Test Bank for Clinical Nursing Skills:
A Concept-Based Approach
4th Edition Volume III
by Pearson Education Chapters 1 - 16
,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
thenurse 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
healthcareprovider.
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
incondition.
D) The nurse will need to reassess the client first, before moving the client, to avoid making
thechange 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
routewill 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
membraneANSWER: 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
rateANSWER: 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
clientwith 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 adiagnostic 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 SafetyNLN
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 SafetyNLN
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 CareNLN
Competencies: Context and Environment
7) When assessing breath sounds, the nurse hears moderate-intensity and moderate-pitch
3
,"blowing" sounds between the scapulae and lateral to the sternum at the first and
secondintercostal spaces. Which action should the nurse take?
A) Encourage the client to cough and deep breathe.
B) Notify the healthcare provider of abnormal breath sounds.
C) Document assessment findings as normal breath sounds.
D) Raise the head of the bed to allow maximum air
excursion.ANSWER: C
Explanation: A) There is no reason to encourage the client to take deep breaths and cough.
B) The nurse would notify the healthcare provider if these were adventitious lung
sounds;however, these are bronchovesicular sounds.
C) These are bronchovesicular sounds.
D) The nurse would implement this if these were adventitious lung sounds; however, these
arebronchovesicular sounds.
Page Ref: 88
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.7 | QSEN Competencies:
Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Context and Environment
8) A client seeks medical attention for shortness of breath and a fever. Which amount of
timeshould the nurse count the peripheral pulse?
A) 15 seconds
B) 30 seconds
C) 1 minute
D) 2
minutes
ANSWER: C
Explanation: A) Count for a full minute if taking a client's pulse for the first time.
B) Count for a full minute if taking a client's pulse for the first time.
C) Count for a full minute if taking a client's pulse for the first time.
D) Count for a full minute if taking a client's pulse for the first
time.Page Ref: 19
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.8 | QSEN Competencies:
Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Quality & Safety
4
,9) The nurse is preparing a dose of digoxin for a client. Which assessment will the
nursecomplete prior to giving this medication?
A) Temperature
B) Apical pulse
C) Respiratory rate
D) Pain using a pain scale
ANSWER: B
Explanation: A) The temperature does not need to be assessed before giving digoxin.
B) The nurse should assess the apical pulse before the administration of a medication that
couldaffect the cardiovascular system, such as before giving a digitalis preparation.
C) The respiratory rate does not need to be assessed before giving digoxin.
D) Pain level does not need to be assessed before giving
digoxin.Page Ref: 18
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies:
Patient-Centered Care
AACN Domains and Comps.: Domain 5: Quality and SafetyNLN
Competencies: Quality & Safety
10) The nurse is completing a general assessment of a newborn. Which technique should
thenurse use?
A) Wrap the tape measure around the head below the ears.
B) Wrap the tape measure around the head starting at the nose.
C) Wrap the tape measure around the abdomen at the umbilicus.
D) Wrap the tape measure around the chest below the nipple
line.ANSWER: C
Explanation: A) When measuring the head circumference, wrap the tape around the head at
thesupraorbital prominence above the eyebrows, above the ears, and around the occipital
prominence.
B) When measuring the head circumference, wrap the tape around the head at the
supraorbitalprominence above the eyebrows, above the ears, and around the occipital
prominence.
C) When measuring the abdomen circumference, wrap the tape around the abdomen at the
levelof the umbilicus.
D) When measuring the chest circumference, wrap the tape measure around the chest, placed
justunder the axilla and at the nipple line.
Page Ref: 31
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies:
Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Quality & Safety
5
,11) The tnurse tis tmeasuring tthe tblood tpressure tof tan tadult tclient. tWhich ttechnique twould
tcausetan terroneously tlow tblood tpressure?
