Test Bank for Clinical Nursing Skills:
ii gii gii gii ii
A Concept-Based Approach
ii gii ii
4th Edition Volume III ii ii ii
by Pearson Education Chapters 1 - 16
gii ii gii ii gii gii
,Testg Bankg forgClinicalgNursingg Skills:g Ag Concept-
Basedg Approachg 4thg EditiongPearsonii
,Clinicalg Nursingg Skills:gAg Concept-
Basedg Approach,g 4eg (Pearson)gEducationg TestgBankiiChapterg 1:g Assessment
1) Ag clientg ong theg medical/surgicalg unitg complainsg ofg suddeng chestg pains.g Whichg actio
ngwillg theiinurseg implementg first?
A) Callg theg healthcareg provider.
B) Administerg paing medication.
C) Reassessg ag newg setg ofg vitalg signs.
D) Turngclientgfromgsupinegtog
lateral.iiANSWER:g C
Explanation:g A)g Theg nurseg willg needg tog reassessg theg clientg first,g beforeg callingg theghealt
hcareprovider.
B) Theg nurseg willg needg tog reassessg theg clientg first,g beforeg administeringg paing medication.
C) Theg nurseg needsg tog implementg ag newg setg ofg vitalg signsg firstg wheng thereg isg
agchangeg iniicondition.
D) Theg nurseg willg needg tog reassessg theg clientg first,g beforeg movingg theg client,g tog avoi
dgmakinggtheiichangeg ing client'sg conditiong worse.
Pageg Ref:g 2
Cognitiveg Level: Applying
Clientg Need/Sub:
Physiologicalg Integrity:g Reductiong ofgRiskg PotentialgS
tandards:g Nursingg Process:g Assessmentg |g Learningg Outcome:g 1.1g |g QSENg
Competencies:Patient-Centeredg Care
AACNg Domainsg andg Comps.:g Domaing 2:g Person-
CenteredgCareiiNLNg Competencies:g Relationshipg Centeredg Car
e
2) Theg nurseg isg observingg theg UAPg takingg theg temperatureg ofg ang unconsciousg client
.gWhichg routeiiwillg theg nurseg questiong theg UAPg using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
iiANSWER:
A
Explanation:g A)g Theg temperatureg ofg ang unconsciousg clientg isg neverg takeng byg mouth.g Th
egrectal,tympanic,g org scannerg methodg isg preferred.
B) Theg rectal,g tympanic,g org scannerg methodg isg preferred.
C) Theg rectal,g tympanic,g org scannerg methodg isg preferred.
D) Thegrectal,gtympanic,g orgscannerg methodgisg
preferred.Pageg Ref:g 24
Cognitiveg Level: Applying
Clientg Need/Sub:
Safeg andg Effectiveg CaregEnvironment:g Safetygandg Infectiong Controlg
Standards:g NursinggProcess:g Evaluationg |g Learningg Outcome:g 1.1g |gQSENg Competencies:
gSafetyAACNg Domainsg andg Comps.:g Domaing 5:g Qualityg andg Safety
NLNg Competencies: Qualityg &g Safety
1
, 3) Theg nurseg isg changingg ag 2-month-
oldg client'sg diaperg andg notesg theg clientg feelsg warmg togtouch.Whichg methodg shouldg theg n
urseg useg tog checkg theg baby'sg temperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanicgmembra
neiiANSWER:
C
Explanation: A)g Oralg isg usedg forg ageg 3g org older.
B) Theg rectalg routeg isg theg leastg desirable.
C) Theg axillaryg routeg mayg notg beg asg accurateg asg otherg routesg forg detectingg feversg ing children.
