TEST BANK Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Pearson
Education
Table of Contents
Chapter 1. Assessment
CLINICAL NURSING SKILLS:
Chapter 2. Caring Interventions
Chapter 3. Comfort
A Concept-Based Approach Chapter 4. Elimination
Chapter 5. Fluids and Electrolytes
4th Edition, Pearson Education Chapter 6. Infection
Chapter 7. Intracranial Regulation
Chapter 8. Metabolism
Chapter 9. Mobility
Chapter 10. Nutrition
Chapter 11. Oxygenation
Chapter 12. Perfusion
Chapter 13. Perioperative Care
Chapter 14. Reproduction
Chapter 15. Safety
Chapter 16. Tissue Integrity
TEST BANK
,Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Education Test Bank 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch.
Chapter 1: Assessment Which method should the nurse use to check the baby's temperature?
A) Oral
1) A client on the medical/surgical unit complains of sudden chest pains. Which action will the B) Rectal
nurse implement first? C) Axillary
A) Call the healthcare provider. D) Tympanic membrane
B) Administer pain medication. Answer: C
C) Reassess a new set of vital signs. Explanation: A) Oral is used for age 3 or older.
D) Turn client from supine to lateral. B) The rectal route is the least desirable.
Answer: C C) The axillary route may not be as accurate as other routes for detecting fevers in children.
Explanation: A) The nurse will need to reassess the client first, before calling the healthcare D) The tympanic membrane may be used for 3 months or older.
provider. Page Ref: 29
B) The nurse will need to reassess the client first, before administering pain medication. Cognitive Level: Applying
C) The nurse needs to implement a new set of vital signs first when there is a change in Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
condition. Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies: Safety
D) The nurse will need to reassess the client first, before moving the client, to avoid making the AACN Domains and Comps.: Domain 5: Quality and Safety
change in client's condition worse. NLN Competencies: Quality & Safety
Page Ref: 2
Cognitive Level: Applying 4) A client comes in with exacerbation of chronic obstructive pulmonary disease (COPD). Which
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential noninvasive diagnostic test will the nurse implement to know that the client is receiving enough
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN Competencies: oxygen?
Patient-Centered Care A) Chest x-ray
AACN Domains and Comps.: Domain 2: Person-Centered Care B) Pulse oximeter
NLN Competencies: Relationship Centered Care C) Arterial blood gasses
D) Assessment of respiratory rate
2) The nurse is observing the UAP taking the temperature of an unconscious client. Which route Answer: B
will the nurse question the UAP using? Explanation: A) A chest x-ray is not an intervention a nurse completes.
A) Oral B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen
B) Rectal saturation, in the blood and provides a pulse reading, which is especially helpful for the client
C) Scanner with a respiratory illness or disease.
D) Tympanic C) Arterial blood gases are an invasive diagnostic test.
Answer: A D) Assessing a respiratory rate is important for the nurse to implement; however, it is not a
Explanation: A) The temperature of an unconscious client is never taken by mouth. The rectal, diagnostic test.
tympanic, or scanner method is preferred. Page Ref: 21
B) The rectal, tympanic, or scanner method is preferred. Cognitive Level: Applying
C) The rectal, tympanic, or scanner method is preferred. Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
D) The rectal, tympanic, or scanner method is preferred. Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Competencies:
Page Ref: 24 Informatics
Cognitive Level: Applying AACN Domains and Comps.: Domain 5: Quality and Safety
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control NLN Competencies: Quality & Safety
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 2
,5) The nurse is preparing to assess a client's musculoskeletal system. Which question should the "blowing" sounds between the scapulae and lateral to the sternum at the first and second
nurse ask before beginning this assessment? intercostal spaces. Which action should the nurse take?
A) "Do you exercise every day?" A) Encourage the client to cough and deep breathe.
B) "Do you have a history of any sports injuries?" B) Notify the healthcare provider of abnormal breath sounds.
C) "Do you take a hot bath to relax your muscles?" C) Document assessment findings as normal breath sounds.
D) "Do you want pain medication before I begin?" D) Raise the head of the bed to allow maximum air excursion.
