Test Bank for Clinical Nursing Skills:
A Concept-Based Approach
4th Edition Volume III
by Pearson Education Chapters 1 - 16
,Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Pearson
,Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Education Test Bank
Chapter 1: Assessment
1) A client on the medical/surgical unit complains of sudden chest pains. Which action will the
nurse implement first?
A) Call the healthcare 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: 2
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN Competencies:
Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
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: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: Safety
AACN Domains and Comps.: Domain 5: Quality and Safety
NLN Competencies: Quality & Safety
1
, 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch.
Which smethod sshould sthe snurse suse sto scheck sthe sbaby's stemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
smembranesANSWER:
sC
Explanation: s A) sOral sis sused sfor sage s3 sor solder.
B) The srectal sroute sis sthe sleast sdesirable.
C) The saxillary sroute smay snot sbe sas saccurate sas sother sroutes sfor sdetecting sfevers sin schildren.
D) The stympanic smembrane smay sbe sused sfor s3 smonths sor
solder.sPage sRef: s29
Cognitive sLevel: s Applying
Client sNeed/Sub: s Physiological sIntegrity: sReduction sof sRisk sPotential
Standards: s Nursing sProcess: sEvaluating s| sLearning sOutcome: s1.2 s| sQSEN sCompetencies:
sSafetysAACN sDomains sand sComps.: s Domain s5: sQuality sand sSafety
NLN sCompetencies: s Quality s& sSafety
4) A sclient scomes sin swith sexacerbation sof schronic sobstructive spulmonary sdisease s(COPD).
sWhichsnoninvasive sdiagnostic stest swill sthe snurse simplement sto sknow sthat sthe sclient sis
sreceiving senough soxygen?
A) Chest sx-ray
B) Pulse soximeter
C) Arterial sblood sgasses
D) Assessment sof srespiratory
sratesANSWER: s B
Explanation: s A) sA schest sx-ray sis snot san sintervention sa snurse scompletes.
B) A spulse soximeter sprovides sa snoninvasive smethod sof smeasuring soxygenation, sor
soxygen ssaturation, sin sthe sblood sand sprovides sa spulse sreading, swhich sis sespecially
shelpful sfor sthe sclientswith sa srespiratory sillness sor sdisease.
C) Arterial sblood sgases sare san sinvasive sdiagnostic stest.
D) Assessing sa srespiratory srate sis simportant sfor sthe snurse sto simplement; showever, sit sis
snot sasdiagnostic stest.
Page sRef: s21
Cognitive sLevel: s Applying
Client sNeed/Sub: s Physiological sIntegrity: sReduction sof sRisk sPotential
Standards: sNursing sProcess: sImplementation s| sLearning sOutcome: s1.3 s| sQSEN
sCompetencies:sInformatics
AACN sDomains sand sComps.: s Domain s5: sQuality sand sSafety
sNLN sCompetencies: s Quality s& sSafety
2
A Concept-Based Approach
4th Edition Volume III
by Pearson Education Chapters 1 - 16
,Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Pearson
,Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Education Test Bank
Chapter 1: Assessment
1) A client on the medical/surgical unit complains of sudden chest pains. Which action will the
nurse implement first?
A) Call the healthcare 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: 2
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN Competencies:
Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
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: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: Safety
AACN Domains and Comps.: Domain 5: Quality and Safety
NLN Competencies: Quality & Safety
1
, 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch.
Which smethod sshould sthe snurse suse sto scheck sthe sbaby's stemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
smembranesANSWER:
sC
Explanation: s A) sOral sis sused sfor sage s3 sor solder.
B) The srectal sroute sis sthe sleast sdesirable.
C) The saxillary sroute smay snot sbe sas saccurate sas sother sroutes sfor sdetecting sfevers sin schildren.
D) The stympanic smembrane smay sbe sused sfor s3 smonths sor
solder.sPage sRef: s29
Cognitive sLevel: s Applying
Client sNeed/Sub: s Physiological sIntegrity: sReduction sof sRisk sPotential
Standards: s Nursing sProcess: sEvaluating s| sLearning sOutcome: s1.2 s| sQSEN sCompetencies:
sSafetysAACN sDomains sand sComps.: s Domain s5: sQuality sand sSafety
NLN sCompetencies: s Quality s& sSafety
4) A sclient scomes sin swith sexacerbation sof schronic sobstructive spulmonary sdisease s(COPD).
sWhichsnoninvasive sdiagnostic stest swill sthe snurse simplement sto sknow sthat sthe sclient sis
sreceiving senough soxygen?
A) Chest sx-ray
B) Pulse soximeter
C) Arterial sblood sgasses
D) Assessment sof srespiratory
sratesANSWER: s B
Explanation: s A) sA schest sx-ray sis snot san sintervention sa snurse scompletes.
B) A spulse soximeter sprovides sa snoninvasive smethod sof smeasuring soxygenation, sor
soxygen ssaturation, sin sthe sblood sand sprovides sa spulse sreading, swhich sis sespecially
shelpful sfor sthe sclientswith sa srespiratory sillness sor sdisease.
C) Arterial sblood sgases sare san sinvasive sdiagnostic stest.
D) Assessing sa srespiratory srate sis simportant sfor sthe snurse sto simplement; showever, sit sis
snot sasdiagnostic stest.
Page sRef: s21
Cognitive sLevel: s Applying
Client sNeed/Sub: s Physiological sIntegrity: sReduction sof sRisk sPotential
Standards: sNursing sProcess: sImplementation s| sLearning sOutcome: s1.3 s| sQSEN
sCompetencies:sInformatics
AACN sDomains sand sComps.: s Domain s5: sQuality sand sSafety
sNLN sCompetencies: s Quality s& sSafety
2
