Test Bank for Clinical Nursing Skills:
A Concept-Based Approach
4th Edition Volume III
by Pearson Education Chapters 1 - 16
,Test45Bank45for45Clinical45Nursing45Skills:45A45Concept-
Based45Approach454th45Edition45Pearson45
,Clinical45Nursing45Skills:45A45Concept-
Based45Approach,454e45(Pearson)45Education45Test45Bank45Chapter451:45Assessment
1) A45client45on45the45medical/surgical45unit45complains45of45sudden45chest45pains.45Which45a
ction45will45the45nurse45implement45first?
A) Call45the45healthcare45provider.
B) Administer45pain45medication.
C) Reassess45a45new45set45of45vital45signs.
D) Turn45client45from45supine45to45la
teral.45ANSWER:45 C
Explanation:45A)45The45nurse45will45need45to45reassess45the45client45first,45before45calling45t
he45healthcare45provider.
B) The45nurse45will45need45to45reassess45the45client45first,45before45administering45pain45medication.
C) The45nurse45needs45to45implement45a45new45set45of45vital45signs45first45when45there4
5is45a45change45in45condition.
D) The45nurse45will45need45to45reassess45the45client45first,45before45moving45the45client,45to45av
oid45making45the45change45in45client's45condition45worse.
Page45Ref:452
Cognitive45Level:4 5 Applying
Client45Need/Sub:4 5 Physiological45Integrity:45Reduction45of45Risk45Potential
Standards:45Nursing45Process:45Assessment45|45Learning45Outcome:451.145|45QSEN45Com
petencies:45Patient-Centered45Care
AACN45Domains45and45Comps.:45Domain452:45Person-
Centered45Care45NLN45Competencies:45 Relationship45Centered45
Care
2) The45nurse45is45observing45the45UAP45taking45the45temperature45of45an45unconscious45client.
45Which45route45will45the45nurse45question45the45UAP45using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
45ANSWER:4
5A
Explanation:45A)45The45temperature45of45an45unconscious45client45is45never45taken45by45mouth.
45The45rectal,45tympanic,45or45scanner45method45is45preferred.
B) The45rectal,45tympanic,45or45scanner45method45is45preferred.
C) The45rectal,45tympanic,45or45scanner45method45is45preferred.
D) The45rectal,45tympanic,45or45scanner45method45is45pr
eferred.45Page45Ref:4524
Cognitive45Level:4 5 Applying
Client45Need/Sub:454545 Safe45and45Effective45Care45Environment:45Safety45and45Infection45Cont
rol45Standards:45 Nursing45Process:45Evaluation45|45Learning45Outcome:451.145|45QSEN45Compet
encies:45Safety45AACN45Domains45and45Comps.:45 Domain455:45Quality45and45Safety
NLN45Competencies:4 5 Quality45&45Safety
1
, 3) The45nurse45is45changing45a452-month-
old45client's45diaper45and45notes45the45client45feels45warm45to45touch.45Which45method45should4
5the45nurse45use45to45check45the45baby's45temperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic45membran
e45ANSWER:45 C
Explanation:4 5 A)45Oral45is45used45for45age45345or45older.
B) The45rectal45route45is45the45least45desirable.
C) The45axillary45route45may45not45be45as45accurate45as45other45routes45for45detecting45fevers45in45childr
en.
D) The45tympanic45membrane45may45be45used45for45345months4
5or45older.45Page45Ref:4529
Cognitive45Level:4 5 Applying
Client45Need/Sub:4 5 Physiological45Integrity:45Reduction45of45Risk45Potential
Standards:45 Nursing45Process:45Evaluating45|45Learning45Outcome:451.245|45QSEN45Competenci
es:45Safety45AACN45Domains45and45Comps.:45 Domain455:45Quality45and45Safety
NLN45Competencies:4 5 Quality45&45Safety
4) A45client45comes45in45with45exacerbation45of45chronic45obstructive45pulmonary45disease45(CO
PD).45Which45noninvasive45diagnostic45test45will45the45nurse45implement45to45know45that45the45cl
ient45is45receiving45enough45oxygen?
A) Chest45x-ray
B) Pulse45oximeter
C) Arterial45blood45gasses
D) Assessment45of45respiratory45r
ate45ANSWER:45 B
Explanation:4 5 A)45A45chest45x-ray45is45not45an45intervention45a45nurse45completes.
B) A45pulse45oximeter45provides45a45noninvasive45method45of45measuring45oxygenation,45or4
5oxygen45saturation,45in45the45blood45and45provides45a45pulse45reading,45which45is45especiall
y45helpful45for45the45client45with45a45respiratory45illness45or45disease.
C) Arterial45blood45gases45are45an45invasive45diagnostic45test.
D) Assessing45a45respiratory45rate45is45important45for45the45nurse45to45implement;45howeve
r,45it45is45not45a45diagnostic45test.