Answer: B Answer: C
Explanation: A) Knowing if a client exercises is an important question but knowing if there are Explanation: A) There is no reason to encourage the client to take deep breaths and cough.
any sports injuries to know about first, is most important before doing a routine musculoskeletal B) The nurse would notify the healthcare provider if these were adventitious lung sounds;
assessment. however, these are bronchovesicular sounds.
B) It is important to note if the client has a history of any sports injuries first to know what the C) These are bronchovesicular sounds.
client will or will not be able to do during a routine musculoskeletal assessment. D) The nurse would implement this if these were adventitious lung sounds; however, these are
C) Knowing if the client takes a hot bath to relax the muscles is not the most important thing to bronchovesicular sounds.
ask before performing a routine musculoskeletal assessment. Page Ref: 88
D) To know if a client is experiencing any pain is an important question; however, this question Cognitive Level: Applying
is assuming the client is in pain by asking if the client wants a pain medication before beginning Client Need/Sub: Health Promotion and Maintenance
a routine musculoskeletal assessment. Standards: Nursing Process: Assessment | Learning Outcome: 1.7 | QSEN Competencies:
Page Ref: 62 Patient-Centered Care
Cognitive Level: Applying AACN Domains and Comps.: Domain 2: Person-Centered Care
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control NLN Competencies: Context and Environment
Standards: Nursing Process: Assessment | Learning Outcome: 1.5 | QSEN Competencies:
Safety 8) A client seeks medical attention for shortness of breath and a fever. Which amount of time
AACN Domains and Comps.: Domain 5: Quality and Safety should the nurse count the peripheral pulse?
NLN Competencies: Quality & Safety A) 15 seconds
B) 30 seconds
6) An adult child mentions that the client seems to have a decline in mental status and seems to C) 1 minute
be forgetting many things in their conversation since being hospitalized. Which response should D) 2 minutes
the nurse make? Answer: C
A) "Give your mom time, because it will take her a little longer when answering questions." Explanation: A) Count for a full minute if taking a client's pulse for the first time.
B) "Let me check the cranial nerve function to see if there is a defect in her mental status." B) Count for a full minute if taking a client's pulse for the first time.
C) "You do not need to worry. This decline is part of the normal process of aging." C) Count for a full minute if taking a client's pulse for the first time.
D) "If you bring some things from her home, it might reduce the confusion." D) Count for a full minute if taking a client's pulse for the first time.
Answer: D Page Ref: 19
Explanation: A) This is expected to give some older adults time to respond, but the daughter is Cognitive Level: Applying
concerned about her forgetting, not the length of the response. Client Need/Sub: Health Promotion and Maintenance
B) Cranial nerve function is an assessment of the cranial nerves and not the mental status of a Standards: Nursing Process: Assessment | Learning Outcome: 1.8 | QSEN Competencies:
client. Patient-Centered Care
C) A decline in mental status is not a normal result of aging, so this response is not true. AACN Domains and Comps.: Domain 2: Person-Centered Care
D) The stress of being in unfamiliar situations can cause confusion in some older adults. NLN Competencies: Quality & Safety
Page Ref: 75
Cognitive Level: Applying
Client Need/Sub: Psychosocial Integrity
Standards: Nursing Process: Planning | Learning Outcome: 1.6 | QSEN Competencies: Patient-
Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Context and Environment
7) When assessing breath sounds, the nurse hears moderate-intensity and moderate-pitch
3 4
, 9) The nurse is preparing a dose of digoxin for a client. Which assessment will the nurse 11) The nurse is measuring the blood pressure of an adult client. Which technique would cause
complete prior to giving this medication? an erroneously low blood pressure?
A) Temperature A) Bladder to cuff ratio too wide
B) Apical pulse B) Arm unsupported
C) Respiratory rate C) Cuff wrapped too loosely
D) Pain using a pain scale D) Arm below heart level
Answer: B Answer: A
Explanation: A) The temperature does not need to be assessed before giving digoxin. Explanation: A) The width of the bladder cuff needs to be 40% of the circumference or 20%
B) The nurse should assess the apical pulse before the administration of a medication that could wider than the diameter of the midpoint.
affect the cardiovascular system, such as before giving a digitalis preparation. B) If the arm is unsupported, it will cause an erroneously high blood pressure.
C) The respiratory rate does not need to be assessed before giving digoxin. C) If the cuff is wrapped too loosely, it will cause an erroneously high blood pressure.
