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 fmethod fshould fthe fnurse fuse fto fcheck fthe fbaby's ftemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
fmembranefANSWER:
fC
Explanation: f A) fOral fis fused ffor fage f3 for folder.
B) The frectal froute fis fthe fleast fdesirable.
C) The faxillary froute fmay fnot fbe fas faccurate fas fother froutes ffor fdetecting ffevers fin fchildren.
D) The ftympanic fmembrane fmay fbe fused ffor f3 fmonths for
folder.fPage fRef: f29
Cognitive fLevel: f Applying
Client fNeed/Sub: f Physiological fIntegrity: fReduction fof fRisk fPotential
Standards: f Nursing fProcess: fEvaluating f| fLearning fOutcome: f1.2 f| fQSEN fCompetencies:
fSafetyfAACN fDomains fand fComps.: f Domain f5: fQuality fand fSafety
NLN fCompetencies: f Quality f& fSafety
4) A fclient fcomes fin fwith fexacerbation fof fchronic fobstructive fpulmonary fdisease f(COPD).
fWhichfnoninvasive fdiagnostic ftest fwill fthe fnurse fimplement fto fknow fthat fthe fclient fis
freceiving fenough foxygen?
A) Chest fx-ray
B) Pulse foximeter
C) Arterial fblood fgasses
D) Assessment fof frespiratory
fratefANSWER: f B
Explanation: f A) fA fchest fx-ray fis fnot fan fintervention fa fnurse fcompletes.
B) A fpulse foximeter fprovides fa fnoninvasive fmethod fof fmeasuring foxygenation, for
foxygen fsaturation, fin fthe fblood fand fprovides fa fpulse freading, fwhich fis fespecially fhelpful
ffor fthe fclientfwith fa frespiratory fillness for fdisease.
C) Arterial fblood fgases fare fan finvasive fdiagnostic ftest.
D) Assessing fa frespiratory frate fis fimportant ffor fthe fnurse fto fimplement; fhowever, fit fis
fnot fafdiagnostic ftest.
Page fRef: f21
Cognitive fLevel: f Applying
Client fNeed/Sub: f Physiological fIntegrity: fReduction fof fRisk fPotential
Standards: fNursing fProcess: fImplementation f| fLearning fOutcome: f1.3 f| fQSEN
fCompetencies:fInformatics
AACN fDomains fand fComps.: f Domain f5: fQuality fand fSafety
fNLN fCompetencies: f Quality f& fSafety
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 fmethod fshould fthe fnurse fuse fto fcheck fthe fbaby's ftemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
fmembranefANSWER:
fC
Explanation: f A) fOral fis fused ffor fage f3 for folder.
B) The frectal froute fis fthe fleast fdesirable.
C) The faxillary froute fmay fnot fbe fas faccurate fas fother froutes ffor fdetecting ffevers fin fchildren.
D) The ftympanic fmembrane fmay fbe fused ffor f3 fmonths for
folder.fPage fRef: f29
Cognitive fLevel: f Applying
Client fNeed/Sub: f Physiological fIntegrity: fReduction fof fRisk fPotential
Standards: f Nursing fProcess: fEvaluating f| fLearning fOutcome: f1.2 f| fQSEN fCompetencies:
fSafetyfAACN fDomains fand fComps.: f Domain f5: fQuality fand fSafety
NLN fCompetencies: f Quality f& fSafety
4) A fclient fcomes fin fwith fexacerbation fof fchronic fobstructive fpulmonary fdisease f(COPD).
fWhichfnoninvasive fdiagnostic ftest fwill fthe fnurse fimplement fto fknow fthat fthe fclient fis
freceiving fenough foxygen?
A) Chest fx-ray
B) Pulse foximeter
C) Arterial fblood fgasses
D) Assessment fof frespiratory
fratefANSWER: f B
Explanation: f A) fA fchest fx-ray fis fnot fan fintervention fa fnurse fcompletes.
B) A fpulse foximeter fprovides fa fnoninvasive fmethod fof fmeasuring foxygenation, for
foxygen fsaturation, fin fthe fblood fand fprovides fa fpulse freading, fwhich fis fespecially fhelpful
ffor fthe fclientfwith fa frespiratory fillness for fdisease.
C) Arterial fblood fgases fare fan finvasive fdiagnostic ftest.
D) Assessing fa frespiratory frate fis fimportant ffor fthe fnurse fto fimplement; fhowever, fit fis
fnot fafdiagnostic ftest.
Page fRef: f21
Cognitive fLevel: f Applying
Client fNeed/Sub: f Physiological fIntegrity: fReduction fof fRisk fPotential
Standards: fNursing fProcess: fImplementation f| fLearning fOutcome: f1.3 f| fQSEN
fCompetencies:fInformatics
AACN fDomains fand fComps.: f Domain f5: fQuality fand fSafety
fNLN fCompetencies: f Quality f& fSafety
2