Page45Ref:4521
Cognitive45Level:4 5 Applying
Client45Need/Sub:4 5 Physiological45Integrity:45Reduction45of45Risk45Potential
Standards:45Nursing45Process:45Implementation45|45Learning45Outcome:451.345|45QSEN45Compe
tencies:45Informatics
AACN45Domains45and45Comps.:45 Domain455:45Quality45and45Sa
fety45NLN45Competencies:45 Quality45&45Safety
2
A Concept-Based Approach
4th Edition Volume III
by Pearson Education Chapters 1 - 16
,Test45Bank45for45Clinical45Nursing45Skills:45A45Concept-
Based45Approach454th45Edition45Pearson45
,Clinical45Nursing45Skills:45A45Concept-
Based45Approach,454e45(Pearson)45Education45Test45Bank45Chapter451:45Assessment
1) A45client45on45the45medical/surgical45unit45complains45of45sudden45chest45pains.45Which45a
ction45will45the45nurse45implement45first?
A) Call45the45healthcare45provider.
B) Administer45pain45medication.
C) Reassess45a45new45set45of45vital45signs.
D) Turn45client45from45supine45to45la
teral.45ANSWER:45 C
Explanation:45A)45The45nurse45will45need45to45reassess45the45client45first,45before45calling45t
he45healthcare45provider.
B) The45nurse45will45need45to45reassess45the45client45first,45before45administering45pain45medication.
C) The45nurse45needs45to45implement45a45new45set45of45vital45signs45first45when45there4
5is45a45change45in45condition.
D) The45nurse45will45need45to45reassess45the45client45first,45before45moving45the45client,45to45av
oid45making45the45change45in45client's45condition45worse.
Page45Ref:452
Cognitive45Level:4 5 Applying
Client45Need/Sub:4 5 Physiological45Integrity:45Reduction45of45Risk45Potential
Standards:45Nursing45Process:45Assessment45|45Learning45Outcome:451.145|45QSEN45Com
petencies:45Patient-Centered45Care
AACN45Domains45and45Comps.:45Domain452:45Person-
Centered45Care45NLN45Competencies:45 Relationship45Centered45
Care
2) The45nurse45is45observing45the45UAP45taking45the45temperature45of45an45unconscious45client.
45Which45route45will45the45nurse45question45the45UAP45using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
45ANSWER:4
5A
Explanation:45A)45The45temperature45of45an45unconscious45client45is45never45taken45by45mouth.
45The45rectal,45tympanic,45or45scanner45method45is45preferred.
B) The45rectal,45tympanic,45or45scanner45method45is45preferred.
C) The45rectal,45tympanic,45or45scanner45method45is45preferred.
D) The45rectal,45tympanic,45or45scanner45method45is45pr
eferred.45Page45Ref:4524
Cognitive45Level:4 5 Applying
Client45Need/Sub:454545 Safe45and45Effective45Care45Environment:45Safety45and45Infection45Cont
rol45Standards:45 Nursing45Process:45Evaluation45|45Learning45Outcome:451.145|45QSEN45Compet
encies:45Safety45AACN45Domains45and45Comps.:45 Domain455:45Quality45and45Safety
NLN45Competencies:4 5 Quality45&45Safety
1
, 3) The45nurse45is45changing45a452-month-
old45client's45diaper45and45notes45the45client45feels45warm45to45touch.45Which45method45should4
5the45nurse45use45to45check45the45baby's45temperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic45membran
e45ANSWER:45 C
Explanation:4 5 A)45Oral45is45used45for45age45345or45older.
B) The45rectal45route45is45the45least45desirable.
C) The45axillary45route45may45not45be45as45accurate45as45other45routes45for45detecting45fevers45in45childr
en.
D) The45tympanic45membrane45may45be45used45for45345months4
5or45older.45Page45Ref:4529
Cognitive45Level:4 5 Applying
Client45Need/Sub:4 5 Physiological45Integrity:45Reduction45of45Risk45Potential
Standards:45 Nursing45Process:45Evaluating45|45Learning45Outcome:451.245|45QSEN45Competenci
es:45Safety45AACN45Domains45and45Comps.:45 Domain455:45Quality45and45Safety
NLN45Competencies:4 5 Quality45&45Safety
4) A45client45comes45in45with45exacerbation45of45chronic45obstructive45pulmonary45disease45(CO
PD).45Which45noninvasive45diagnostic45test45will45the45nurse45implement45to45know45that45the45cl
ient45is45receiving45enough45oxygen?
A) Chest45x-ray
B) Pulse45oximeter
C) Arterial45blood45gasses
D) Assessment45of45respiratory45r
ate45ANSWER:45 B
Explanation:4 5 A)45A45chest45x-ray45is45not45an45intervention45a45nurse45completes.
B) A45pulse45oximeter45provides45a45noninvasive45method45of45measuring45oxygenation,45or4
5oxygen45saturation,45in45the45blood45and45provides45a45pulse45reading,45which45is45especiall
y45helpful45for45the45client45with45a45respiratory45illness45or45disease.
C) Arterial45blood45gases45are45an45invasive45diagnostic45test.
D) Assessing45a45respiratory45rate45is45important45for45the45nurse45to45implement;45howeve
r,45it45is45not45a45diagnostic45test.
Page45Ref:4521
Cognitive45Level:4 5 Applying
Client45Need/Sub:4 5 Physiological45Integrity:45Reduction45of45Risk45Potential
Standards:45Nursing45Process:45Implementation45|45Learning45Outcome:451.345|45QSEN45Compe
tencies:45Informatics
AACN45Domains45and45Comps.:45 Domain455:45Quality45and45Sa
fety45NLN45Competencies:45 Quality45&45Safety
2
