Test Bank For Concept-Based Clinical
Nursing Skills, 2nd Edition
Fundamental to Advanced Competencies
Authors :
Loren Nell Melton Stein & Connie J Hollen
,Chapter 1: Foundations of Safe Client Care
1. Which of the following is the primary responsibility of a nurse when providing safe
care to a client?
A) To administer medications exactly as prescribed
B) To ensure the client's comfort at all times
C) To assess, monitor, and evaluate client conditions
D) To maintain an updated client record
Answer: C) To assess, monitor, and evaluate client conditions
Rationale: The primary responsibility of a nurse is to assess, monitor, and evaluate the client's
condition continuously to ensure the safety and effectiveness of care. Administering medications
and ensuring comfort are also important, but monitoring and assessment are central to safe
practice.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Client Needs
2. What is the most appropriate action for a nurse to take when a client expresses
concerns about their upcoming surgery?
A) Reassure the client that everything will be fine
B) Dismiss the concern to avoid causing unnecessary anxiety
C) Provide the client with information about the surgery and encourage questions
D) Tell the client to speak to the surgeon for more details
Answer: C) Provide the client with information about the surgery and encourage questions
Rationale: It is essential to address a client’s concerns by providing accurate information and
encouraging open communication, which helps reduce anxiety and promote informed decision-
making.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Psychosocial Integrity
3. When preparing a sterile field, which action demonstrates the nurse’s
understanding of infection control principles?
A) Place sterile items directly on the sterile field without touching them
B) Use gloves to place sterile items on the sterile field
C) Touch sterile items as long as the hands are clean
D) Leave the sterile field unattended until the procedure is ready to begin
Answer: B) Use gloves to place sterile items on the sterile field
Rationale: Sterile items should be handled with sterile technique, and gloves should be worn
when handling sterile materials to prevent contamination. Non-sterile hands should not touch
,sterile items.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Health Promotion and Maintenance
4. Which of the following is the most appropriate way to prevent medication errors
when administering a drug to a client?
A) Administer the medication quickly to reduce client discomfort
B) Verify the client’s identity using at least two identifiers
C) Only verify the drug with the healthcare provider if unsure
D) Wait until the client asks about the medication before explaining its purpose
Answer: B) Verify the client’s identity using at least two identifiers
Rationale: To prevent medication errors, it is essential to verify the client’s identity using at
least two identifiers (e.g., name and date of birth) before administering any medications. This is a
key step in safe medication administration.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Physiological Integrity
5. A nurse is caring for a client who is at risk for falling. Which of the following
interventions should be prioritized to ensure safety?
A) Providing a comfortable chair for the client
B) Encouraging the client to stay in bed to prevent falls
C) Installing bed and chair alarms to alert staff of movement
D) Instructing the client to call for assistance before moving
Answer: C) Installing bed and chair alarms to alert staff of movement
Rationale: Installing bed and chair alarms helps to monitor a client at risk of falling, ensuring
immediate intervention if the client attempts to move. This is a proactive approach to preventing
falls.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Client Needs
6. What should the nurse do when a client refuses a prescribed medication?
A) Administer the medication anyway, as it is part of the treatment plan
B) Document the refusal and report it to the healthcare provider
C) Try to convince the client to take the medication
D) Ignore the refusal if it is not a life-threatening medication
Answer: B) Document the refusal and report it to the healthcare provider
Rationale: If a client refuses a prescribed medication, the nurse must document the refusal and
, notify the healthcare provider. It is important to understand the reason for refusal and address
any concerns the client may have.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Client Needs
7. Which of the following would be the most appropriate way to establish rapport with
a client?
A) Maintain a formal, impersonal demeanor
B) Engage in casual conversation unrelated to the client’s condition
C) Greet the client by name and listen attentively to their concerns
D) Focus only on the medical aspects of care
Answer: C) Greet the client by name and listen attentively to their concerns
Rationale: Establishing rapport with a client is vital for effective communication and fostering
trust. Greeting the client by name and listening to their concerns builds a relationship that
encourages open dialogue.
DIF: Application
TOP: Psychosocial Integrity
MSC: Client Needs
8. What is the nurse’s role when advocating for a client who has limited understanding
of their diagnosis and treatment options?
A) To make decisions on behalf of the client
B) To provide the client with information in a simplified manner
C) To ignore the client’s concerns if they are not well understood
D) To defer to family members to make decisions for the client
Answer: B) To provide the client with information in a simplified manner
Rationale: Nurses advocate for clients by ensuring they understand their diagnosis and treatment
options. Providing clear, simplified information helps the client make informed decisions about
their care.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Client Needs
9. Which of the following actions should the nurse take to maintain a safe environment
for a client receiving intravenous therapy?
