III by Pearson Education Chapters 1 - 16
,Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Pearson
vx vx vx vx vx vx vx vx vx vx vx vx
,Clinical Nursing Skills: A Concept-
vx vx vx vx
Based Approach, 4e (Pearson) Education Test BankChapter 1: Assessment
vx vx vx vx vx vx vx vx vx
1) A client on the medical/surgical unit complains of sudden chest pains. Which action will the
vx vx vx vx vx vx vx vx vx vx vx vx vx vx vx
nurse implement first?
vx vx
A) Call the healthcare provider.
vx vx vx
B) Administer pain medication. vx vx
C) Reassess a new set of vital signs. vx vx vx vx vx vx
D) Turn client from supine to lateral.
vx vx vx vx vx vx
ANSWER: C vx
Explanation: A) The nurse will need to reassess the client first, before calling the healthcare
vx vx vx vx vx vx vx vx vx vx vx vx vx vx vx
provider.
B) The nurse will need to reassess the client first, before administering pain medication.
vx vx vx vx vx vx vx vx vx vx vx vx
C) The nurse needs to implement a new set of vital signs first when there is a change in
vx vx vx vx vx vx vx vx vx vx vx vx vx vx vx vx vx vx
condition.
D) The nurse will need to reassess the client first, before moving the client, to avoid making the
vx vx vx vx vx vx vx vx vx vx vx vx vx vx vx vx vx
change in client's condition worse.
vx vx vx vx
Page Ref: 2
vx vx
Cognitive Level: Applying vx v x
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
vx v x vx vx vx vx vx
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN Competencies:
vx vx vx vx vx vx vx vx vx vx vx
Patient-Centered Care vx
AACN Domains and Comps.: Domain 2: Person-
vx vx vx vx vx vx
Centered CareNLN Competencies: Relationship Centered Care
vx vx vx vx vx vx
2) The nurse is observing the UAP taking the temperature of an unconscious client. Which route
vx vx vx vx vx vx vx vx vx vx vx vx vx vx vx
will the nurse question the UAP using?
vx vx vx vx vx vx
A) Oral
B) Rectal
C) Scanner
D) Tympanic vx
ANSWER: vx
1
, A
Explanation: A) The temperature of an unconscious client is never taken by mouth. The rectal,t
vx vx vx vx vx vx vx vx vx vx vx vx vx vx vx
ympanic, or scanner method is preferred.
vx vx vx vx vx
B) The rectal, tympanic, or scanner method is preferred.
vx vx vx vx vx vx vx
C) The rectal, tympanic, or scanner method is preferred.
vx vx vx vx vx vx vx
D) The rectal, tympanic, or scanner method is preferred.
vx vx vx vx vx vx vx vx
Page Ref: 24
vx vx
Cognitive Level: Applying vx v x
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standard
vx vxvxv x vx vx vx vx vx vx vx vx vx
s: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: SafetyAACN D
vx vx vx vx vx vx vx vx vx vx vx vx vx
omains and Comps.: Domain 5: Quality and Safety
vx vx vx vx vx vx vx
NLN Competencies: Quality & Safety
vx v x vx vx
2