A) Bladder tto tcuff tratio ttoo twide
B) Arm tunsupported
C) Cuff twrapped ttoo tloosely
D) Arm tbelow theart
tleveltANSWER: t A
Explanation: tA) tThe twidth tof tthe tbladder tcuff tneeds tto tbe t40% tof tthe tcircumference tor
t20%twider tthan tthe tdiameter tof tthe tmidpoint.
B) If tthe tarm tis tunsupported, tit twill tcause tan terroneously thigh tblood tpressure.
C) If tthe tcuff tis twrapped ttoo tloosely, tit twill tcause tan terroneously thigh tblood tpressure.
D) If tthe tarm tis tbelow theart tlevel, tit twill tcause tan terroneously thigh tblood
tpressure.tPage tRef: t11
Cognitive tLevel: t Applying
Client tNeed/Sub: t Health tPromotion tand tMaintenance
Standards: tNursing tProcess: tAssessment t| tLearning tOutcome: t1.4 t| tQSEN
tCompetencies:tPatient-Centered tCare
AACN tDomains tand tComps.: tDomain t2: tPerson-Centered
tCaretNLN tCompetencies: t Quality t& tSafety
12) The tnurse tis treviewing tcollected tdata. tWhich tclient tshould tthe tnurse tsee tfirst?
A) Infant trespirations t38/min
B) 2-year-old tpulse t112/min
C) 6-year-old taxillary ttemperature t97.5°F
D) 10-year-old tblood tpressure
t138/88tANSWER: t D
Explanation: t A) tAn tinfant's trespiration trange tis t20-40/min.
B) A t2-year-old tchild's tpulse trange tis t70-120/min.
C) A t6-year-old tchild's ttemperature trange tis t98.6°F tbut taxillary tis t1°F tlower tthan toral.
D) A t10-year-old tchild's tblood tpressure trange tis tsystolic t95-116 tand tdiastolic t60-70.
tThis tistmuch thigher tthan tthe trange tfor tthe tage tof tthis tclient.
Page tRef: t15
Cognitive tLevel: t Analyzing
Client tNeed/Sub: t Health tPromotion tand tMaintenance
Standards: tNursing tProcess: tAssessment t| tLearning tOutcome: t1.4 t| tQSEN
tCompetencies:tPatient-Centered tCare
AACN tDomains tand tComps.: tDomain t2: tPerson-Centered
tCaretNLN tCompetencies: t Quality t& tSafety
6
,13) The tnurse tis tcaring tfor ta tclient twith tdiaphoresis. tWhich troute tshould tthe tnurse tuse tto
tassesstthe tclient's ttemperature? tSelect tall tthat tapply.
A) Oral
B) Rectal
C) Axillary
D) Tympanic
E) Heat tsensitive
tANSWER: t tA, tB,
tD
Explanation: t A) tOral tdoes tnot tinterfere twith tdiaphoresis tbecause tthe tprobe tis tin tthe tmouth.
B) Rectal tdoes tnot tinterfere twith tdiaphoresis tbecause tthe tprobe tis tin tthe trectum.
C) Axillary tmight tbe twet tand tcause tan terror tin tthe treading ttemperature.
D) Tympanic tdoes tnot tinterfere twith tdiaphoresis tbecause tthe tprobe tis tin tthe tear. tHowever,
tdo tnottuse tif tear tis tdraining tor tinfected.
E) Heat tsensitive tmight thave tareas tof tthe tskin tthat tare twet tand tcause tan terror tin
treadingttemperature.
Page tRef: t26, t28
Cognitive tLevel: t Applying
Client tNeed/Sub: t Health tPromotion tand tMaintenance
Standards: tNursing tProcess: tAssessment t| tLearning tOutcome: t1.4 t| tQSEN
tCompetencies:tPatient-Centered tCare
AACN tDomains tand tComps.: tDomain t2: tPerson-Centered
tCaretNLN tCompetencies: t Quality t& tSafety
14) The tnurse tis tpreparing tto tassess ta tclient's tabdomen. tWhich tresponse twill tthe tnurse
tmaketwhen tasked twhy tthe tstethoscope tis twarmed tup tbefore tplacing tit ton tthe
tabdomen?
