Test Bank for Clinical Nursing Skills:
ss ss ss ss ss
A Concept-Based Approach
ss ss ss
4th Edition Volume III
ss ss ss
by Pearson Education Chapters 1 - 16
ss ss ss ss ss ss
,Test ssBank ssfor ssClinical ssNursing ssSkills: ssA ssConcept-Based ssApproach ss4th ssEdition
ssPearsons
,Clinical ssNursing ssSkills: ssA ssConcept-Based ssApproach, ss4e ss(Pearson) ssEducation ssTest
ssBanksChapter ss1: ssAssessment
1) A ssclient sson ssthe ssmedical/surgical ssunit sscomplains ssof sssudden sschest sspains. ssWhich
ssaction sswill ssthen
s urse ssimplement ssfirst?
A) Call ssthe sshealthcare ssprovider.
B) Administer sspain ssmedication.
C) Reassess ssa ssnew ssset ssof ssvital sssigns.
D) Turn ssclient ssfrom sssupine ssto
sslateral. sANSWER: ss C
Explanation: ssA) ssThe ssnurse sswill ssneed ssto ssreassess ssthe ssclient ssfirst, ssbefore sscalling ssthe
sshealthcaresprovider.
B) The ssnurse sswill ssneed ssto ssreassess ssthe ssclient ssfirst, ssbefore ssadministering sspain ssmedication.
C) The ssnurse ssneeds ssto ssimplement ssa ssnew ssset ssof ssvital sssigns ssfirst sswhen ssthere ssis ssa
sschange ssinscondition.
D) The ssnurse sswill ssneed ssto ssreassess ssthe ssclient ssfirst, ssbefore ssmoving ssthe ssclient, ssto ssavoid
ssmaking sstheschange ssin ssclient's sscondition ssworse.
Page ssRef: ss2
Cognitive ssLevel: s s Applying
Client ssNeed/Sub: s s Physiological ssIntegrity: ssReduction ssof ssRisk ssPotential
Standards: ssNursing ssProcess: ssAssessment ss| ssLearning ssOutcome: ss1.1 ss| ssQSEN
ssCompetencies:sPatient-Centered ssCare
AACN ssDomains ssand ssComps.: ssDomain ss2: ssPerson-Centered
ssCaresNLN ssCompetencies: ss Relationship ss Centered ssCare
2) The ssnurse ssis ssobserving ssthe ssUAP sstaking ssthe sstemperature ssof ssan ssunconscious ssclient.
ssWhich ssroutew s ill ssthe ssnurse ssquestion ssthe ssUAP ss using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
sANSWER:
ss A
Explanation: ssA) ssThe sstemperature ssof ssan ssunconscious ssclient ssis ssnever sstaken ssby ssmouth.
ssThe ssrectal,stympanic, ssor ssscanner ssmethod ssis sspreferred.
B) The ssrectal, sstympanic, ssor ssscanner ssmethod ssis sspreferred.
C) The ssrectal, sstympanic, ssor ssscanner ssmethod ssis sspreferred.
D) The ssrectal, sstympanic, ssor ssscanner ssmethod ssis
sspreferred. sPage ssRef: ss24
Cognitive ssLevel: s s Applying
Client ssNeed/Sub: ss ss ss Safe ssand ssEffective ssCare ssEnvironment: ssSafety ssand ssInfection ssControl
ssStandards: s s Nursing ssProcess: ssEvaluation ss| ssLearning ssOutcome: ss1.1 ss| ssQSEN ssCompetencies:
ssSafetysAACN ssDomains ssand ss Comps.: s s Domain ss 5: ssQuality ssand ssSafety
NLN ssCompetencies: s s Quality ss& ssSafety
1
, 3) The ssnurse ssis sschanging ssa ss2-month-old ssclient's ssdiaper ssand ssnotes ssthe ssclient ssfeels sswarm
ssto sstouch.W
s hich ssmethod ssshould ssthe ssnurse ssuse ssto sscheck ssthe ssbaby's sstemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
ssmembranesANSWER:
ss C
Explanation: s s A) ssOral ssis ssused ssfor ssage ss3 ssor ssolder.
B) The ssrectal ssroute ssis ssthe ssleast ssdesirable.
C) The ssaxillary ssroute ssmay ssnot ssbe ssas ssaccurate ssas ssother ssroutes ssfor ssdetecting ssfevers ssin sschildren.
