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