,test Bank for Clinical Nursing
tj t j tj tj Skills: A Conce pt-Based Approach 4th Edition Pearson
t j tj t j t j t j tj
,Clinical Nursing Skills: A Concept-
tjtj tj t j t j
Based Approach, 4e (Pearson) Education Test Bank Chapter tjtj tj tj tj t j t j 1: Assessment
1) A client on the medical/surgical unit complains of sudden chest
pains. Which a ction will the nurse implement first?
tj tj tj t j tj t j t j
A) Call the healthcare provider.
B) Administer pain medication. t j tj tj
C) Reassess a new set of vital signs. t j t j
D) Turn client from supine to l
tj tj tj tj tj
ateral. ANSWER: C tj t j
Explanation: A) The nurse will need to reassess the client first, before
calli ng the h ealthcareprovider.
tj tj tj
B) The nurse will need to reassess the client first, before administering pain medication.
t j t j t j t j
C) The nurse needs to implement a new set of vital signs first
t j t j t j
w hen tj there is a change in condition. tj t j gt j t j tj
D) The nurse will need to reassess the client first, before moving the
t j t j
c lient,
tj to avoid making the change in client's condition worse.
tj tj tj tj t j t j
Page Ref:
2 Cognitiv tj
e Level:
t j
Applying
Client Need/Sub t j
: Physiological Integrity: Reduction of Risk Potential t j t j t j tj t j
Standards: Nursing Process: Assessment | Learning Outcome: 1.1
| QS EN Competencies:Patient-Centered Care
tj tj t j
AACN Domains and Comps.: Domain 2: Person-
t j t j
Centered Care NLN Competencies: Relationship Centered Ca r
tj tj t j t j t j t j tj
e
2) The nurse is observing the UAP taking the temperature of an
uncon scious cl ient. Which route will the nursequestion
tj the UAP tj tj tj
using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
iiANSWER:
A
Explanation: A) The temperature of an unconscious client is never taken
by mouth. The rectal,tympanic, or scanner
tj method is tj tj tj
preferred.
B) The rectal, tympanic, or scanner method is preferred.
t j t j t j t j t j t j t j t j t j t j
C) The rectal, tympanic, or scanner method is preferred.
t j t j t j t j t j
D) The rectal, tympanic, or scanner method is
tj tj t j tj t j py t
j preferred.Page Ref: 24 t j t j
Cognitive Level: t j
Applying
Client Need/Sub t j
: Safe and Effective Care Environment: Safety and Infection Control Stan tj tj tj tj tj tj tj tj tj
1
, dards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN
tj tj
Competen ci es: SafetyAACN Domains and Comps.: Domain 5:
tj tj tj Quality
and Safety
NLN Competencies: Quality & Safety
tjtj t j t j
2
tj t j tj tj Skills: A Conce pt-Based Approach 4th Edition Pearson
t j tj t j t j t j tj
,Clinical Nursing Skills: A Concept-
tjtj tj t j t j
Based Approach, 4e (Pearson) Education Test Bank Chapter tjtj tj tj tj t j t j 1: Assessment
1) A client on the medical/surgical unit complains of sudden chest
pains. Which a ction will the nurse implement first?
tj tj tj t j tj t j t j
A) Call the healthcare provider.
B) Administer pain medication. t j tj tj
C) Reassess a new set of vital signs. t j t j
D) Turn client from supine to l
tj tj tj tj tj
ateral. ANSWER: C tj t j
Explanation: A) The nurse will need to reassess the client first, before
calli ng the h ealthcareprovider.
tj tj tj
B) The nurse will need to reassess the client first, before administering pain medication.
t j t j t j t j
C) The nurse needs to implement a new set of vital signs first
t j t j t j
w hen tj there is a change in condition. tj t j gt j t j tj
D) The nurse will need to reassess the client first, before moving the
t j t j
c lient,
tj to avoid making the change in client's condition worse.
tj tj tj tj t j t j
Page Ref:
2 Cognitiv tj
e Level:
t j
Applying
Client Need/Sub t j
: Physiological Integrity: Reduction of Risk Potential t j t j t j tj t j
Standards: Nursing Process: Assessment | Learning Outcome: 1.1
| QS EN Competencies:Patient-Centered Care
tj tj t j
AACN Domains and Comps.: Domain 2: Person-
t j t j
Centered Care NLN Competencies: Relationship Centered Ca r
tj tj t j t j t j t j tj
e
2) The nurse is observing the UAP taking the temperature of an
uncon scious cl ient. Which route will the nursequestion
tj the UAP tj tj tj
using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
iiANSWER:
A
Explanation: A) The temperature of an unconscious client is never taken
by mouth. The rectal,tympanic, or scanner
tj method is tj tj tj
preferred.
B) The rectal, tympanic, or scanner method is preferred.
t j t j t j t j t j t j t j t j t j t j
C) The rectal, tympanic, or scanner method is preferred.
t j t j t j t j t j
D) The rectal, tympanic, or scanner method is
tj tj t j tj t j py t
j preferred.Page Ref: 24 t j t j
Cognitive Level: t j
Applying
Client Need/Sub t j
: Safe and Effective Care Environment: Safety and Infection Control Stan tj tj tj tj tj tj tj tj tj
1
, dards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN
tj tj
Competen ci es: SafetyAACN Domains and Comps.: Domain 5:
tj tj tj Quality
and Safety
NLN Competencies: Quality & Safety
tjtj t j t j
2
