Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Volume III by Pearson Education Chapters 1 - 16

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 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 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