Test Bank for Clinical Nursing Skills:
ii ii ii ii ii
A Concept-Based Approach
ii ii ii
4th Edition Volume III
ii ii ii
by Pearson Education Chapters 1 - 16
ii ii ii ii ii ii
,Test Bank for Clinical Nursing Skills: A Concept-
g d g d gd gd g d g d g d
Based Approach 4th Edition Pearsonii
g d g d g d gd
,Clinical Nursing Skills: A Concept-
g d g d gd g d
Based Approach, 4e (Pearson) Education Test BankiiChapter 1: Assessment
g d g d g d gd g d gd g d g d
1) A client on the medical/surgical unit complains of sudden chest pains. Which a
g d g d g d g d g d g d g d g d g d g d g d g d
ction will theiinurse implement first?
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A) Call the healthcare provider.
g d g d g d
B) Administer pain medication. g d g d
C) Reassess a new set of vital signs. g d g d g d g d g d g d
D) Turn client from supine togd gd gd gd gd
lateral.iiANSWER: C g d
Explanation: A) The nurse will need to reassess the client first, before calling the h
g d g d g d g d g d g d g d g d g d g d g d g d g d gd
ealthcareprovider.
B) The nurse will need to reassess the client first, before administering pain medication.
g d gd g d g d g d g d g d g d g d g d g d g d
C) The nurse needs to implement a new set of vital signs first when there
g d g d g d g d g d g d g d g d g d g d g d g d g d
is a change iniicondition.
g d g d gd g d
D) The nurse will need to reassess the client first, before moving the client, to
gd g d g d g d g d g d g d g d g d g d gd g d g d g d
avoid making theiichange in client's condition worse.
gd gd g d g d g d g d
Page Ref: 2 g d g d
Cognitive Level: Applying g d
Client Need/Sub: g d
Physiological Integrity: Reduction of Risk Potential g d g d g d gd g d gd
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QS
g d g d g d g d g d g d g d g d g d
EN Competencies:Patient-Centered Care
gd g d
AACN Domains and Comps.: Domain 2: Person-
g d g d g d g d g d g d
Centered CareiiNLN Competencies: Relationship Centered Ca
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re
2) The nurse is observing the UAP taking the temperature of an unconscious cl
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ient. Which routeiiwill the nurse question the UAP using?
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A) Oral
B) Rectal
C) Scanner
D) Tympanic
iiANSWER:
A
Explanation: A) The temperature of an unconscious client is never taken by mouth.
g d g d g d g d g d g d g d g d g d g d g d g d
g d The rectal,tympanic, or scanner method is preferred.
gd g d g d g d g d g d
B) The rectal, tympanic, or scanner method is preferred.
g d g d g d g d g d g d g d
C) The rectal, tympanic, or scanner method is preferred.
gd g d g d g d g d g d g d
D) The rectal, tympanic, or scanner method is
gd gd g d gd g d gd gd
preferred.Page Ref: 24 g d g d
Cognitive Level: Applying g d
Client Need/Sub: g d
Safe and Effective Care Environment: Safety and Infection Control g d g d g d gd g d gd g d g d
gd Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competenci
g d gd g d g d g d g d g d g d gd g d
es: SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
gd g d g d g d g d g d g d g d g d
NLN Competencies:
g d Quality & Safety g d g d
1
, 3) The nurse is changing a 2-month-
g d g d g d g d g d
old client's diaper and notes the client feels warm to touch.Which method should th
g d g d g d g d g d g d g d g d g d gd g d g d g d
e nurse use to check the baby's temperature?
g d g d g d g d g d g d g d
A) Oral
B) Rectal
C) Axillary
D) Tympanic membra gd
neiiANSWER:
C
Explanation: A) Oral is used for age 3 or older. g d g d g d g d g d g d g d g d
B) The rectal route is the least desirable.
g d g d g d g d g d g d
C) The axillary route may not be as accurate as other routes for detecting fevers in children.
