Test Bank for Clinical Nursing Skills:
nn nn nn nn nn
A Concept-Based Approach
nn nn nn
4th Edition Volume III
nn nn nn
by Pearson Education Chapters 1 - 16
nn nn nn nn nn nn
,Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition
nn nn nn nn nn nn nn nn nn nn
Pearson
nn n
,Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Education Test
nn nn nn nn nn nn nn nn nn
BankChapter 1: Assessment
nn n nn nn
1) A client on the medical/surgical unit complains of sudden chest pains. Which action will
nn nn nn nn nn nn nn nn nn nn nn nn nn
thenurse implement first?
nn n nn nn
A) Call the healthcare provider.
nn nn nn
B) Administer pain medication. nn nn
C) Reassess a new set of vital signs. nn nn nn nn nn nn
D) Turn client from supine to nn nn nn nn
lateral.ANSWER: C
nn n nn
Explanation: A) The nurse will need to reassess the client first, before calling the
nn nn nn nn nn nn nn nn nn nn nn nn nn
healthcareprovider.
nn n
B) The nurse will need to reassess the client first, before administering pain medication.
nn nn nn nn nn nn nn nn nn nn nn nn
C) The nurse needs to implement a new set of vital signs first when there is a change
nn nn nn nn nn nn nn nn nn nn nn nn nn nn nn nn
incondition.
nn n
D) The nurse will need to reassess the client first, before moving the client, to avoid making
nn nn nn nn nn nn nn nn nn nn nn nn nn nn nn
thechange in client's condition worse.
nn n nn nn nn nn
Page Ref: 2 nn nn
Cognitive Level: Applying nn n n
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
nn n n nn nn nn nn nn
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN
nn nn nn nn nn nn nn nn nn
Competencies:Patient-Centered Care
nn n nn
AACN Domains and Comps.: Domain 2: Person-Centered Care
nn nn nn nn nn nn nn
NLN Competencies: Relationship Centered Care
n nn nn nn nn
2) The nurse is observing the UAP taking the temperature of an unconscious client. Which
nn nn nn nn nn nn nn nn nn nn nn nn nn
routewill the nurse question the UAP using?
nn n nn nn nn nn nn nn
A) Oral
B) Rectal
C) Scanner
D) Tympanic
ANSWER:
n
A
nn
Explanation: A) The temperature of an unconscious client is never taken by mouth. The
nn nn nn nn nn nn nn nn nn nn nn nn nn
rectal,tympanic, or scanner method is preferred.
nn n nn nn nn nn nn
B) The rectal, tympanic, or scanner method is preferred.
nn nn nn nn nn nn nn
C) The rectal, tympanic, or scanner method is preferred.
nn nn nn nn nn nn nn
D) The rectal, tympanic, or scanner method is
nn nn nn nn nn nn
preferred.Page Ref: 24
nn n nn nn
Cognitive Level: Applying nn n n
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control
nn nn nn n n nn nn nn nn nn nn nn nn
Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies:
nn nn nn nn nn nn nn nn nn nn nn
SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
nn n nn nn nn nn nn nn nn nn
NLN Competencies: Quality & Safety
nn n n nn nn
1
, 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to
nn nn nn nn nn nn nn nn nn nn nn nn nn nn
touch.Which method should the nurse use to check the baby's temperature?
nn n nn nn nn nn nn nn nn nn nn nn
A) Oral
B) Rectal
C) Axillary
D) Tympanic
membraneANSWER:
nn n
C
nn
Explanation: A) Oral is used for age 3 or older. n n nn nn nn nn nn nn nn nn
B) The rectal route is the least desirable.
nn nn nn nn nn nn
C) The axillary route may not be as accurate as other routes for detecting fevers in children.
nn nn nn nn nn nn nn nn nn nn nn nn nn nn nn
D) The tympanic membrane may be used for 3 months or
nn nn nn nn nn nn nn nn nn
older.Page Ref: 29
nn n nn nn
Cognitive Level: Applying nn n n
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
nn n n nn nn nn nn nn
Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies:
nn nn nn nn nn nn nn nn nn nn
SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
nn n nn nn nn nn nn nn nn nn
NLN Competencies: Quality & Safety
nn n n nn nn
4) A client comes in with exacerbation of chronic obstructive pulmonary disease (COPD).
nn nn nn nn nn nn nn nn nn nn nn
Whichnoninvasive diagnostic test will the nurse implement to know that the client is receiving
nn n nn nn nn nn nn nn nn nn nn nn nn nn nn
enough oxygen?
nn nn
A) Chest x-ray nn
B) Pulse oximeter nn
C) Arterial blood gasses nn nn
D) Assessment of respiratory rate nn nn nn
ANSWER: B
n nn
Explanation: A) A chest x-ray is not an intervention a nurse completes.
n n nn nn nn nn nn nn nn nn nn nn
B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen
nn nn nn nn nn nn nn nn nn nn nn
saturation, in the blood and provides a pulse reading, which is especially helpful for the
nn nn nn nn nn nn nn nn nn nn nn nn nn nn nn
clientwith a respiratory illness or disease.
nn n nn nn nn nn nn
C) Arterial blood gases are an invasive diagnostic test.
nn nn nn nn nn nn nn
D) Assessing a respiratory rate is important for the nurse to implement; however, it is
nn nn nn nn nn nn nn nn nn nn nn nn nn
not adiagnostic test.
