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) Tympani
c 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 method should the nurse use to check the 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 axillary route may not be as accurate as other routes for detecting fevers in children.
D) The tympanic membrane may be used for 3 months or
older. Page Ref: 29
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN
Competencies: Safety AACN Domains and Comps.: Domain 5: Quality and Safety
NLN Competencies: Quality & 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: Physiological Integrity: Reduction of Risk Potential
Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN
Competencies: Informatics
AACN Domains and Comps.: Domain 5: Quality and
Safety NLN Competencies: Quality & Safety
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) Tympani
c 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 method should the nurse use to check the 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 axillary route may not be as accurate as other routes for detecting fevers in children.
D) The tympanic membrane may be used for 3 months or
older. Page Ref: 29
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN
Competencies: Safety AACN Domains and Comps.: Domain 5: Quality and Safety
NLN Competencies: Quality & 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: Physiological Integrity: Reduction of Risk Potential
Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN
Competencies: Informatics
AACN Domains and Comps.: Domain 5: Quality and
Safety NLN Competencies: Quality & Safety
2