g d gd g d g d g d g d g d g d g d g d g d g d g d g d g d
D) The tympanic membrane may be used for 3 months
gd g d g d gd g d g d gd g d g d
or older.Page Ref: 29
gd g d g d
Cognitive Level: Applying g d
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
g d g d g d g d gd g d
Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competenci
g d g d g d g d g d g d g d g d g d g d
es: SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
gd g d g d g d g d g d g d g d g d
NLN Competencies: Quality & Safety
g d g d g d
4) A client comes in with exacerbation of chronic obstructive pulmonary disease (CO
g d g d g d g d g d g d g d g d g d gd g d
PD). Whichiinoninvasive diagnostic test will the nurse implement to know that the cl
gd g d g d g d g d g d g d g d g d g d g d g d
ient is receiving enough oxygen?
g d gd g d g d
A) Chest x-ray g d
B) Pulse oximeter g d
C) Arterial blood gasses g d g d
D) Assessment of respiratory gd gd g
drateiiANSWER: B g d
Explanation: A) A chest x-ray is not an intervention a nurse completes.
g d g d g d g d g d g d g d g d g d g d g d g d g d
B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxy
gd gd gd gd gd gd gd gd gd gd gd
gen saturation, in the blood and provides a pulse reading, which is especially helpful
gd gd gd gd gd gd gd gd gd gd gd gd gd g d
for the clientiiwith a respiratory illness or disease.
g d g d g d g d gd g d g d
C) Arterial blood gases are an invasive diagnostic test.
g d g d g d g d g d g d g d
D) Assessing a respiratory rate is important for the nurse to implement; howeve
g d g d g d g d g d g d g d g d g d g d g d
r, it is not aiidiagnostic test.
g d gd g d g d g d
Page Ref: 21 g d g d
Cognitive Level: Applying g d
Client Need/Sub: g d
Physiological Integrity: Reduction of Risk Potential Stan g d g d g d gd g d gd
dards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN
g d g d g d g d g d g d g d g d g d gd
Competencies:Informatics
AACN Domains and Comps.: Domain 5: Quality and Safet
g d g d g d g d g d g d gd g d
y NLN Competencies: Quality & Safety
gd g d g d gd g d
2
ii ii ii ii ii
A Concept-Based Approach
ii ii ii
4th Edition Volume III
ii ii ii
by Pearson Education Chapters 1 - 16
ii ii ii ii ii ii
,Test Bank for Clinical Nursing Skills: A Concept-
g d g d gd gd g d g d g d
Based Approach 4th Edition Pearsonii
g d g d g d gd
,Clinical Nursing Skills: A Concept-
g d g d gd g d
Based Approach, 4e (Pearson) Education Test BankiiChapter 1: Assessment
g d g d g d gd g d gd g d g d
1) A client on the medical/surgical unit complains of sudden chest pains. Which a
g d g d g d g d g d g d g d g d g d g d g d g d
ction will theiinurse implement first?
gd g d g d g d
A) Call the healthcare provider.
g d g d g d
B) Administer pain medication. g d g d
C) Reassess a new set of vital signs. g d g d g d g d g d g d
D) Turn client from supine togd gd gd gd gd
lateral.iiANSWER: C g d
Explanation: A) The nurse will need to reassess the client first, before calling the h
g d g d g d g d g d g d g d g d g d g d g d g d g d gd
ealthcareprovider.
B) The nurse will need to reassess the client first, before administering pain medication.
g d gd g d g d g d g d g d g d g d g d g d g d
C) The nurse needs to implement a new set of vital signs first when there
g d g d g d g d g d g d g d g d g d g d g d g d g d
is a change iniicondition.
g d g d gd g d
D) The nurse will need to reassess the client first, before moving the client, to
gd g d g d g d g d g d g d g d g d g d gd g d g d g d
avoid making theiichange in client's condition worse.
gd gd g d g d g d g d
Page Ref: 2 g d g d
Cognitive Level: Applying g d
Client Need/Sub: g d
Physiological Integrity: Reduction of Risk Potential g d g d g d gd g d gd
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QS
g d g d g d g d g d g d g d g d g d
EN Competencies:Patient-Centered Care
gd g d
AACN Domains and Comps.: Domain 2: Person-
g d g d g d g d g d g d
Centered CareiiNLN Competencies: Relationship Centered Ca
gd g d g d g d g d
re
2) The nurse is observing the UAP taking the temperature of an unconscious cl
g d g d g d g d g d g d g d g d g d g d g d g d
ient. Which routeiiwill the nurse question the UAP using?
