Test Bank for Clinical Nursing Skills: A Concept-Based Approach, 3e (Pearson)

1) A client on the medical/surgical unit complains of sudden chest pains. Which is the first action the nurse will implement? A) Call the health care 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: 3 Cognitive Level: Applying Client Need/Sub: Reduction of Risk Potential: System Specific Assessments Standards: Nursing Process: Implementation | Learning Outcome: 1.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice 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) Tympanic 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: Remembering Client Need/Sub: Management of Care: Assignment, Delegation, and Supervision Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch. Which is the best method for checking this 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 tympanic membrane route may be more accurate in determining temperature in febrile newborns or infants. D) The tympanic membrane may be used for 3 months or older. Page Ref: 29 Cognitive Level: Understanding Client Need/Sub: Reduction of Risk Potential: Diagnostic Tests Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and 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: Reduction of Risk Potential: Diagnostic Tests Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Competencies: Informatics AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 5) Which is the most important question the nurse should ask a client before performing a routine musculoskeletal 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 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: Analyzing Client Need/Sub: Safety and Infection Control: Accident/Error/Injury Prevention Standards: Nursing Process: Assessment | Learning Outcome: 1.5 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 6) A client's daughter mentions to the nurse that her mom seems to have a decline in mental status and seems to be forgetting many things in their conversation since this hospitalization. Which is the best response by the nurse? 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. D) The stress of being in unfamiliar situations can cause confusion in some older adults. Page Ref: 68 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Therapeutic Environment Standards: Nursing Process: Planning | Learning Outcome: 1.6 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Context and Environment 7) The nurse coming on duty received in report that the client's lung sounds were clear to auscultation in all lobes. The nurse coming on heard moderate-intensity and moderate-pitch "blowing" sounds between the scapulae and lateral to the sternum at the first and second intercostal spaces when doing her own assessment. Which should the nurse do next? 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) The nurse would implement this if these were adventitious lung sounds; however, these are bronchovesicular sounds. B) The nurse would notify the healthcare provider if these were adventitious lung sounds; however, these are bronchovesicular sounds. C) This is correct, because 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: Analyzing Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Context and Environment 8) A new client came to the clinic complaining of shortness of breath and fever. How long should the triage 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: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 9) Prior to administering digoxin, which should the nurse assess first? A) Temperature B) Apical pulse C) Respiratory rate D) Pain using a pain scale Answer: B Explanation: A) The nurse should assess the apical pulse before the administration of a medication that could affect the cardiovascular systems, such as before giving a digitalis preparation. B) The nurse should assess the apical pulse before the administration of a medication that could affect the cardiovascular systems, such as before giving a digitalis preparation. C) The nurse should assess the apical pulse before the administration of a medication that could affect the cardiovascular systems, such as before giving a digitalis preparation. D) The nurse should assess the apical pulse before the administration of a medication that could affect the cardiovascular systems, such as before giving a digitalis preparation. Page Ref: 3 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 10) When measuring the newborn during a general assessment, which is the correct assessment? 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) Correct. 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: 9 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 11) Which would cause an erroneously low blood pressure during a general assessment for an adult client? 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: 15 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 12) Based on the information provided, 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: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 13) Which is the best route to check a temperature for a client who is diaphoretic? 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: Analyzing Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 14) Which is the best response by the nurse when explaining to the client as to 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 client's comfort; however, it is to decrease the abdominal muscles to contract, otherwise the nurse might hear unnecessary contractions. C) A cold stethoscope may cause your abdominal muscles to contract which the nurse might hear with a cold stethoscope. D) Warming up the stethoscope has no effect with digestion of food. A warm stethoscope will decrease the abdominal muscles to contract, so the nurse will not hear any unnecessary noises. Page Ref: 31 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety 15) Which are signs and symptoms of colon cancer? 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) Correct. C) Unusual cough is more a sign and symptom of a lung infection or lung cancer. D) Correct 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: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice NLN Competencies: Quality and Safety