TestBankforClinicalNursingSkills:
. . . . .
AConcept-BasedApproach
. . .
4thEditionVolumeIII
. . .
byPearsonEducationChapters1-16
. . . . . .
,TestBank forClinicalNursingSkills: AConcept-BasedApproach 4thEdition Pearson
. . . . . . . . . . . .
,ClinicalNursing Skills:A Concept-Based Approach, 4e (Pearson)Education Test
. . . . . . . . .
BankChapter1: Assessment
. . . .
1) A client on the medical/surgical unit complains of sudden chest pains. Which action will thenurse
. . . . . . . . . . . . . . .
implement first?
. .
A) Callthe healthcareprovider. . . .
B) Administerpainmedication. . .
C) Reassess anew set of vital signs. . . . . . .
D) Turnclientfromsupineto . . . .
lateral.ANSWER: C
. . .
Explanation: A) The nurse will need to reassess the client first, before calling the . . . . . . . . . . . . .
healthcareprovider.
. .
B) Thenursewill need to reassess the client first, before administeringpain medication.
. . . . . . . . . . . .
C) Thenurseneeds to implement a new set of vital signs first when thereis a change
. . . . . . . . . . . . . . . .
incondition.
. .
D) Thenursewill need to reassess the client first, before movingthe client, to avoid makingthechange
. . . . . . . . . . . . . . . . .
in client's condition worse.
. . . .
PageRef: 2 . .
Cognitive Level: Applying . .
ClientNeed/Sub: Physiological Integrity: Reduction ofRisk Potential
. . . . . . .
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN . . . . . . . . .
Competencies:Patient-Centered Care
. . .
AACN Domains and Comps.: Domain 2: Person-Centered CareNLN
. . . . . . . .
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 bymouth. The . . . . . . . . . . . . .
rectal,tympanic, or scanner method is preferred.
. . . . . . .
B) The rectal,tympanic, orscannermethodispreferred.
. . . . . . .
C) Therectal,tympanic, orscanner methodis preferred.
. . . . . . .
D) Therectal,tympanic, orscannermethodis . . . . . .
preferred.PageRef: 24
. . . .
Cognitive Level: Applying . .
Client Need/Sub: Safeand Effective CareEnvironment: Safetyand Infection Control Standards:
. .. . . . . . . . . . .
NursingProcess: Evaluation |Learning Outcome: 1.1 |QSEN Competencies: SafetyAACN Domains
. . . . . . . . . . . . .
and Comps.: Domain 5: Qualityand Safety
. . . . . . .
NLN Competencies: Quality&Safety
. . . .
1
, 3) Thenurseis changing a2-month-old client's diaper and notes the client feels warm totouch.Which
. . . . . . . . . . . . . . . .
method should the nurseuse to check the baby's temperature?
. . . . . . . . . .
A) Oral
B) Rectal
C) Axillary
D) Tympanic
membraneANSWER: C
. . .
Explanation: A)Oral is used for age 3 orolder. . . . . . . . . .
B) The rectal route is the least desirable. . . . . . .
C) Theaxillaryroutemaynot be as accurateas other routes for detecting fevers in children.
. . . . . . . . . . . . . . .
D) Thetympanicmembrane maybeused for3 months orolder.Page
. . . . . . . . . . .
Ref: 29
. .
Cognitive Level: Applying . .
ClientNeed/Sub: Physiological Integrity: Reduction ofRisk Potential
. . . . . . .
Standards: NursingProcess: Evaluating | LearningOutcome: 1.2 |QSEN Competencies: . . . . . . . . . .
SafetyAACN Domains and Comps.: Domain 5: Qualityand Safety
. . . . . . . . . .
NLN Competencies: Quality&Safety
. . . .
4) Aclient comes inwith exacerbation of chronic obstructivepulmonarydisease(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) Assessmentof .
respiratoryrateANSWER: 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 theblood and provides apulse reading, which is especiallyhelpful forthe clientwith a
. . . . . . . . . . . . . . . . . .
respiratoryillness or disease.
. . . .
C) Arterialblood gases arean invasivediagnostic test. . . . . . . .
D) Assessinga respiratoryrate is important for the nurseto implement; however, it is not . . . . . . . . . . . . . .
adiagnostic test.
. . .
PageRef: 21 . .
Cognitive Level: Applying . .
ClientNeed/Sub: Physiological Integrity: Reduction ofRisk Potential
. . . . . . .
Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN . . . . . . . . .
Competencies:Informatics
. .
AACN Domains and Comps.: Domain 5: Qualityand SafetyNLN
. . . . . . . . .
Competencies: Quality&Safety
. . . .