A) "I tmight thear ta tfriction trub twith ta tcold tstethoscope."
B) "A tnice tnurse twill tput ta twarm tstethoscope ton tyour tabdomen."
C) "A tcold tstethoscope tmay tcause tyour tabdominal tmuscles tto tcontract."
D) "Warming tup tthe tstethoscope twill thelp twith tthe tdigestion tof tyour
tfood."tANSWER: t C
Explanation: tA) tThe tnurse tmight thear ta tfriction trub tdue tto tan tinflammation, tinfection,
tortabdominal tgrowth, tnot tfrom ta tcold tstethoscope.
B) Warming tup ta tstethoscope tcan tbe tnice tfor tthe tclient's tcomfort; thowever, tit tis tdone tto
tdecreasetthe tpossibility tof tabdominal tmuscles tcontracting; totherwise tthe tnurse tmight thear
tunnecessary tcontractions.
C) A tcold tstethoscope tmay tcause tthe tabdominal tmuscles tto tcontract twhich tthe tnurse
tmight theartwith ta tcold tstethoscope.
D) Warming tup tthe tstethoscope thas tno teffect ton tthe tdigestion tof tfood. tA twarm
tstethoscope twilltdecrease tthe tpossibility tof tabdominal tmuscles tcontracting, teliminating tthe
tpossibility tof tthe tnurse thearing tany tunnecessary tnoises.
Page tRef: t31
Cognitive tLevel: t Applying
Client tNeed/Sub: t Health tPromotion tand tMaintenance
7
, Standards: t Nursing tProcess: tAssessment t| tLearning tOutcome: t1.4 t| tQSEN
tCompetencies:tPatient-Centered tCare
AACN tDomains tand tComps.: tDomain t2: tPerson-Centered
tCaretNLN tCompetencies: t Quality t& tSafety
8
A Concept-Based Approach
4th Edition Volume III
by Pearson Education Chapters 1 - 16
,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
thenurse 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
healthcareprovider.
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
incondition.
D) The nurse will need to reassess the client first, before moving the client, to avoid making
thechange 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
routewill 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
membraneANSWER: 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
rateANSWER: 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
clientwith 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 adiagnostic 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 SafetyNLN
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 SafetyNLN
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 CareNLN
Competencies: Context and Environment
7) When assessing breath sounds, the nurse hears moderate-intensity and moderate-pitch
3
,"blowing" sounds between the scapulae and lateral to the sternum at the first and
secondintercostal spaces. Which action should the nurse take?
A) Encourage the client to cough and deep breathe.
B) Notify the healthcare provider of abnormal breath sounds.
C) Document assessment findings as normal breath sounds.
D) Raise the head of the bed to allow maximum air
excursion.ANSWER: C
Explanation: A) There is no reason to encourage the client to take deep breaths and cough.
B) The nurse would notify the healthcare provider if these were adventitious lung
sounds;however, these are bronchovesicular sounds.
C) These are bronchovesicular sounds.
D) The nurse would implement this if these were adventitious lung sounds; however, these
arebronchovesicular sounds.
Page Ref: 88
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.7 | QSEN Competencies:
Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Context and Environment
8) A client seeks medical attention for shortness of breath and a fever. Which amount of
timeshould the nurse count the peripheral pulse?
A) 15 seconds
B) 30 seconds
C) 1 minute
D) 2
minutes
ANSWER: C
Explanation: A) Count for a full minute if taking a client's pulse for the first time.
B) Count for a full minute if taking a client's pulse for the first time.
C) Count for a full minute if taking a client's pulse for the first time.
D) Count for a full minute if taking a client's pulse for the first
time.Page Ref: 19
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.8 | QSEN Competencies:
Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Quality & Safety
4
,9) The nurse is preparing a dose of digoxin for a client. Which assessment will the
nursecomplete prior to giving this medication?
