood often seen in a recent wound that is infected. Serosanguineous drainage is clear fluid combined with blood often seen in surgical incisions. Sanguineous drainage is blood ranging from bright to dark red. Purulent drainage is thick blue, green, or yellow drainage, depending on the infective agent.
Cognitive Level: Application
Client Need: Physiological Integrity
Nursing Process: Implementation
Objective: Learning Outcome 4-1: Define the key terms used in the skills of diagnostic testing,
aspiration/biopsy procedures, and care of clients receiving contrast media.

3) The nurse is assisting the physician to collect cerebrospinal fluid for testing to rule out meningitis. 3) What are the nurse’s responsibilities? Select all that apply.
A) Explain the procedure and obtain signed consent.
B) Teach the client how to assist during the procedure by maintaining proper positioning.
C) Observe sterile technique when preparing the equipment for the procedure.
D) Label all specimens collected and send them to the lab.
E) Assess the client before, during, and after the procedure.
Answer: B, C, D, E

Explanation: A) The nurse does not explain the procedure prior to obtaining the consent; this is the role of the physician. The nurse may witness the signature if the client says she has no questions. The client should be taught how to maintain proper positioning during the procedure to prevent complications. Once the fluid has been collected, all tubes should be properly labeled and sent to the lab. While the nurse may delegate this to the unlicensed assistive personnel, the nurse is responsible. The nurse’s primary responsibility is to monitor the client’s condition before, during, and after the procedure. The nurse also observes sterile technique when setting up the sterile tray in preparation for the procedure.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
B) The nurse does not explain the procedure prior to obtaining the consent; this is the role of the physician. The nurse may witness the signature if the client says she has no questions. The client should be taught how to maintain proper positioning during the procedure to prevent complications. Once the fluid has been collected, all tubes should be properly labeled and sent to the lab. While the nurse may delegate this to the unlicensed assistive personnel, the nurse is responsible. The nurse’s primary responsibility is to monitor the client’s condition before, during, and after the procedure. The nurse also observes sterile technique when setting up the sterile tray in preparation for the procedure.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
C) The nurse does not explain the procedure prior to obtaining the consent; this is the role of the physician. The nurse may witness the signature if the client says she has no questions. The client should be taught how to maintain proper positioning during the procedure to prevent complications. Once the fluid has been collected, all tubes should be properly labeled and sent to the lab. While the nurse may delegate this to the unlicensed assistive personnel, the nurse is responsible. The nurse’s primary responsibility is to monitor the client’s condition before, during, and after the procedure. The nurse also observes sterile technique when setting up the sterile tray in preparation for the procedure.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
D) The nurse does not explain the procedure prior to obtaining the consent; this is the role of the physician. The nurse may witness the signature if the client says she has no questions. The client should be taught how to maintain proper positioning during the procedure to prevent complications. Once the fluid has been collected, all tubes should be properly labeled and sent to the lab. While the nurse may delegate this to the unlicensed assistive personnel, the nurse is responsible. The nurse’s primary responsibility is to monitor the client’s condition before, during, and after the procedure. The nurse also observes sterile technique when setting up the sterile tray in preparation for the procedure.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation

E) The nurse does not explain the procedure prior to obtaining the consent; this is the role of the physician. The nurse may witness the signature if the client says she has no questions. The client should be taught how to maintain proper positioning during the procedure to prevent complications. Once the fluid has been collected, all tubes should be properly labeled and sent to the lab. While the nurse may delegate this to the unlicensed assistive personnel, the nurse is responsible. The nurse’s primary responsibility is to monitor the client’s condition before, during, and after the procedure. The nurse also observes sterile technique when setting up the sterile tray in preparation for the procedure.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
Objective: Learning Outcome 4-2: Describe the nursing responsibilities for specimen collection.

4) The nurse receives an order to collect a midstream urine specimen from the client. The nurse 4) assumes all of the following responsibilities except:
A) Teach the client how to clean the genitals prior to collecting the specimen.
B) Label the specimen and send it to the lab.
C) Assure that the specimen is collected following sterile technique.
D) Document that the specimen has been collected and what was done with it.
Answer: C
Explanation: A) When a midstream urine specimen is ordered, the nurse teaches the client how to collect the specimen, labels the collection bottle, and documents the specimen collection. Midstream urine specimens are kept as clean as possible, but the only way to collect a truly sterile specimen is by inserting a catheter to collect the urine specimen.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
B) When a midstream urine specimen is ordered, the nurse teaches the client how to collect the specimen, labels the collection bottle, and documents the specimen collection. Midstream urine specimens are kept as clean as possible, but the only way to collect a truly sterile specimen is by inserting a catheter to collect the urine specimen.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
C) When a midstream urine specimen is ordered, the nurse teaches the client how to collect the specimen, labels the collection bottle, and documents the specimen collection. Midstream urine specimens are kept as clean as possible, but the only way to collect a truly sterile specimen is by inserting a catheter to collect the urine specimen.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation
D) When a midstream urine specimen is ordered, the nurse teaches the client how to collect the specimen, labels the collection bottle, and documents the specimen collection. Midstream urine specimens are kept as clean as possible, but the only way to collect a truly sterile specimen is by inserting a catheter to collect the urine specimen.
Cognitive Level: Analysis
Client Need: Safe, Effective Care Environment
Nursing Process: Implementation

Objective: Learning Outcome 4-2: Describe the nursing responsibilities for specimen collection.

5) The nurse may use capillary blood specimen collection for all of the following except: 5)
A) Testing a serum glucose level. B) Measuring a client’s hematocrit.
C) Obtaining blood specimens on an infant. D) Measuring an arterial blood gas.
Answer: D
Explanation: A) Capillary blood collection is safe and effective for testing glucose and hematocrit, and may be used for blood specimens on infants. Arterial blood gases require artery puncture, and cannot be performed on a capillary specimen, although it is possible to perform a capillary blood gas, which is less effective than an arterial sample but
is less invasive.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
B) Capillary blood collection is safe and effective for testing glucose and hematocrit, and may be used for blood specimens on infants. Arterial blood gases require artery puncture, and cannot be performed on a capillary specimen, although it is possible to perform a capillary blood gas, which is less effective than an arterial sample but
is less invasive.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
C) Capillary blood collection is safe and effective for testing glucose and hematocrit, and may be used for blood specimens on infants. Arterial blood gases require artery puncture, and cannot be performed on a capillary specimen, although it is possible to perform a capillary blood gas, which is less effective than an arterial sample but
is less invasive.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
D) Capillary blood collection is safe and effective for testing glucose and hematocrit, and may be used for blood specimens on infants. Arterial blood gases require artery puncture, and cannot be performed on a capillary specimen, although it is possible to perform a capillary blood gas, which is less effective than an arterial sample but
is less invasive.
Cognitive Level: Application
Client Need: Safe, Effective Care Environment
Nursing Process: Planning
Objective: Learning Outcome 4-3: Explain the rationale for the collection of a:
A. Capillary blood specimen.
B. Stool specimen.
C. Routine urine specimen.
D. Timed urine specimen.
E. Urine specimen for culture and sensitivity.
F. Sputum specimen.
G. Nose and throat specimen.
H. Wound drainage specimen.