gd g d g d g d g d g d g d g d
A) Oral
B) Rectal
C) Scanner
D) Tympanic
iiANSWER:
A
Explanation: A) The temperature of an unconscious client is never taken by mouth.
g d g d g d g d g d g d g d g d g d g d g d g d
g d The rectal,tympanic, or scanner method is preferred.
gd g d g d g d g d g d
B) The rectal, tympanic, or scanner method is preferred.
g d g d g d g d g d g d g d
C) The rectal, tympanic, or scanner method is preferred.
gd g d g d g d g d g d g d
D) The rectal, tympanic, or scanner method is
gd gd g d gd g d gd gd
preferred.Page Ref: 24 g d g d
Cognitive Level: Applying g d
Client Need/Sub: g d
Safe and Effective Care Environment: Safety and Infection Control g d g d g d gd g d gd g d g d
gd Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competenci
g d gd g d g d g d g d g d g d gd g d
es: SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
gd g d g d g d g d g d g d g d g d
NLN Competencies:
g d Quality & Safety g d g d
1
, 3) The nurse is changing a 2-month-
g d g d g d g d g d
old client's diaper and notes the client feels warm to touch.Which method should th
g d g d g d g d g d g d g d g d g d gd g d g d g d
e nurse use to check the baby's temperature?
g d g d g d g d g d g d g d
A) Oral
B) Rectal
C) Axillary
D) Tympanic membra gd
neiiANSWER:
C
Explanation: A) Oral is used for age 3 or older. g d g d g d g d g d g d g d g d
B) The rectal route is the least desirable.
g d g d g d g d g d g d
C) The axillary route may not be as accurate as other routes for detecting fevers in children.
g d gd g d g d g d g d g d g d g d g d g d g d g d g d g d
D) The tympanic membrane may be used for 3 months
gd g d g d gd g d g d gd g d g d
or older.Page Ref: 29
gd g d g d
Cognitive Level: Applying g d
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
g d g d g d g d gd g d
Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competenci
g d g d g d g d g d g d g d g d g d g d
es: SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
gd g d g d g d g d g d g d g d g d
NLN Competencies: Quality & Safety
g d g d g d
4) A client comes in with exacerbation of chronic obstructive pulmonary disease (CO
g d g d g d g d g d g d g d g d g d gd g d
PD). Whichiinoninvasive diagnostic test will the nurse implement to know that the cl
gd g d g d g d g d g d g d g d g d g d g d g d
ient is receiving enough oxygen?
g d gd g d g d
A) Chest x-ray g d
B) Pulse oximeter g d
C) Arterial blood gasses g d g d
D) Assessment of respiratory gd gd g
drateiiANSWER: B g d
Explanation: A) A chest x-ray is not an intervention a nurse completes.
g d g d g d g d g d g d g d g d g d g d g d g d g d
B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxy
gd gd gd gd gd gd gd gd gd gd gd
gen saturation, in the blood and provides a pulse reading, which is especially helpful
gd gd gd gd gd gd gd gd gd gd gd gd gd g d
for the clientiiwith a respiratory illness or disease.
g d g d g d g d gd g d g d
C) Arterial blood gases are an invasive diagnostic test.
g d g d g d g d g d g d g d
D) Assessing a respiratory rate is important for the nurse to implement; howeve
g d g d g d g d g d g d g d g d g d g d g d
r, it is not aiidiagnostic test.
g d gd g d g d g d
Page Ref: 21 g d g d
Cognitive Level: Applying g d
Client Need/Sub: g d
Physiological Integrity: Reduction of Risk Potential Stan g d g d g d gd g d gd
dards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN
g d g d g d g d g d g d g d g d g d gd
Competencies:Informatics
AACN Domains and Comps.: Domain 5: Quality and Safet
g d g d g d g d g d g d gd g d
y NLN Competencies: Quality & Safety
gd g d g d gd g d
2