nn nn n nn
Page Ref: 21
nn nn
Cognitive Level: Applying nn n n
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
nn n n nn nn nn nn nn
Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Competencies:
nn nn nn nn nn nn nn nn nn nn
Informatics
n
AACN Domains and Comps.: Domain 5: Quality and Safety
nn nn nn nn nn nn nn nn
NLN Competencies: Quality & Safety
n nn nn nn nn
2
nn nn nn nn nn
A Concept-Based Approach
nn nn nn
4th Edition Volume III
nn nn nn
by Pearson Education Chapters 1 - 16
nn nn nn nn nn nn
,Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition
nn nn nn nn nn nn nn nn nn nn
Pearson
nn n
,Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Education Test
nn nn nn nn nn nn nn nn nn
BankChapter 1: Assessment
nn n nn nn
1) A client on the medical/surgical unit complains of sudden chest pains. Which action will
nn nn nn nn nn nn nn nn nn nn nn nn nn
thenurse implement first?
nn n nn nn
A) Call the healthcare provider.
nn nn nn
B) Administer pain medication. nn nn
C) Reassess a new set of vital signs. nn nn nn nn nn nn
D) Turn client from supine to nn nn nn nn
lateral.ANSWER: C
nn n nn
Explanation: A) The nurse will need to reassess the client first, before calling the
nn nn nn nn nn nn nn nn nn nn nn nn nn
healthcareprovider.
nn n
B) The nurse will need to reassess the client first, before administering pain medication.
nn nn nn nn nn nn nn nn nn nn nn nn
C) The nurse needs to implement a new set of vital signs first when there is a change
nn nn nn nn nn nn nn nn nn nn nn nn nn nn nn nn
incondition.
nn n
D) The nurse will need to reassess the client first, before moving the client, to avoid making
nn nn nn nn nn nn nn nn nn nn nn nn nn nn nn
thechange in client's condition worse.
nn n nn nn nn nn
Page Ref: 2 nn nn
Cognitive Level: Applying nn n n
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
nn n n nn nn nn nn nn
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN
nn nn nn nn nn nn nn nn nn
Competencies:Patient-Centered Care
nn n nn
AACN Domains and Comps.: Domain 2: Person-Centered Care
nn nn nn nn nn nn nn
NLN Competencies: Relationship Centered Care
n nn nn nn nn
2) The nurse is observing the UAP taking the temperature of an unconscious client. Which
nn nn nn nn nn nn nn nn nn nn nn nn nn
routewill the nurse question the UAP using?
nn n nn nn nn nn nn nn
A) Oral
B) Rectal
C) Scanner
D) Tympanic
ANSWER:
n
A
nn
Explanation: A) The temperature of an unconscious client is never taken by mouth. The
nn nn nn nn nn nn nn nn nn nn nn nn nn
rectal,tympanic, or scanner method is preferred.
nn n nn nn nn nn nn
B) The rectal, tympanic, or scanner method is preferred.
nn nn nn nn nn nn nn
C) The rectal, tympanic, or scanner method is preferred.
nn nn nn nn nn nn nn
D) The rectal, tympanic, or scanner method is
nn nn nn nn nn nn
preferred.Page Ref: 24
nn n nn nn
Cognitive Level: Applying nn n n
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control
nn nn nn n n nn nn nn nn nn nn nn nn
Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies:
nn nn nn nn nn nn nn nn nn nn nn
SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
nn n nn nn nn nn nn nn nn nn
NLN Competencies: Quality & Safety
nn n n nn nn
1
, 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to
nn nn nn nn nn nn nn nn nn nn nn nn nn nn
touch.Which method should the nurse use to check the baby's temperature?
nn n nn nn nn nn nn nn nn nn nn nn
A) Oral
B) Rectal
C) Axillary
D) Tympanic
membraneANSWER:
nn n
C
nn
Explanation: A) Oral is used for age 3 or older. n n nn nn nn nn nn nn nn nn
B) The rectal route is the least desirable.
nn nn nn nn nn nn
C) The axillary route may not be as accurate as other routes for detecting fevers in children.
nn nn nn nn nn nn nn nn nn nn nn nn nn nn nn
D) The tympanic membrane may be used for 3 months or
nn nn nn nn nn nn nn nn nn
older.Page Ref: 29
nn n nn nn
Cognitive Level: Applying nn n n
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
nn n n nn nn nn nn nn
Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies:
nn nn nn nn nn nn nn nn nn nn
SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
nn n nn nn nn nn nn nn nn nn
NLN Competencies: Quality & Safety
nn n n nn nn
4) A client comes in with exacerbation of chronic obstructive pulmonary disease (COPD).
nn nn nn nn nn nn nn nn nn nn nn
Whichnoninvasive diagnostic test will the nurse implement to know that the client is receiving
nn n nn nn nn nn nn nn nn nn nn nn nn nn nn
enough oxygen?
nn nn
A) Chest x-ray nn
B) Pulse oximeter nn
C) Arterial blood gasses nn nn
D) Assessment of respiratory rate nn nn nn
ANSWER: B
n nn
Explanation: A) A chest x-ray is not an intervention a nurse completes.
n n nn nn nn nn nn nn nn nn nn nn
B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen
nn nn nn nn nn nn nn nn nn nn nn
saturation, in the blood and provides a pulse reading, which is especially helpful for the
nn nn nn nn nn nn nn nn nn nn nn nn nn nn nn
clientwith a respiratory illness or disease.
nn n nn nn nn nn nn
C) Arterial blood gases are an invasive diagnostic test.
nn nn nn nn nn nn nn
D) Assessing a respiratory rate is important for the nurse to implement; however, it is
nn nn nn nn nn nn nn nn nn nn nn nn nn
not adiagnostic test.
nn nn n nn
Page Ref: 21
nn nn
Cognitive Level: Applying nn n n
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
nn n n nn nn nn nn nn
Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Competencies:
nn nn nn nn nn nn nn nn nn nn
Informatics
n
AACN Domains and Comps.: Domain 5: Quality and Safety
nn nn nn nn nn nn nn nn
NLN Competencies: Quality & Safety
n nn nn nn nn
2