D) Pain level does not need to be assessed before giving digoxin. D) If the arm is below heart level, it will cause an erroneously high blood pressure.
Page Ref: 18 Page Ref: 11
Cognitive Level: Applying Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies:
Patient-Centered Care Patient-Centered Care
AACN Domains and Comps.: Domain 5: Quality and Safety AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Quality & Safety NLN Competencies: Quality & Safety
10) The nurse is completing a general assessment of a newborn. Which technique should the 12) The nurse is reviewing collected data. Which client should the nurse see first?
nurse use? A) Infant respirations 38/min
A) Wrap the tape measure around the head below the ears. B) 2-year-old pulse 112/min
B) Wrap the tape measure around the head starting at the nose. C) 6-year-old axillary temperature 97.5°F
C) Wrap the tape measure around the abdomen at the umbilicus. D) 10-year-old blood pressure 138/88
D) Wrap the tape measure around the chest below the nipple line. Answer: D
Answer: C Explanation: A) An infant's respiration range is 20-40/min.
Explanation: A) When measuring the head circumference, wrap the tape around the head at the B) A 2-year-old child's pulse range is 70-120/min.
supraorbital prominence above the eyebrows, above the ears, and around the occipital C) A 6-year-old child's temperature range is 98.6°F but axillary is 1°F lower than oral.
prominence. D) A 10-year-old child's blood pressure range is systolic 95-116 and diastolic 60-70. This is
B) When measuring the head circumference, wrap the tape around the head at the supraorbital much higher than the range for the age of this client.
prominence above the eyebrows, above the ears, and around the occipital prominence. Page Ref: 15
C) When measuring the abdomen circumference, wrap the tape around the abdomen at the level Cognitive Level: Analyzing
of the umbilicus. Client Need/Sub: Health Promotion and Maintenance
D) When measuring the chest circumference, wrap the tape measure around the chest, placed just Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies:
under the axilla and at the nipple line. Patient-Centered Care
Page Ref: 31 AACN Domains and Comps.: Domain 2: Person-Centered Care
Cognitive Level: Applying NLN Competencies: Quality & Safety
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies:
Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Quality & Safety
5 6
Education
Table of Contents
Chapter 1. Assessment
CLINICAL NURSING SKILLS:
Chapter 2. Caring Interventions
Chapter 3. Comfort
A Concept-Based Approach Chapter 4. Elimination
Chapter 5. Fluids and Electrolytes
4th Edition, Pearson Education Chapter 6. Infection
Chapter 7. Intracranial Regulation
Chapter 8. Metabolism
Chapter 9. Mobility
Chapter 10. Nutrition
Chapter 11. Oxygenation
Chapter 12. Perfusion
Chapter 13. Perioperative Care
Chapter 14. Reproduction
Chapter 15. Safety
Chapter 16. Tissue Integrity
TEST BANK
,Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Education Test Bank 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch.
Chapter 1: Assessment Which method should the nurse use to check the baby's temperature?
A) Oral
1) A client on the medical/surgical unit complains of sudden chest pains. Which action will the B) Rectal
nurse implement first? C) Axillary
A) Call the healthcare provider. D) Tympanic membrane
B) Administer pain medication. Answer: C
C) Reassess a new set of vital signs. Explanation: A) Oral is used for age 3 or older.
D) Turn client from supine to lateral. B) The rectal route is the least desirable.
Answer: C C) The axillary route may not be as accurate as other routes for detecting fevers in children.
Explanation: A) The nurse will need to reassess the client first, before calling the healthcare D) The tympanic membrane may be used for 3 months or older.
provider. Page Ref: 29
B) The nurse will need to reassess the client first, before administering pain medication. Cognitive Level: Applying
C) The nurse needs to implement a new set of vital signs first when there is a change in Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
condition. Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies: Safety
D) The nurse will need to reassess the client first, before moving the client, to avoid making the AACN Domains and Comps.: Domain 5: Quality and Safety
change in client's condition worse. NLN Competencies: Quality & Safety
Page Ref: 2
Cognitive Level: Applying 4) A client comes in with exacerbation of chronic obstructive pulmonary disease (COPD). Which
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential noninvasive diagnostic test will the nurse implement to know that the client is receiving enough
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN Competencies: oxygen?