D) The sstympanic ssmembrane ssmay ssbe ssused ssfor ss3 ssmonths ssor
ssolder.sPage ssRef: ss29
Cognitive ssLevel: s s Applying
Client ssNeed/Sub: s s Physiological ssIntegrity: ssReduction ssof ssRisk ssPotential
Standards: s s Nursing ssProcess: ssEvaluating ss| ssLearning ssOutcome: ss1.2 ss| ssQSEN ssCompetencies:
ssSafetysAACN ssDomains ssand ss Comps.: s s Domain ss 5: ssQuality ssand ssSafety
NLN ssCompetencies: s s Quality ss& ssSafety
4) A ssclient sscomes ssin sswith ssexacerbation ssof sschronic ssobstructive sspulmonary ssdisease ss(COPD).
ssWhichn s oninvasive ssdiagnostic sstest ss will ssthe ssnurse ssimplement ssto ssknow ssthat ssthe ssclient ssis
ssreceiving ssenough ssoxygen?
A) Chest ssx-ray
B) Pulse ssoximeter
C) Arterial ssblood ssgasses
D) Assessment ssof ssrespiratory
ssratesANSWER: s s B
Explanation: s s A) ssA sschest ssx-ray ssis ssnot ssan ssintervention ssa ssnurse sscompletes.
B) A sspulse ssoximeter ssprovides ssa ssnoninvasive ssmethod ssof ssmeasuring ssoxygenation, ssor
ssoxygen sssaturation, ssin ssthe ssblood ssand ssprovides ss a sspulse ssreading, sswhich ssis ssespecially
sshelpful ssfor ssthe ssclientswith ssa ssrespiratory ssillness ss or ssdisease.
C) Arterial ssblood ssgases ssare ssan ssinvasive ssdiagnostic sstest.
D) Assessing ssa ssrespiratory ssrate ssis ssimportant ssfor ssthe ssnurse ssto ssimplement; sshowever,
ssit ssis ssnot ssasdiagnostic sstest.
Page ssRef: ss21
Cognitive ssLevel: s s Applying
Client ssNeed/Sub: s s Physiological ssIntegrity: ssReduction ssof ssRisk ssPotential
Standards: ssNursing ssProcess: ssImplementation ss| ssLearning ssOutcome: ss1.3 ss| ssQSEN
ssCompetencies:sInformatics
AACN ssDomains ssand ssComps.: s s Domain ss5: ssQuality ssand
ssSafetysNLN ssCompetencies: s s Quality ss& ssSafety
2
ss ss ss ss ss
A Concept-Based Approach
ss ss ss
4th Edition Volume III
ss ss ss
by Pearson Education Chapters 1 - 16
ss ss ss ss ss ss
,Test ssBank ssfor ssClinical ssNursing ssSkills: ssA ssConcept-Based ssApproach ss4th ssEdition
ssPearsons
,Clinical ssNursing ssSkills: ssA ssConcept-Based ssApproach, ss4e ss(Pearson) ssEducation ssTest
ssBanksChapter ss1: ssAssessment
1) A ssclient sson ssthe ssmedical/surgical ssunit sscomplains ssof sssudden sschest sspains. ssWhich
ssaction sswill ssthen
s urse ssimplement ssfirst?
A) Call ssthe sshealthcare ssprovider.
B) Administer sspain ssmedication.
C) Reassess ssa ssnew ssset ssof ssvital sssigns.
D) Turn ssclient ssfrom sssupine ssto
sslateral. sANSWER: ss C
Explanation: ssA) ssThe ssnurse sswill ssneed ssto ssreassess ssthe ssclient ssfirst, ssbefore sscalling ssthe
sshealthcaresprovider.
B) The ssnurse sswill ssneed ssto ssreassess ssthe ssclient ssfirst, ssbefore ssadministering sspain ssmedication.
C) The ssnurse ssneeds ssto ssimplement ssa ssnew ssset ssof ssvital sssigns ssfirst sswhen ssthere ssis ssa
sschange ssinscondition.
D) The ssnurse sswill ssneed ssto ssreassess ssthe ssclient ssfirst, ssbefore ssmoving ssthe ssclient, ssto ssavoid
ssmaking sstheschange ssin ssclient's sscondition ssworse.
Page ssRef: ss2
Cognitive ssLevel: s s Applying
Client ssNeed/Sub: s s Physiological ssIntegrity: ssReduction ssof ssRisk ssPotential
Standards: ssNursing ssProcess: ssAssessment ss| ssLearning ssOutcome: ss1.1 ss| ssQSEN
ssCompetencies:sPatient-Centered ssCare
AACN ssDomains ssand ssComps.: ssDomain ss2: ssPerson-Centered
ssCaresNLN ssCompetencies: ss Relationship ss Centered ssCare
2) The ssnurse ssis ssobserving ssthe ssUAP sstaking ssthe sstemperature ssof ssan ssunconscious ssclient.
ssWhich ssroutew s ill ssthe ssnurse ssquestion ssthe ssUAP ss using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
sANSWER:
ss A
Explanation: ssA) ssThe sstemperature ssof ssan ssunconscious ssclient ssis ssnever sstaken ssby ssmouth.
ssThe ssrectal,stympanic, ssor ssscanner ssmethod ssis sspreferred.
