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.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 dnurse dis dchanging da d2-month-old dclient's ddiaper dand dnotes dthe dclient dfeels
dwarm dto dtouch.dWhich dmethod dshould dthe dnurse duse dto dcheck dthe dbaby's
dtemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
dmembranedANSWER:
dC
Explanation: d A) dOral dis dused dfor dage d3 dor dolder.
B) The drectal droute dis dthe dleast ddesirable.
C) The daxillary droute dmay dnot dbe das daccurate das dother droutes dfor ddetecting dfevers din dchildren.
D) The dtympanic dmembrane dmay dbe dused dfor d3 dmonths
dor dolder.dPage dRef: d29
Cognitive dLevel: d Applying
Client dNeed/Sub: d Physiological dIntegrity: dReduction dof dRisk dPotential
Standards: d Nursing dProcess: dEvaluating d| dLearning dOutcome: d1.2 d| dQSEN dCompetencies:
dSafetydAACN dDomains dand dComps.: d Domain d5: dQuality dand dSafety
NLN dCompetencies: d Quality d& dSafety
4) A dclient dcomes din dwith dexacerbation dof dchronic dobstructive dpulmonary ddisease d(COPD).
dWhichdnoninvasive ddiagnostic dtest dwill dthe dnurse dimplement dto dknow dthat dthe dclient dis
dreceiving denough doxygen?
A) Chest dx-ray
B) Pulse doximeter
C) Arterial dblood dgasses
D) Assessment dof drespiratory
dratedANSWER: d B
Explanation: d A) dA dchest dx-ray dis dnot dan dintervention da dnurse dcompletes.
B) A dpulse doximeter dprovides da dnoninvasive dmethod dof dmeasuring doxygenation, dor
doxygen dsaturation, din dthe dblood dand dprovides da dpulse dreading, dwhich dis despecially
dhelpful dfor dthe dclientdwith da drespiratory dillness dor ddisease.
C) Arterial dblood dgases dare dan dinvasive ddiagnostic dtest.
D) Assessing da drespiratory drate dis dimportant dfor dthe dnurse dto dimplement; dhowever,
dit dis dnot daddiagnostic dtest.
Page dRef: d21
Cognitive dLevel: d Applying
Client dNeed/Sub: d Physiological dIntegrity: dReduction dof dRisk dPotential
Standards: dNursing dProcess: dImplementation d| dLearning dOutcome: d1.3 d| dQSEN
dCompetencies:dInformatics
AACN dDomains dand dComps.: d Domain d5: dQuality dand dSafety
dNLN dCompetencies: d Quality d& dSafety
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
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.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 dnurse dis dchanging da d2-month-old dclient's ddiaper dand dnotes dthe dclient dfeels
dwarm dto dtouch.dWhich dmethod dshould dthe dnurse duse dto dcheck dthe dbaby's
dtemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
dmembranedANSWER:
dC
Explanation: d A) dOral dis dused dfor dage d3 dor dolder.
B) The drectal droute dis dthe dleast ddesirable.
C) The daxillary droute dmay dnot dbe das daccurate das dother droutes dfor ddetecting dfevers din dchildren.
D) The dtympanic dmembrane dmay dbe dused dfor d3 dmonths
dor dolder.dPage dRef: d29
Cognitive dLevel: d Applying
Client dNeed/Sub: d Physiological dIntegrity: dReduction dof dRisk dPotential
Standards: d Nursing dProcess: dEvaluating d| dLearning dOutcome: d1.2 d| dQSEN dCompetencies:
dSafetydAACN dDomains dand dComps.: d Domain d5: dQuality dand dSafety
NLN dCompetencies: d Quality d& dSafety
4) A dclient dcomes din dwith dexacerbation dof dchronic dobstructive dpulmonary ddisease d(COPD).
dWhichdnoninvasive ddiagnostic dtest dwill dthe dnurse dimplement dto dknow dthat dthe dclient dis
dreceiving denough doxygen?
A) Chest dx-ray
B) Pulse doximeter
C) Arterial dblood dgasses
D) Assessment dof drespiratory
dratedANSWER: d B
Explanation: d A) dA dchest dx-ray dis dnot dan dintervention da dnurse dcompletes.
B) A dpulse doximeter dprovides da dnoninvasive dmethod dof dmeasuring doxygenation, dor
doxygen dsaturation, din dthe dblood dand dprovides da dpulse dreading, dwhich dis despecially
dhelpful dfor dthe dclientdwith da drespiratory dillness dor ddisease.
C) Arterial dblood dgases dare dan dinvasive ddiagnostic dtest.
D) Assessing da drespiratory drate dis dimportant dfor dthe dnurse dto dimplement; dhowever,
dit dis dnot daddiagnostic dtest.
Page dRef: d21
Cognitive dLevel: d Applying
Client dNeed/Sub: d Physiological dIntegrity: dReduction dof dRisk dPotential
Standards: dNursing dProcess: dImplementation d| dLearning dOutcome: d1.3 d| dQSEN
dCompetencies:dInformatics
AACN dDomains dand dComps.: d Domain d5: dQuality dand dSafety
dNLN dCompetencies: d Quality d& dSafety
2