Patient-Centered Care A) Chest x-ray
AACN Domains and Comps.: Domain 2: Person-Centered Care B) Pulse oximeter
NLN Competencies: Relationship Centered Care C) Arterial blood gasses
D) Assessment of respiratory rate
2) The nurse is observing the UAP taking the temperature of an unconscious client. Which route Answer: B
will the nurse question the UAP using? Explanation: A) A chest x-ray is not an intervention a nurse completes.
A) Oral B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen
B) Rectal saturation, in the blood and provides a pulse reading, which is especially helpful for the client
C) Scanner with a respiratory illness or disease.
D) Tympanic C) Arterial blood gases are an invasive diagnostic test.
Answer: A D) Assessing a respiratory rate is important for the nurse to implement; however, it is not a
Explanation: A) The temperature of an unconscious client is never taken by mouth. The rectal, diagnostic test.
tympanic, or scanner method is preferred. Page Ref: 21
B) The rectal, tympanic, or scanner method is preferred. Cognitive Level: Applying
C) The rectal, tympanic, or scanner method is preferred. Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
D) The rectal, tympanic, or scanner method is preferred. Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Competencies:
Page Ref: 24 Informatics
Cognitive Level: Applying AACN Domains and Comps.: Domain 5: Quality and Safety
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control NLN Competencies: Quality & Safety
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 2
,5) The nurse is preparing to assess a client's musculoskeletal system. Which question should the "blowing" sounds between the scapulae and lateral to the sternum at the first and second
nurse ask before beginning this assessment? intercostal spaces. Which action should the nurse take?
A) "Do you exercise every day?" A) Encourage the client to cough and deep breathe.
B) "Do you have a history of any sports injuries?" B) Notify the healthcare provider of abnormal breath sounds.
C) "Do you take a hot bath to relax your muscles?" C) Document assessment findings as normal breath sounds.
D) "Do you want pain medication before I begin?" D) Raise the head of the bed to allow maximum air excursion.
Answer: B Answer: C
Explanation: A) Knowing if a client exercises is an important question but knowing if there are Explanation: A) There is no reason to encourage the client to take deep breaths and cough.
any sports injuries to know about first, is most important before doing a routine musculoskeletal B) The nurse would notify the healthcare provider if these were adventitious lung sounds;
assessment. however, these are bronchovesicular sounds.
B) It is important to note if the client has a history of any sports injuries first to know what the C) These are bronchovesicular sounds.
client will or will not be able to do during a routine musculoskeletal assessment. D) The nurse would implement this if these were adventitious lung sounds; however, these are
C) Knowing if the client takes a hot bath to relax the muscles is not the most important thing to bronchovesicular sounds.
ask before performing a routine musculoskeletal assessment. Page Ref: 88
D) To know if a client is experiencing any pain is an important question; however, this question Cognitive Level: Applying
is assuming the client is in pain by asking if the client wants a pain medication before beginning Client Need/Sub: Health Promotion and Maintenance
a routine musculoskeletal assessment. Standards: Nursing Process: Assessment | Learning Outcome: 1.7 | QSEN Competencies:
Page Ref: 62 Patient-Centered Care
Cognitive Level: Applying AACN Domains and Comps.: Domain 2: Person-Centered Care
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control NLN Competencies: Context and Environment
Standards: Nursing Process: Assessment | Learning Outcome: 1.5 | QSEN Competencies:
Safety 8) A client seeks medical attention for shortness of breath and a fever. Which amount of time
AACN Domains and Comps.: Domain 5: Quality and Safety should the nurse count the peripheral pulse?
NLN Competencies: Quality & Safety A) 15 seconds
B) 30 seconds
6) An adult child mentions that the client seems to have a decline in mental status and seems to C) 1 minute
be forgetting many things in their conversation since being hospitalized. Which response should D) 2 minutes
the nurse make? Answer: C
A) "Give your mom time, because it will take her a little longer when answering questions." Explanation: A) Count for a full minute if taking a client's pulse for the first time.
B) "Let me check the cranial nerve function to see if there is a defect in her mental status." B) Count for a full minute if taking a client's pulse for the first time.
C) "You do not need to worry. This decline is part of the normal process of aging." C) Count for a full minute if taking a client's pulse for the first time.
