Test Bank for Clinical Nursing Skills:
A Concept-Based Approach
4th Edition Volume III
by Pearson Education Chapters 1 - 16
,Test 11Bank 11for 11Clinical 11Nursing 11Skills: 11A 11Concept-Based 11Approach 114th 11Edition
11Pearson1
,Clinical 11Nursing 11Skills: 11A 11Concept-Based 11Approach, 114e 11(Pearson) 11Education 11Test
11Bank1Chapter 111: 11Assessment
1) A 11client 11on 11the 11medical/surgical 11unit 11complains 11of 11sudden 11chest 11pains. 11Which
11action 11will 11the1nurse 11implement 11first?
A) Call 11the 11healthcare 11provider.
B) Administer 11pain 11medication.
C) Reassess 11a 11new 11set 11of 11vital 11signs.
D) Turn 11client 11from 11supine 11to
11lateral.1ANSWER: 11 C
Explanation: 11A) 11The 11nurse 11will 11need 11to 11reassess 11the 11client 11first, 11before 11calling
11the 11healthcare1provider.
B) The 11nurse 11will 11need 11to 11reassess 11the 11client 11first, 11before 11administering 11pain 11medication.
C) The 11nurse 11needs 11to 11implement 11a 11new 11set 11of 11vital 11signs 11first 11when 11there
11is 11a 11change 11in1condition.
D) The 11nurse 11will 11need 11to 11reassess 11the 11client 11first, 11before 11moving 11the 11client, 11to
11avoid 11making 11the1change 11in 11client's 11condition 11worse.
Page 11Ref: 112
Cognitive 11Level: 1 1 Applying
Client 11Need/Sub: 1 1 Physiological 11Integrity: 11Reduction 11of 11Risk 11Potential
Standards: 11Nursing 11Process: 11Assessment 11| 11Learning 11Outcome: 111.1 11| 11QSEN
11Competencies:1Patient-Centered 11Care
AACN 11Domains 11and 11Comps.: 11Domain 112: 11Person-Centered
11Care1NLN 11Competencies: 11 Relationship 11Centered 11Care
2) The 11nurse 11is 11observing 11the 11UAP 11taking 11the 11temperature 11of 11an 11unconscious 11client.
11Which 11route1will 11the 11nurse 11question 11the 11UAP 11using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
1ANSWER: 11 A
Explanation: 11A) 11The 11temperature 11of 11an 11unconscious 11client 11is 11never 11taken 11by 11mouth.
11The 11rectal,1tympanic, 11or 11scanner 11method 11is 11preferred.
B) The 11rectal, 11tympanic, 11or 11scanner 11method 11is 11preferred.
C) The 11rectal, 11tympanic, 11or 11scanner 11method 11is 11preferred.
D) The 11rectal, 11tympanic, 11or 11scanner 11method 11is
11preferred.1Page 11Ref: 1124
Cognitive 11Level: 1 1 Applying
Client 11Need/Sub: 11 11 11 Safe 11and 11Effective 11Care 11Environment: 11Safety 11and 11Infection
11Control 11Standards: 11 Nursing 11Process: 11Evaluation 11| 11Learning 11Outcome: 111.1 11| 11QSEN
11Competencies: 11Safety1AACN 11Domains 11and 11Comps.: 1 1 Domain 115: 11Quality 11and 11Safety
NLN 11Competencies: 1 1 Quality 11& 11Safety
1
, 3) The 11nurse 11is 11changing 11a 112-month-old 11client's 11diaper 11and 11notes 11the 11client 11feels
11warm 11to 11touch.1Which 11method 11should 11the 11nurse 11use 11to 11check 11the 11baby's
11temperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
11membrane1ANSWER:
11 C
Explanation: 1 1 A) 11Oral 11is 11used 11for 11age 113 11or 11older.
B) The 11rectal 11route 11is 11the 11least 11desirable.
C) The 11axillary 11route 11may 11not 11be 11as 11accurate 11as 11other 11routes 11for 11detecting 11fevers 11in
11children.
