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 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.tPage t Ref: t 24
Cognitive t Level: t Applying
Client t Need/Sub: t t t Safe t and t Effective t Care t Environment: t Safety t and t Infection t Control t
Standards: t Nursing t Process: t Evaluation t | t Learning t Outcome: t 1.1 t | t QSEN t Competencies:
t SafetytAACN t Domains t and t Comps.: t Domain t 5: t Quality t and t Safety
NLN t Competencies: t Quality t & t Safety



1

, 3) The t nurse t is t changing t a t 2-month-old t client's t diaper t and t notes t the t client t feels t
warm t to t touch.tWhich t method t should t the t nurse t use t to t check t the t baby's t
temperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic t
membranetANSWER: t C
Explanation: t A) t Oral t is t used t for t age t 3 t or t older.
B) The t rectal t route t is t the t least t desirable.
C) The t axillary t route t may t not t be t as t accurate t as t other t routes t for t detecting t fevers t in t children.
D) The t tympanic t membrane t may t be t used t for t 3 t months t
or t older.tPage t Ref: t 29
Cognitive t Level: t Applying
Client t Need/Sub: t Physiological t Integrity: t Reduction t of t Risk t Potential
Standards: t Nursing t Process: t Evaluating t | t Learning t Outcome: t 1.2 t | t QSEN t Competencies:
t SafetytAACN t Domains t and t Comps.: t Domain t 5: t Quality t and t Safety
NLN t Competencies: t Quality t & t Safety

4) A t client t comes t in t with t exacerbation t of t chronic t obstructive t pulmonary t disease t
(COPD). t Whichtnoninvasive t diagnostic t test t will t the t nurse t implement t to t know t that t the t
client t is t receiving t enough t oxygen?
A) Chest t x-ray
B) Pulse t oximeter
C) Arterial t blood t gasses
D) Assessment t of t respiratory t
ratetANSWER: t B
Explanation: t A) t A t chest t x-ray t is t not t an t intervention t a t nurse t completes.
B) A t pulse t oximeter t provides t a t noninvasive t method t of t measuring t oxygenation, t or t
oxygen t saturation, t in t the t blood t and t provides t a t pulse t reading, t which t is t especially t
helpful t for t the t clienttwith t a t respiratory t illness t or t disease.
C) Arterial t blood t gases t are t an t invasive t diagnostic t test.
D) Assessing t a t respiratory t rate t is t important t for t the t nurse t to t implement; t however,
t it t is t not t atdiagnostic t test.
Page t Ref: t 21
Cognitive t Level: t Applying
Client t Need/Sub: t Physiological t Integrity: t Reduction t of t Risk t Potential
Standards: t Nursing t Process: t Implementation t | t Learning t Outcome: t 1.3 t | t QSEN t
Competencies:Informatics
t
AACN t Domains t and t Comps.: t Domain t 5: t Quality t and t Safetyt
NLN t Competencies: t Quality t & t Safety




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