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 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 older.
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: Safety
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). Which
noninvasive diagnostic test will the nurse implement to know that the client is receiving enough
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 client
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 not 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
, 5) The nurse is preparing to assess a client's musculoskeletal system. Which question should the
nurse ask before beginning this assessment?
A) "Do you exercise every day?"
B) "Do you have a history of any sports injuries?"
C) "Do you take a hot bath to relax your muscles?"
D) "Do you want pain medication before I begin?"
ANSWER: B
Explanation: A) Knowing if a client exercises is an important question but knowing if there are
any sports injuries to know about first, is most important before doing a routine musculoskeletal
assessment.
B) It is important to note if the client has a history of any sports injuries first to know what the
client will or will not be able to do during a routine musculoskeletal assessment.
C) Knowing if the client takes a hot bath to relax the muscles is not the most important thing to
ask before performing a routine musculoskeletal assessment.
D) To know if a client is experiencing any pain is an important question; however, this question
is assuming the client is in pain by asking if the client wants a pain medication before beginning
a routine musculoskeletal assessment.
Page Ref: 62
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: Nursing Process: Assessment | Learning Outcome: 1.5 | QSEN Competencies:
Safety
AACN Domains and Comps.: Domain 5: Quality and Safety
NLN Competencies: Quality & Safety
6) An adult child mentions that the client seems to have a decline in mental status and seems to
be forgetting many things in their conversation since being hospitalized. Which response should
the nurse make?
A) "Give your mom time, because it will take her a little longer when answering questions."
B) "Let me check the cranial nerve function to see if there is a defect in her mental status."
C) "You do not need to worry. This decline is part of the normal process of aging."
D) "If you bring some things from her home, it might reduce the confusion."
ANSWER: D
Explanation: A) This is expected to give some older adults time to respond, but the daughter is
concerned about her forgetting, not the length of the response.
B) Cranial nerve function is an assessment of the cranial nerves and not the mental status of a
client.
C) A decline in mental status is not a normal result of aging, so this response is not true.
D) The stress of being in unfamiliar situations can cause confusion in some older adults.
Page Ref: 75
Cognitive Level: Applying
Client Need/Sub: Psychosocial Integrity
Standards: Nursing Process: Planning | Learning Outcome: 1.6 | QSEN Competencies: Patient-
Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Context and Environment
7) When assessing breath sounds, the nurse hears moderate-intensity and moderate-pitch
3
,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 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 older.
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: Safety
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). Which
noninvasive diagnostic test will the nurse implement to know that the client is receiving enough
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 client
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 not 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
, 5) The nurse is preparing to assess a client's musculoskeletal system. Which question should the
nurse ask before beginning this assessment?
A) "Do you exercise every day?"
B) "Do you have a history of any sports injuries?"
C) "Do you take a hot bath to relax your muscles?"
D) "Do you want pain medication before I begin?"
ANSWER: B
Explanation: A) Knowing if a client exercises is an important question but knowing if there are
any sports injuries to know about first, is most important before doing a routine musculoskeletal
assessment.
B) It is important to note if the client has a history of any sports injuries first to know what the
client will or will not be able to do during a routine musculoskeletal assessment.
C) Knowing if the client takes a hot bath to relax the muscles is not the most important thing to
ask before performing a routine musculoskeletal assessment.
D) To know if a client is experiencing any pain is an important question; however, this question
is assuming the client is in pain by asking if the client wants a pain medication before beginning
a routine musculoskeletal assessment.
Page Ref: 62
Cognitive Level: Applying
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: Nursing Process: Assessment | Learning Outcome: 1.5 | QSEN Competencies:
Safety
AACN Domains and Comps.: Domain 5: Quality and Safety
NLN Competencies: Quality & Safety
6) An adult child mentions that the client seems to have a decline in mental status and seems to
be forgetting many things in their conversation since being hospitalized. Which response should
the nurse make?
A) "Give your mom time, because it will take her a little longer when answering questions."
B) "Let me check the cranial nerve function to see if there is a defect in her mental status."
C) "You do not need to worry. This decline is part of the normal process of aging."
D) "If you bring some things from her home, it might reduce the confusion."
ANSWER: D
Explanation: A) This is expected to give some older adults time to respond, but the daughter is
concerned about her forgetting, not the length of the response.
B) Cranial nerve function is an assessment of the cranial nerves and not the mental status of a
client.
C) A decline in mental status is not a normal result of aging, so this response is not true.
D) The stress of being in unfamiliar situations can cause confusion in some older adults.
Page Ref: 75
Cognitive Level: Applying
Client Need/Sub: Psychosocial Integrity
Standards: Nursing Process: Planning | Learning Outcome: 1.6 | QSEN Competencies: Patient-
Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Context and Environment
7) When assessing breath sounds, the nurse hears moderate-intensity and moderate-pitch
3