D) "If you bring some things from her home, it might reduce the confusion." D) Count for a full minute if taking a client's pulse for the first time.
Answer: D Page Ref: 19
Explanation: A) This is expected to give some older adults time to respond, but the daughter is Cognitive Level: Applying
concerned about her forgetting, not the length of the response. Client Need/Sub: Health Promotion and Maintenance
B) Cranial nerve function is an assessment of the cranial nerves and not the mental status of a Standards: Nursing Process: Assessment | Learning Outcome: 1.8 | QSEN Competencies:
client. Patient-Centered Care
C) A decline in mental status is not a normal result of aging, so this response is not true. AACN Domains and Comps.: Domain 2: Person-Centered Care
D) The stress of being in unfamiliar situations can cause confusion in some older adults. NLN Competencies: Quality & Safety
Page Ref: 75
Cognitive Level: Applying
Client Need/Sub: Psychosocial Integrity
Standards: Nursing Process: Planning | Learning Outcome: 1.6 | QSEN Competencies: Patient-
Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Context and Environment
7) When assessing breath sounds, the nurse hears moderate-intensity and moderate-pitch
3 4
, 9) The nurse is preparing a dose of digoxin for a client. Which assessment will the nurse 11) The nurse is measuring the blood pressure of an adult client. Which technique would cause
complete prior to giving this medication? an erroneously low blood pressure?
A) Temperature A) Bladder to cuff ratio too wide
B) Apical pulse B) Arm unsupported
C) Respiratory rate C) Cuff wrapped too loosely
D) Pain using a pain scale D) Arm below heart level
Answer: B Answer: A
Explanation: A) The temperature does not need to be assessed before giving digoxin. Explanation: A) The width of the bladder cuff needs to be 40% of the circumference or 20%
B) The nurse should assess the apical pulse before the administration of a medication that could wider than the diameter of the midpoint.
affect the cardiovascular system, such as before giving a digitalis preparation. B) If the arm is unsupported, it will cause an erroneously high blood pressure.
C) The respiratory rate does not need to be assessed before giving digoxin. C) If the cuff is wrapped too loosely, it will cause an erroneously high blood pressure.
D) Pain level does not need to be assessed before giving digoxin. D) If the arm is below heart level, it will cause an erroneously high blood pressure.
Page Ref: 18 Page Ref: 11
Cognitive Level: Applying Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies: Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies:
Patient-Centered Care Patient-Centered Care
AACN Domains and Comps.: Domain 5: Quality and Safety AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Quality & Safety NLN Competencies: Quality & Safety
10) The nurse is completing a general assessment of a newborn. Which technique should the 12) The nurse is reviewing collected data. Which client should the nurse see first?
nurse use? A) Infant respirations 38/min
A) Wrap the tape measure around the head below the ears. B) 2-year-old pulse 112/min
B) Wrap the tape measure around the head starting at the nose. C) 6-year-old axillary temperature 97.5°F
C) Wrap the tape measure around the abdomen at the umbilicus. D) 10-year-old blood pressure 138/88
D) Wrap the tape measure around the chest below the nipple line. Answer: D
Answer: C Explanation: A) An infant's respiration range is 20-40/min.
Explanation: A) When measuring the head circumference, wrap the tape around the head at the B) A 2-year-old child's pulse range is 70-120/min.
supraorbital prominence above the eyebrows, above the ears, and around the occipital C) A 6-year-old child's temperature range is 98.6°F but axillary is 1°F lower than oral.
prominence. D) A 10-year-old child's blood pressure range is systolic 95-116 and diastolic 60-70. This is
B) When measuring the head circumference, wrap the tape around the head at the supraorbital much higher than the range for the age of this client.
prominence above the eyebrows, above the ears, and around the occipital prominence. Page Ref: 15
C) When measuring the abdomen circumference, wrap the tape around the abdomen at the level Cognitive Level: Analyzing
of the umbilicus. Client Need/Sub: Health Promotion and Maintenance
D) When measuring the chest circumference, wrap the tape measure around the chest, placed just Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies:
under the axilla and at the nipple line. Patient-Centered Care
Page Ref: 31 AACN Domains and Comps.: Domain 2: Person-Centered Care
Cognitive Level: Applying NLN Competencies: Quality & Safety
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies:
Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Quality & Safety
5 6