A) Temperature
B) Apical pulse
C) Respiratory rate
D) Pain using a pain scale
ANSWER: B
Explanation: A) The temperature does not need to be assessed before giving digoxin.
B) The nurse should assess the apical pulse before the administration of a medication that
couldaffect the cardiovascular system, such as before giving a digitalis preparation.
C) The respiratory rate does not need to be assessed before giving digoxin.
D) Pain level does not need to be assessed before giving
digoxin.Page Ref: 18
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies:
Patient-Centered Care
AACN Domains and Comps.: Domain 5: Quality and SafetyNLN
Competencies: Quality & Safety
10) The nurse is completing a general assessment of a newborn. Which technique should
thenurse use?
A) Wrap the tape measure around the head below the ears.
B) Wrap the tape measure around the head starting at the nose.
C) Wrap the tape measure around the abdomen at the umbilicus.
D) Wrap the tape measure around the chest below the nipple
line.ANSWER: C
Explanation: A) When measuring the head circumference, wrap the tape around the head at
thesupraorbital prominence above the eyebrows, above the ears, and around the occipital
prominence.
B) When measuring the head circumference, wrap the tape around the head at the
supraorbitalprominence above the eyebrows, above the ears, and around the occipital
prominence.
C) When measuring the abdomen circumference, wrap the tape around the abdomen at the
levelof the umbilicus.
D) When measuring the chest circumference, wrap the tape measure around the chest, placed
justunder the axilla and at the nipple line.
Page Ref: 31
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: Nursing Process: Assessment | Learning Outcome: 1.4 | QSEN Competencies:
Patient-Centered Care
AACN Domains and Comps.: Domain 2: Person-Centered Care
NLN Competencies: Quality & Safety
5
,11) The tnurse tis tmeasuring tthe tblood tpressure tof tan tadult tclient. tWhich ttechnique twould
tcausetan terroneously tlow tblood tpressure?
A) Bladder tto tcuff tratio ttoo twide
B) Arm tunsupported
C) Cuff twrapped ttoo tloosely
D) Arm tbelow theart
tleveltANSWER: t A
Explanation: tA) tThe twidth tof tthe tbladder tcuff tneeds tto tbe t40% tof tthe tcircumference tor
t20%twider tthan tthe tdiameter tof tthe tmidpoint.
B) If tthe tarm tis tunsupported, tit twill tcause tan terroneously thigh tblood tpressure.
C) If tthe tcuff tis twrapped ttoo tloosely, tit twill tcause tan terroneously thigh tblood tpressure.
D) If tthe tarm tis tbelow theart tlevel, tit twill tcause tan terroneously thigh tblood
tpressure.tPage tRef: t11
Cognitive tLevel: t Applying
Client tNeed/Sub: t Health tPromotion tand tMaintenance
Standards: tNursing tProcess: tAssessment t| tLearning tOutcome: t1.4 t| tQSEN
tCompetencies:tPatient-Centered tCare
AACN tDomains tand tComps.: tDomain t2: tPerson-Centered
tCaretNLN tCompetencies: t Quality t& tSafety
12) The tnurse tis treviewing tcollected tdata. tWhich tclient tshould tthe tnurse tsee tfirst?
A) Infant trespirations t38/min
B) 2-year-old tpulse t112/min
C) 6-year-old taxillary ttemperature t97.5°F
D) 10-year-old tblood tpressure
t138/88tANSWER: t D
Explanation: t A) tAn tinfant's trespiration trange tis t20-40/min.
B) A t2-year-old tchild's tpulse trange tis t70-120/min.
C) A t6-year-old tchild's ttemperature trange tis t98.6°F tbut taxillary tis t1°F tlower tthan toral.
D) A t10-year-old tchild's tblood tpressure trange tis tsystolic t95-116 tand tdiastolic t60-70.
tThis tistmuch thigher tthan tthe trange tfor tthe tage tof tthis tclient.
