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
thenurse 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
healthcareprovider.
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
incondition.
D) The nurse will need to reassess the client first, before moving the client, to avoid making
thechange 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
routewill 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
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
membraneANSWER: 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
3
, 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
rateANSWER: 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
clientwith 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 adiagnostic 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 SafetyNLN
Competencies: Quality & Safety
5) The nurse is preparing to assess a client's musculoskeletal system. Which question should
thenurse ask before beginning this assessment?
A) "Do you exercise every day?"
B) "Do you have a history of any sports injuries?"
C) "Do you take a hot bath to relax your muscles?"
D) "Do you want pain medication before I
begin?"ANSWER: B
Explanation: A) Knowing if a client exercises is an important question but knowing if there are
any sports injuries to know about first, is most important before doing a routine
musculoskeletalassessment.
B) It is important to note if the client has a history of any sports injuries first to know what
theclient will or will not be able to do during a routine musculoskeletal assessment.
C) Knowing if the client takes a hot bath to relax the muscles is not the most important thing
toask before performing a routine musculoskeletal assessment.
D) To know if a client is experiencing any pain is an important question; however, this
question is assuming the client is in pain by asking if the client wants a pain medication before
beginninga routine musculoskeletal assessment.
Page Ref: 62
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control
4
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
thenurse 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
healthcareprovider.
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
incondition.
D) The nurse will need to reassess the client first, before moving the client, to avoid making
thechange 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
routewill 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
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
membraneANSWER: 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
3
, 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
rateANSWER: 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
clientwith 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 adiagnostic 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 SafetyNLN
Competencies: Quality & Safety
5) The nurse is preparing to assess a client's musculoskeletal system. Which question should
thenurse ask before beginning this assessment?
A) "Do you exercise every day?"
B) "Do you have a history of any sports injuries?"
C) "Do you take a hot bath to relax your muscles?"
D) "Do you want pain medication before I
begin?"ANSWER: B
Explanation: A) Knowing if a client exercises is an important question but knowing if there are
any sports injuries to know about first, is most important before doing a routine
musculoskeletalassessment.
B) It is important to note if the client has a history of any sports injuries first to know what
theclient will or will not be able to do during a routine musculoskeletal assessment.
C) Knowing if the client takes a hot bath to relax the muscles is not the most important thing
toask before performing a routine musculoskeletal assessment.
D) To know if a client is experiencing any pain is an important question; however, this
question is assuming the client is in pain by asking if the client wants a pain medication before
beginninga routine musculoskeletal assessment.
Page Ref: 62
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control
4