2
. . . . .
AConcept-BasedApproach
. . .
4thEditionVolumeIII
. . .
byPearsonEducationChapters1-16
. . . . . .
,TestBank forClinicalNursingSkills: AConcept-BasedApproach 4thEdition Pearson
. . . . . . . . . . . .
,ClinicalNursing Skills:A Concept-Based Approach, 4e (Pearson)Education Test
. . . . . . . . .
BankChapter1: Assessment
. . . .
1) A client on the medical/surgical unit complains of sudden chest pains. Which action will thenurse
. . . . . . . . . . . . . . .
implement first?
. .
A) Callthe healthcareprovider. . . .
B) Administerpainmedication. . .
C) Reassess anew set of vital signs. . . . . . .
D) Turnclientfromsupineto . . . .
lateral.ANSWER: C
. . .
Explanation: A) The nurse will need to reassess the client first, before calling the . . . . . . . . . . . . .
healthcareprovider.
. .
B) Thenursewill need to reassess the client first, before administeringpain medication.
. . . . . . . . . . . .
C) Thenurseneeds to implement a new set of vital signs first when thereis a change
. . . . . . . . . . . . . . . .
incondition.
. .
D) Thenursewill need to reassess the client first, before movingthe client, to avoid makingthechange
. . . . . . . . . . . . . . . . .
in client's condition worse.
. . . .
PageRef: 2 . .
Cognitive Level: Applying . .
ClientNeed/Sub: Physiological Integrity: Reduction ofRisk Potential
. . . . . . .
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN . . . . . . . . .
Competencies:Patient-Centered Care
. . .
AACN Domains and Comps.: Domain 2: Person-Centered CareNLN
. . . . . . . .
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 bymouth. The . . . . . . . . . . . . .
rectal,tympanic, or scanner method is preferred.
. . . . . . .
B) The rectal,tympanic, orscannermethodispreferred.
. . . . . . .
C) Therectal,tympanic, orscanner methodis preferred.
. . . . . . .
D) Therectal,tympanic, orscannermethodis . . . . . .
preferred.PageRef: 24
. . . .
Cognitive Level: Applying . .
Client Need/Sub: Safeand Effective CareEnvironment: Safetyand Infection Control Standards:
. .. . . . . . . . . . .
NursingProcess: Evaluation |Learning Outcome: 1.1 |QSEN Competencies: SafetyAACN Domains
. . . . . . . . . . . . .
and Comps.: Domain 5: Qualityand Safety
. . . . . . .
NLN Competencies: Quality&Safety
. . . .
1
, 3) Thenurseis changing a2-month-old client's diaper and notes the client feels warm totouch.Which
. . . . . . . . . . . . . . . .
method should the nurseuse to check the baby's temperature?
. . . . . . . . . .
A) Oral
B) Rectal
C) Axillary
D) Tympanic
membraneANSWER: C
. . .
Explanation: A)Oral is used for age 3 orolder. . . . . . . . . .
B) The rectal route is the least desirable. . . . . . .
C) Theaxillaryroutemaynot be as accurateas other routes for detecting fevers in children.
. . . . . . . . . . . . . . .
D) Thetympanicmembrane maybeused for3 months orolder.Page
. . . . . . . . . . .
Ref: 29
. .
Cognitive Level: Applying . .
ClientNeed/Sub: Physiological Integrity: Reduction ofRisk Potential
. . . . . . .
Standards: NursingProcess: Evaluating | LearningOutcome: 1.2 |QSEN Competencies: . . . . . . . . . .
SafetyAACN Domains and Comps.: Domain 5: Qualityand Safety
. . . . . . . . . .
NLN Competencies: Quality&Safety
. . . .
4) Aclient comes inwith exacerbation of chronic obstructivepulmonarydisease(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) Assessmentof .
respiratoryrateANSWER: 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 theblood and provides apulse reading, which is especiallyhelpful forthe clientwith a
. . . . . . . . . . . . . . . . . .
respiratoryillness or disease.
. . . .
C) Arterialblood gases arean invasivediagnostic test. . . . . . . .
D) Assessinga respiratoryrate is important for the nurseto implement; however, it is not . . . . . . . . . . . . . .
adiagnostic test.
. . .
PageRef: 21 . .
Cognitive Level: Applying . .
ClientNeed/Sub: Physiological Integrity: Reduction ofRisk Potential
. . . . . . .
Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN . . . . . . . . .
Competencies:Informatics
. .
AACN Domains and Comps.: Domain 5: Qualityand SafetyNLN
. . . . . . . . .
Competencies: Quality&Safety
. . . .
2