A) Check the intravenous site for signs of infiltration only once a shift
B) Change the intravenous tubing every 72 hours as a routine
C) Ensure that the IV site is properly secured and regularly assessed for complications
D) Only check the intravenous site if the client complains of discomfort
Nursing Skills, 2nd Edition
Fundamental to Advanced Competencies
Authors :
Loren Nell Melton Stein & Connie J Hollen
,Chapter 1: Foundations of Safe Client Care
1. Which of the following is the primary responsibility of a nurse when providing safe
care to a client?
A) To administer medications exactly as prescribed
B) To ensure the client's comfort at all times
C) To assess, monitor, and evaluate client conditions
D) To maintain an updated client record
Answer: C) To assess, monitor, and evaluate client conditions
Rationale: The primary responsibility of a nurse is to assess, monitor, and evaluate the client's
condition continuously to ensure the safety and effectiveness of care. Administering medications
and ensuring comfort are also important, but monitoring and assessment are central to safe
practice.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Client Needs
2. What is the most appropriate action for a nurse to take when a client expresses
concerns about their upcoming surgery?
A) Reassure the client that everything will be fine
B) Dismiss the concern to avoid causing unnecessary anxiety
C) Provide the client with information about the surgery and encourage questions
D) Tell the client to speak to the surgeon for more details
Answer: C) Provide the client with information about the surgery and encourage questions
Rationale: It is essential to address a client’s concerns by providing accurate information and
encouraging open communication, which helps reduce anxiety and promote informed decision-
making.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Psychosocial Integrity
3. When preparing a sterile field, which action demonstrates the nurse’s
understanding of infection control principles?
A) Place sterile items directly on the sterile field without touching them
B) Use gloves to place sterile items on the sterile field
C) Touch sterile items as long as the hands are clean
D) Leave the sterile field unattended until the procedure is ready to begin
Answer: B) Use gloves to place sterile items on the sterile field
Rationale: Sterile items should be handled with sterile technique, and gloves should be worn
when handling sterile materials to prevent contamination. Non-sterile hands should not touch
,sterile items.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Health Promotion and Maintenance
4. Which of the following is the most appropriate way to prevent medication errors
when administering a drug to a client?
A) Administer the medication quickly to reduce client discomfort
B) Verify the client’s identity using at least two identifiers
C) Only verify the drug with the healthcare provider if unsure
D) Wait until the client asks about the medication before explaining its purpose
Answer: B) Verify the client’s identity using at least two identifiers
Rationale: To prevent medication errors, it is essential to verify the client’s identity using at
least two identifiers (e.g., name and date of birth) before administering any medications. This is a
key step in safe medication administration.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Physiological Integrity
5. A nurse is caring for a client who is at risk for falling. Which of the following
interventions should be prioritized to ensure safety?
A) Providing a comfortable chair for the client
B) Encouraging the client to stay in bed to prevent falls
C) Installing bed and chair alarms to alert staff of movement
D) Instructing the client to call for assistance before moving
Answer: C) Installing bed and chair alarms to alert staff of movement
Rationale: Installing bed and chair alarms helps to monitor a client at risk of falling, ensuring
immediate intervention if the client attempts to move. This is a proactive approach to preventing
falls.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Client Needs
6. What should the nurse do when a client refuses a prescribed medication?
A) Administer the medication anyway, as it is part of the treatment plan
B) Document the refusal and report it to the healthcare provider
C) Try to convince the client to take the medication
D) Ignore the refusal if it is not a life-threatening medication
Answer: B) Document the refusal and report it to the healthcare provider
Rationale: If a client refuses a prescribed medication, the nurse must document the refusal and
, notify the healthcare provider. It is important to understand the reason for refusal and address
any concerns the client may have.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Client Needs
7. Which of the following would be the most appropriate way to establish rapport with
a client?
A) Maintain a formal, impersonal demeanor
B) Engage in casual conversation unrelated to the client’s condition
C) Greet the client by name and listen attentively to their concerns
D) Focus only on the medical aspects of care
Answer: C) Greet the client by name and listen attentively to their concerns
Rationale: Establishing rapport with a client is vital for effective communication and fostering
trust. Greeting the client by name and listening to their concerns builds a relationship that
encourages open dialogue.
DIF: Application
TOP: Psychosocial Integrity
MSC: Client Needs
8. What is the nurse’s role when advocating for a client who has limited understanding
of their diagnosis and treatment options?
A) To make decisions on behalf of the client
B) To provide the client with information in a simplified manner
C) To ignore the client’s concerns if they are not well understood
D) To defer to family members to make decisions for the client
Answer: B) To provide the client with information in a simplified manner
Rationale: Nurses advocate for clients by ensuring they understand their diagnosis and treatment
options. Providing clear, simplified information helps the client make informed decisions about
their care.
DIF: Application
TOP: Safe and Effective Care Environment
MSC: Client Needs
9. Which of the following actions should the nurse take to maintain a safe environment
for a client receiving intravenous therapy?
A) Check the intravenous site for signs of infiltration only once a shift
B) Change the intravenous tubing every 72 hours as a routine
C) Ensure that the IV site is properly secured and regularly assessed for complications
D) Only check the intravenous site if the client complains of discomfort