D) The 11tympanic 11membrane 11may 11be 11used 11for 113 11months
11or 11older.1Page 11Ref: 1129
Cognitive 11Level: 1 1 Applying
Client 11Need/Sub: 1 1 Physiological 11Integrity: 11Reduction 11of 11Risk 11Potential
Standards: 11 Nursing 11Process: 11Evaluating 11| 11Learning 11Outcome: 111.2 11| 11QSEN
11Competencies: 11Safety1AACN 11Domains 11and 11Comps.: 1 1 Domain 115: 11Quality 11and 11Safety
NLN 11Competencies: 1 1 Quality 11& 11Safety
4) A 11client 11comes 11in 11with 11exacerbation 11of 11chronic 11obstructive 11pulmonary 11disease
11(COPD). 11Which1noninvasive 11diagnostic 11test 11will 11the 11nurse 11implement 11to 11know 11that
11the 11client 11is 11receiving 11enough 11oxygen?
A) Chest 11x-ray
B) Pulse 11oximeter
C) Arterial 11blood 11gasses
D) Assessment 11of 11respiratory
11rate1ANSWER: 1 1 B
Explanation: 1 1 A) 11A 11chest 11x-ray 11is 11not 11an 11intervention 11a 11nurse 11completes.
B) A 11pulse 11oximeter 11provides 11a 11noninvasive 11method 11of 11measuring 11oxygenation, 11or
11oxygen 11saturation, 11in 11the 11blood 11and 11provides 11a 11pulse 11reading, 11which 11is
11especially 11helpful 11for 11the 11client1with 11a 11respiratory 11illness 11or 11disease.
C) Arterial 11blood 11gases 11are 11an 11invasive 11diagnostic 11test.
D) Assessing 11a 11respiratory 11rate 11is 11important 11for 11the 11nurse 11to 11implement;
11however, 11it 11is 11not 11a1diagnostic 11test.
Page 11Ref: 1121
Cognitive 11Level: 1 1 Applying
Client 11Need/Sub: 1 1 Physiological 11Integrity: 11Reduction 11of 11Risk 11Potential
Standards: 11Nursing 11Process: 11Implementation 11| 11Learning 11Outcome: 111.3 11| 11QSEN
11Competencies:1Informatics
AACN 11Domains 11and 11Comps.: 11 Domain 115: 11Quality 11and
11Safety1NLN 11Competencies: 11 Quality 11& 11Safety
2
A Concept-Based Approach
4th Edition Volume III
by Pearson Education Chapters 1 - 16
,Test 11Bank 11for 11Clinical 11Nursing 11Skills: 11A 11Concept-Based 11Approach 114th 11Edition
11Pearson1
,Clinical 11Nursing 11Skills: 11A 11Concept-Based 11Approach, 114e 11(Pearson) 11Education 11Test
11Bank1Chapter 111: 11Assessment
1) A 11client 11on 11the 11medical/surgical 11unit 11complains 11of 11sudden 11chest 11pains. 11Which
11action 11will 11the1nurse 11implement 11first?
A) Call 11the 11healthcare 11provider.
B) Administer 11pain 11medication.
C) Reassess 11a 11new 11set 11of 11vital 11signs.
D) Turn 11client 11from 11supine 11to
11lateral.1ANSWER: 11 C
Explanation: 11A) 11The 11nurse 11will 11need 11to 11reassess 11the 11client 11first, 11before 11calling
11the 11healthcare1provider.
B) The 11nurse 11will 11need 11to 11reassess 11the 11client 11first, 11before 11administering 11pain 11medication.
C) The 11nurse 11needs 11to 11implement 11a 11new 11set 11of 11vital 11signs 11first 11when 11there
11is 11a 11change 11in1condition.
D) The 11nurse 11will 11need 11to 11reassess 11the 11client 11first, 11before 11moving 11the 11client, 11to
11avoid 11making 11the1change 11in 11client's 11condition 11worse.
Page 11Ref: 112
Cognitive 11Level: 1 1 Applying
Client 11Need/Sub: 1 1 Physiological 11Integrity: 11Reduction 11of 11Risk 11Potential
Standards: 11Nursing 11Process: 11Assessment 11| 11Learning 11Outcome: 111.1 11| 11QSEN
11Competencies:1Patient-Centered 11Care
AACN 11Domains 11and 11Comps.: 11Domain 112: 11Person-Centered
11Care1NLN 11Competencies: 11 Relationship 11Centered 11Care
2) The 11nurse 11is 11observing 11the 11UAP 11taking 11the 11temperature 11of 11an 11unconscious 11client.