Page tRef: t15
Cognitive tLevel: t Analyzing
Client tNeed/Sub: t Health tPromotion tand tMaintenance
Standards: tNursing tProcess: tAssessment t| tLearning tOutcome: t1.4 t| tQSEN
tCompetencies:tPatient-Centered tCare
AACN tDomains tand tComps.: tDomain t2: tPerson-Centered
tCaretNLN tCompetencies: t Quality t& tSafety
6
,13) The tnurse tis tcaring tfor ta tclient twith tdiaphoresis. tWhich troute tshould tthe tnurse tuse tto
tassesstthe tclient's ttemperature? tSelect tall tthat tapply.
A) Oral
B) Rectal
C) Axillary
D) Tympanic
E) Heat tsensitive
tANSWER: t tA, tB,
tD
Explanation: t A) tOral tdoes tnot tinterfere twith tdiaphoresis tbecause tthe tprobe tis tin tthe tmouth.
B) Rectal tdoes tnot tinterfere twith tdiaphoresis tbecause tthe tprobe tis tin tthe trectum.
C) Axillary tmight tbe twet tand tcause tan terror tin tthe treading ttemperature.
D) Tympanic tdoes tnot tinterfere twith tdiaphoresis tbecause tthe tprobe tis tin tthe tear. tHowever,
tdo tnottuse tif tear tis tdraining tor tinfected.
E) Heat tsensitive tmight thave tareas tof tthe tskin tthat tare twet tand tcause tan terror tin
treadingttemperature.
Page tRef: t26, t28
Cognitive tLevel: t Applying
Client tNeed/Sub: t Health tPromotion tand tMaintenance
Standards: tNursing tProcess: tAssessment t| tLearning tOutcome: t1.4 t| tQSEN
tCompetencies:tPatient-Centered tCare
AACN tDomains tand tComps.: tDomain t2: tPerson-Centered
tCaretNLN tCompetencies: t Quality t& tSafety
14) The tnurse tis tpreparing tto tassess ta tclient's tabdomen. tWhich tresponse twill tthe tnurse
tmaketwhen tasked twhy tthe tstethoscope tis twarmed tup tbefore tplacing tit ton tthe
tabdomen?
A) "I tmight thear ta tfriction trub twith ta tcold tstethoscope."
B) "A tnice tnurse twill tput ta twarm tstethoscope ton tyour tabdomen."
C) "A tcold tstethoscope tmay tcause tyour tabdominal tmuscles tto tcontract."
D) "Warming tup tthe tstethoscope twill thelp twith tthe tdigestion tof tyour
tfood."tANSWER: t C
Explanation: tA) tThe tnurse tmight thear ta tfriction trub tdue tto tan tinflammation, tinfection,
tortabdominal tgrowth, tnot tfrom ta tcold tstethoscope.
B) Warming tup ta tstethoscope tcan tbe tnice tfor tthe tclient's tcomfort; thowever, tit tis tdone tto
tdecreasetthe tpossibility tof tabdominal tmuscles tcontracting; totherwise tthe tnurse tmight thear
tunnecessary tcontractions.
C) A tcold tstethoscope tmay tcause tthe tabdominal tmuscles tto tcontract twhich tthe tnurse
tmight theartwith ta tcold tstethoscope.
D) Warming tup tthe tstethoscope thas tno teffect ton tthe tdigestion tof tfood. tA twarm
tstethoscope twilltdecrease tthe tpossibility tof tabdominal tmuscles tcontracting, teliminating tthe
tpossibility tof tthe tnurse thearing tany tunnecessary tnoises.
Page tRef: t31
Cognitive tLevel: t Applying
Client tNeed/Sub: t Health tPromotion tand tMaintenance
7
, Standards: t Nursing tProcess: tAssessment t| tLearning tOutcome: t1.4 t| tQSEN
tCompetencies:tPatient-Centered tCare
AACN tDomains tand tComps.: tDomain t2: tPerson-Centered
tCaretNLN tCompetencies: t Quality t& tSafety
8
