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 the
nurse 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 healthcare
provider.
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 in
condition.
D) The nurse will need to reassess the client first, before moving the client, to avoid making the
change 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 route
will 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
1
, 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 axillaryroute maynot be as accurate as other routes for detecting fevers in children.
* * * * * * * * * * * * * * *
D) The tympanic membrane maybe used for 3 months or older.Page
* * * * * * * * * * *
Ref: 29
* *
Cognitive Level: Applying * *
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
* * * * * * *
Standards: NursingProcess: Evaluating | Learning Outcome: 1.2 |QSEN Competencies: * * * * * * * * * *
SafetyAACN Domains and Comps.: Domain 5: Qualityand Safety
* * * * * * * * * *
NLN Competencies: Quality& Safety
* * * *
4) A client comes in with exacerbation of chronic obstructive pulmonarydisease (COPD).
* * * * * * * * * * *
Whichnoninvasive diagnostic test will the nurse implement to know that the client is receiving enough
* * * * * * * * * * * * * * * *
oxygen?
*
A) Chest x-ray *
B) Pulse oximeter *
C) Arterialblood gasses * *
D) Assessmentofrespiratory * *
rateANSWER: B
* * *
Explanation: A) A chest x-rayis 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 especiallyhelpful for the clientwith a
* * * * * * * * * * * * * * * * * *
respiratoryillness or disease.
* * * *
C) Arterial blood gases are an invasive diagnostic test. * * * * * * *
D) Assessinga respiratoryrate 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
* * * *
2
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 the
nurse 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 healthcare
provider.
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 in
condition.
D) The nurse will need to reassess the client first, before moving the client, to avoid making the
change 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 route
will 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
1
, 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 axillaryroute maynot be as accurate as other routes for detecting fevers in children.
* * * * * * * * * * * * * * *
D) The tympanic membrane maybe used for 3 months or older.Page
* * * * * * * * * * *
Ref: 29
* *
Cognitive Level: Applying * *
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
* * * * * * *
Standards: NursingProcess: Evaluating | Learning Outcome: 1.2 |QSEN Competencies: * * * * * * * * * *
SafetyAACN Domains and Comps.: Domain 5: Qualityand Safety
* * * * * * * * * *
NLN Competencies: Quality& Safety
* * * *
4) A client comes in with exacerbation of chronic obstructive pulmonarydisease (COPD).
* * * * * * * * * * *
Whichnoninvasive diagnostic test will the nurse implement to know that the client is receiving enough
* * * * * * * * * * * * * * * *
oxygen?
*
A) Chest x-ray *
B) Pulse oximeter *
C) Arterialblood gasses * *
D) Assessmentofrespiratory * *
rateANSWER: B
* * *
Explanation: A) A chest x-rayis 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 especiallyhelpful for the clientwith a
* * * * * * * * * * * * * * * * * *
respiratoryillness or disease.
* * * *
C) Arterial blood gases are an invasive diagnostic test. * * * * * * *
D) Assessinga respiratoryrate 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
* * * *
2