B) The ssrectal, sstympanic, ssor ssscanner ssmethod ssis sspreferred.
C) The ssrectal, sstympanic, ssor ssscanner ssmethod ssis sspreferred.
D) The ssrectal, sstympanic, ssor ssscanner ssmethod ssis
sspreferred. sPage ssRef: ss24
Cognitive ssLevel: s s Applying
Client ssNeed/Sub: ss ss ss Safe ssand ssEffective ssCare ssEnvironment: ssSafety ssand ssInfection ssControl
ssStandards: s s Nursing ssProcess: ssEvaluation ss| ssLearning ssOutcome: ss1.1 ss| ssQSEN ssCompetencies:
ssSafetysAACN ssDomains ssand ss Comps.: s s Domain ss 5: ssQuality ssand ssSafety
NLN ssCompetencies: s s Quality ss& ssSafety
1
, 3) The ssnurse ssis sschanging ssa ss2-month-old ssclient's ssdiaper ssand ssnotes ssthe ssclient ssfeels sswarm
ssto sstouch.W
s hich ssmethod ssshould ssthe ssnurse ssuse ssto sscheck ssthe ssbaby's sstemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
ssmembranesANSWER:
ss C
Explanation: s s A) ssOral ssis ssused ssfor ssage ss3 ssor ssolder.
B) The ssrectal ssroute ssis ssthe ssleast ssdesirable.
C) The ssaxillary ssroute ssmay ssnot ssbe ssas ssaccurate ssas ssother ssroutes ssfor ssdetecting ssfevers ssin sschildren.
D) The sstympanic ssmembrane ssmay ssbe ssused ssfor ss3 ssmonths ssor
ssolder.sPage ssRef: ss29
Cognitive ssLevel: s s Applying
Client ssNeed/Sub: s s Physiological ssIntegrity: ssReduction ssof ssRisk ssPotential
Standards: s s Nursing ssProcess: ssEvaluating ss| ssLearning ssOutcome: ss1.2 ss| ssQSEN ssCompetencies:
ssSafetysAACN ssDomains ssand ss Comps.: s s Domain ss 5: ssQuality ssand ssSafety
NLN ssCompetencies: s s Quality ss& ssSafety
4) A ssclient sscomes ssin sswith ssexacerbation ssof sschronic ssobstructive sspulmonary ssdisease ss(COPD).
ssWhichn s oninvasive ssdiagnostic sstest ss will ssthe ssnurse ssimplement ssto ssknow ssthat ssthe ssclient ssis
ssreceiving ssenough ssoxygen?
A) Chest ssx-ray
B) Pulse ssoximeter
C) Arterial ssblood ssgasses
D) Assessment ssof ssrespiratory
ssratesANSWER: s s B
Explanation: s s A) ssA sschest ssx-ray ssis ssnot ssan ssintervention ssa ssnurse sscompletes.
B) A sspulse ssoximeter ssprovides ssa ssnoninvasive ssmethod ssof ssmeasuring ssoxygenation, ssor
ssoxygen sssaturation, ssin ssthe ssblood ssand ssprovides ss a sspulse ssreading, sswhich ssis ssespecially
sshelpful ssfor ssthe ssclientswith ssa ssrespiratory ssillness ss or ssdisease.
C) Arterial ssblood ssgases ssare ssan ssinvasive ssdiagnostic sstest.
D) Assessing ssa ssrespiratory ssrate ssis ssimportant ssfor ssthe ssnurse ssto ssimplement; sshowever,
ssit ssis ssnot ssasdiagnostic sstest.
Page ssRef: ss21
Cognitive ssLevel: s s Applying
Client ssNeed/Sub: s s Physiological ssIntegrity: ssReduction ssof ssRisk ssPotential
Standards: ssNursing ssProcess: ssImplementation ss| ssLearning ssOutcome: ss1.3 ss| ssQSEN
ssCompetencies:sInformatics
AACN ssDomains ssand ssComps.: s s Domain ss5: ssQuality ssand
ssSafetysNLN ssCompetencies: s s Quality ss& ssSafety
2