11Which 11route1will 11the 11nurse 11question 11the 11UAP 11using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
1ANSWER: 11 A
Explanation: 11A) 11The 11temperature 11of 11an 11unconscious 11client 11is 11never 11taken 11by 11mouth.
11The 11rectal,1tympanic, 11or 11scanner 11method 11is 11preferred.
B) The 11rectal, 11tympanic, 11or 11scanner 11method 11is 11preferred.
C) The 11rectal, 11tympanic, 11or 11scanner 11method 11is 11preferred.
D) The 11rectal, 11tympanic, 11or 11scanner 11method 11is
11preferred.1Page 11Ref: 1124
Cognitive 11Level: 1 1 Applying
Client 11Need/Sub: 11 11 11 Safe 11and 11Effective 11Care 11Environment: 11Safety 11and 11Infection
11Control 11Standards: 11 Nursing 11Process: 11Evaluation 11| 11Learning 11Outcome: 111.1 11| 11QSEN
11Competencies: 11Safety1AACN 11Domains 11and 11Comps.: 1 1 Domain 115: 11Quality 11and 11Safety
NLN 11Competencies: 1 1 Quality 11& 11Safety
1
, 3) The 11nurse 11is 11changing 11a 112-month-old 11client's 11diaper 11and 11notes 11the 11client 11feels
11warm 11to 11touch.1Which 11method 11should 11the 11nurse 11use 11to 11check 11the 11baby's
11temperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
11membrane1ANSWER:
11 C
Explanation: 1 1 A) 11Oral 11is 11used 11for 11age 113 11or 11older.
B) The 11rectal 11route 11is 11the 11least 11desirable.
C) The 11axillary 11route 11may 11not 11be 11as 11accurate 11as 11other 11routes 11for 11detecting 11fevers 11in
11children.
D) The 11tympanic 11membrane 11may 11be 11used 11for 113 11months
11or 11older.1Page 11Ref: 1129
Cognitive 11Level: 1 1 Applying
Client 11Need/Sub: 1 1 Physiological 11Integrity: 11Reduction 11of 11Risk 11Potential
Standards: 11 Nursing 11Process: 11Evaluating 11| 11Learning 11Outcome: 111.2 11| 11QSEN
11Competencies: 11Safety1AACN 11Domains 11and 11Comps.: 1 1 Domain 115: 11Quality 11and 11Safety
NLN 11Competencies: 1 1 Quality 11& 11Safety
4) A 11client 11comes 11in 11with 11exacerbation 11of 11chronic 11obstructive 11pulmonary 11disease
11(COPD). 11Which1noninvasive 11diagnostic 11test 11will 11the 11nurse 11implement 11to 11know 11that
11the 11client 11is 11receiving 11enough 11oxygen?
A) Chest 11x-ray
B) Pulse 11oximeter
C) Arterial 11blood 11gasses
D) Assessment 11of 11respiratory
11rate1ANSWER: 1 1 B
Explanation: 1 1 A) 11A 11chest 11x-ray 11is 11not 11an 11intervention 11a 11nurse 11completes.
B) A 11pulse 11oximeter 11provides 11a 11noninvasive 11method 11of 11measuring 11oxygenation, 11or
11oxygen 11saturation, 11in 11the 11blood 11and 11provides 11a 11pulse 11reading, 11which 11is
11especially 11helpful 11for 11the 11client1with 11a 11respiratory 11illness 11or 11disease.
C) Arterial 11blood 11gases 11are 11an 11invasive 11diagnostic 11test.
D) Assessing 11a 11respiratory 11rate 11is 11important 11for 11the 11nurse 11to 11implement;
11however, 11it 11is 11not 11a1diagnostic 11test.
Page 11Ref: 1121
Cognitive 11Level: 1 1 Applying
Client 11Need/Sub: 1 1 Physiological 11Integrity: 11Reduction 11of 11Risk 11Potential
Standards: 11Nursing 11Process: 11Implementation 11| 11Learning 11Outcome: 111.3 11| 11QSEN
11Competencies:1Informatics
AACN 11Domains 11and 11Comps.: 11 Domain 115: 11Quality 11and
11Safety1NLN 11Competencies: 11 Quality 11& 11Safety
2
