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
rv rv rv rv rv rv rv rv rv rv rv rv
,Clinical Nursing Skills: A Concept- rv rv rv rv
Based Approach, 4e (Pearson) Education Test BankChapter 1: Assessment
rv rv rv rv rv rv rv rv rv
1) A client on the medical/surgical unit complains of sudden chest pains. Which action will thenu
rv rv rv rv rv rv rv rv rv rv rv rv rv rv vr
rse implement first?
rv rv
A) Call the healthcare provider. rv rv rv
B) Administer pain medication. rv rv
C) Reassess a new set of vital signs. rv rv rv rv rv rv
D) Turn client from supine to lateral. rv rv rv rv rv vr
ANSWER: C rv
Explanation: A) The nurse will need to reassess the client first, before calling the healthcarepr
rv rv rv rv rv rv rv rv rv rv rv rv rv rv vr
ovider.
B) The nurse will need to reassess the client first, before administering pain medication.
rv rv rv rv rv rv rv rv rv rv rv rv
C) The nurse needs to implement a new set of vital signs first when there is a change inco
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv vr
ndition.
D) The nurse will need to reassess the client first, before moving the client, to avoid making thech
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv vr
ange in client's condition worse.
rv rv rv rv
Page Ref: 2 rv rv
Cognitive Level: Applying rv r v
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
rv r v rv rv rv rv rv
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN Competencies:Pa
rv rv rv rv rv rv rv rv rv rv vr
tient-Centered Care rv
AACN Domains and Comps.: Domain 2: Person-
rv rv rv rv rv rv
Centered CareNLN Competencies: Relationship Centered Care rv vr rv rv rv rv
2) The nurse is observing the UAP taking the temperature of an unconscious client. Which routew
rv rv rv rv rv rv rv rv rv rv rv rv rv rv vr
ill the nurse question the UAP using?
rv rv rv rv rv rv
A) Oral
B) Rectal
C) Scanner
D) Tympanic vr
ANSWER: A rv
Explanation: A) The temperature of an unconscious client is never taken by mouth. The rectal,tym
rv rv rv rv rv rv rv rv rv rv rv rv rv rv vr
panic, or scanner method is preferred.
rv rv rv rv rv
B) The rectal, tympanic, or scanner method is preferred.
rv rv rv rv rv rv rv
C) The rectal, tympanic, or scanner method is preferred.
rv rv rv rv rv rv rv
D) The rectal, tympanic, or scanner method is preferred.
rv rv rv rv rv rv rv vr
Page Ref: 24 rv rv
Cognitive Level: Applying rv r v
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: N
rv rvrvr v rv rv rv rv rv rv rv rv rv rv
ursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: SafetyAACN Domains
rv rv rv rv rv rv rv rv rv rv vr rv rv
and Comps.: Domain 5: Quality and Safety
rv rv rv rv rv rv
NLN Competencies: Quality & Safety
rv r v rv rv
1
, 3) The nurse is changing a 2-month- rv rv rv rv rv
old client's diaper and notes the client feels warm to touch.Which method should the nurse use t
rv rv rv rv rv rv rv rv rv rv vr rv rv rv rv rv rv
o check the baby's temperature?
rv rv rv rv
A) Oral
B) Rectal
C) Axillary
D) Tympanic membrane rv vr
ANSWER: C rv
Explanation: A) Oral is used for age 3 or older. r v rv rv rv rv rv rv rv rv
B) The rectal route is the least desirable.
rv rv rv rv rv rv
C) The axillary route may not be as accurate as other routes for detecting fevers in children.
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
D) The tympanic membrane may be used for 3 months or older.P
rv rv rv rv rv rv rv rv rv rv vr
age Ref: 29 rv rv
Cognitive Level: Applying rv r v
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
rv r v rv rv rv rv rv
Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies: SafetyAA
rv rv rv rv rv rv rv rv rv rv rv vr
CN Domains and Comps.: Domain 5: Quality and Safety
rv rv rv rv rv rv rv rv
NLN Competencies: Quality & Safety
rv r v rv rv
4) A client comes in with exacerbation of chronic obstructive pulmonary disease (COPD). Whichno
rv rv rv rv rv rv rv rv rv rv rv rv vr
ninvasive diagnostic test will the nurse implement to know that the client is receiving enough oxyg
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
en?
A) Chest x-ray rv
B) Pulse oximeter rv
C) Arterial blood gasses rv rv
D) Assessment of respiratory rate rv rv rv vr
ANSWER: B rv
Explanation: A) A chest x-ray is not an intervention a nurse completes. r v rv rv rv rv rv rv rv rv rv rv
B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen satu
rv rv rv rv rv rv rv rv rv rv rv rv
ration, in the blood and provides a pulse reading, which is especially helpful for the clientwith a
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv vr rv rv
respiratory illness or disease. rv rv rv
C) Arterial blood gases are an invasive diagnostic test. rv rv rv rv rv rv rv
D) Assessing a respiratory rate is important for the nurse to implement; however, it is not ad rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv vr
iagnostic test. rv
Page Ref: 21 rv rv
Cognitive Level: Applying rv r v
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
rv r v rv rv rv rv rv
Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Competencies:Info
rv rv rv rv rv rv rv rv rv rv vr
rmatics
AACN Domains and Comps.: Domain 5: Quality and SafetyNLN Co
rv rv rv rv rv rv rv rv vr rv
mpetencies: Quality & Safety rv rv rv
2