TESTBANK ;.
CLINICAL NURSING SKILLS:
;. ;.
A Concept-Based Approach
;. ;.
4th; . Edition,;.Pearson;.Education
TESTBANK ;.
,Test;.Bank;.for;.Clinical;.Nursing;.Skills:;.A;.Concept-
Based;.Approach;.4th;.Edition;.Pearson;.Education
Table;.of;.Contents
Chapter;.1.;.Assessment
Chapter;.2.;.Caring;.Interventions
Chapter;.3.;.Comfort
Chapter;.4.;.Elimination
Chapter;.5.;.Fluids;.and;.Electrolytes
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
,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;.chang
e;.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;.Competenci
es:;.Patient-Centered;.Care
AACN;.Domains;.and;.Comps.:; . Domain;.2:;.Person-
Centered;.Care;.NLN;.Competencies:; . Relationship;.Centered;.Car
e
2) The;.nurse;.is;.observing;.the;.UAP;.taking;.the;.temperature;.of;.an;.unconscious;.client.;.Which;.ro
ute;.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;.rect
al,;.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;.preferre
d.;.Page;.Ref:;.24
Cognitive;.Level:; . ; . Applying
Client;.Need/Sub:; . Safe;.and;.Effective;.Care;.Environment:;.Safety;.and;.Infection;.Control;.Stand
ards:; . Nursing;.Process:;.Evaluation;.|;.Learning;.Outcome:;.1.1;.|;.QSEN;.Competencies:;.Safety;.A
ACN;.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;.membrane
;.Answer:; . 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;.old
er.;.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:;.Saf
ety;.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).;.Whi
ch;.noninvasive;.diagnostic;.test;.will;.the;.nurse;.implement;.to;.know;.that;.the;.client;.is;.receiving;.e
nough;.oxygen?
A) Chest;.x-ray
B) Pulse;.oximeter
C) Arterial;.blood;.gasses
D) Assessment;.of;.respiratory;.rate
;.Answer:; . 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;.cl
ient;.with;.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;.n
ot;.a;.diagnostic;.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;.Safety;.
NLN;.Competencies:; . Quality;.&;.Safety
2
CLINICAL NURSING SKILLS:
;. ;.
A Concept-Based Approach
;. ;.
4th; . Edition,;.Pearson;.Education
TESTBANK ;.
,Test;.Bank;.for;.Clinical;.Nursing;.Skills:;.A;.Concept-
Based;.Approach;.4th;.Edition;.Pearson;.Education
Table;.of;.Contents
Chapter;.1.;.Assessment
Chapter;.2.;.Caring;.Interventions
Chapter;.3.;.Comfort
Chapter;.4.;.Elimination
Chapter;.5.;.Fluids;.and;.Electrolytes
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
,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;.chang
e;.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;.Competenci
es:;.Patient-Centered;.Care
AACN;.Domains;.and;.Comps.:; . Domain;.2:;.Person-
Centered;.Care;.NLN;.Competencies:; . Relationship;.Centered;.Car
e
2) The;.nurse;.is;.observing;.the;.UAP;.taking;.the;.temperature;.of;.an;.unconscious;.client.;.Which;.ro
ute;.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;.rect
al,;.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;.preferre
d.;.Page;.Ref:;.24
Cognitive;.Level:; . ; . Applying
Client;.Need/Sub:; . Safe;.and;.Effective;.Care;.Environment:;.Safety;.and;.Infection;.Control;.Stand
ards:; . Nursing;.Process:;.Evaluation;.|;.Learning;.Outcome:;.1.1;.|;.QSEN;.Competencies:;.Safety;.A
ACN;.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;.membrane
;.Answer:; . 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;.old
er.;.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:;.Saf
ety;.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).;.Whi
ch;.noninvasive;.diagnostic;.test;.will;.the;.nurse;.implement;.to;.know;.that;.the;.client;.is;.receiving;.e
nough;.oxygen?
A) Chest;.x-ray
B) Pulse;.oximeter
C) Arterial;.blood;.gasses
D) Assessment;.of;.respiratory;.rate
;.Answer:; . 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;.cl
ient;.with;.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;.n
ot;.a;.diagnostic;.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;.Safety;.
NLN;.Competencies:; . Quality;.&;.Safety
2