D) Thegtympanicg membraneg maygbeg usedg forg3g monthsg or
golder.Pageg Ref:g 29
Cognitiveg Level: Applying
Clientg Need/Sub: Physiologicalg Integrity:g Reductiong ofg Riskg Potential
Standards:g Nursingg Process:g Evaluatingg |g Learningg Outcome:g 1.2g |g QSENg Competencies:
gSafetyAACNg Domainsg andg Comps.:g Domaing 5:g Qualityg andg Safety
NLNg Competencies: Qualityg &g Safety
4) Ag clientg comesg ing withg exacerbationg ofg chronicg obstructiveg pulmonarygdiseaseg (COPD
).gWhichiinoninvasiveg diagnosticg testg willg theg nurseg implementg tog knowg thatg theg clientg is
greceivingg enoughg oxygen?
A) Chestg x-ray
B) Pulseg oximeter
C) Arterialg bloodg gasses
D) Assessmentgofgrespiratory
grateiiANSWER:g B
Explanation:g g g A)g Ag chestg x-rayg isg notg ang interventiong ag nurseg completes.
B) Agpulsegoximetergprovidesgagnoninvasivegmethodgofgmeasuringgoxygenation,gorgox
ygengsaturation,gingthegbloodgandgprovidesgagpulsegreading,gwhichgisgespeciallyghelpfu
lg forg theg clientiiwithg ag respiratorygillnessg org disease.
C) Arterialg bloodg gasesg areg ang invasiveg diagnosticg test.
D) Assessingg ag respiratoryg rateg isg importantg forg theg nurseg tog implement;g however,g i
tgisg notg aiidiagnosticg test.
Pageg Ref:g 21
Cognitiveg Level: Applying
Clientg Need/Sub:
Physiologicalg Integrity:g Reductiong ofgRiskg PotentialgStand
ards:g Nursingg Process:g Implementationg |g Learningg Outcome:g 1.3g |g QSENgCo
mpetencies:Informatics
AACNg Domainsg andg Comps.:g Domaing 5:g Qualitygandg Safetyg
NLNg Competencies:g Qualityg&g Safety
2
ii gii gii gii ii
A Concept-Based Approach
ii gii ii
4th Edition Volume III ii ii ii
by Pearson Education Chapters 1 - 16
gii ii gii ii gii gii
,Testg Bankg forgClinicalgNursingg Skills:g Ag Concept-
Basedg Approachg 4thg EditiongPearsonii
,Clinicalg Nursingg Skills:gAg Concept-
Basedg Approach,g 4eg (Pearson)gEducationg TestgBankiiChapterg 1:g Assessment
1) Ag clientg ong theg medical/surgicalg unitg complainsg ofg suddeng chestg pains.g Whichg actio
ngwillg theiinurseg implementg first?
A) Callg theg healthcareg provider.
B) Administerg paing medication.
C) Reassessg ag newg setg ofg vitalg signs.
D) Turngclientgfromgsupinegtog
lateral.iiANSWER:g C
Explanation:g A)g Theg nurseg willg needg tog reassessg theg clientg first,g beforeg callingg theghealt
hcareprovider.
B) Theg nurseg willg needg tog reassessg theg clientg first,g beforeg administeringg paing medication.
C) Theg nurseg needsg tog implementg ag newg setg ofg vitalg signsg firstg wheng thereg isg
agchangeg iniicondition.
D) Theg nurseg willg needg tog reassessg theg clientg first,g beforeg movingg theg client,g tog avoi
dgmakinggtheiichangeg ing client'sg conditiong worse.
Pageg Ref:g 2
Cognitiveg Level: Applying
Clientg Need/Sub:
Physiologicalg Integrity:g Reductiong ofgRiskg PotentialgS
tandards:g Nursingg Process:g Assessmentg |g Learningg Outcome:g 1.1g |g QSENg
Competencies:Patient-Centeredg Care
AACNg Domainsg andg Comps.:g Domaing 2:g Person-
CenteredgCareiiNLNg Competencies:g Relationshipg Centeredg Car
e
2) Theg nurseg isg observingg theg UAPg takingg theg temperatureg ofg ang unconsciousg client
.gWhichg routeiiwillg theg nurseg questiong theg UAPg using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
iiANSWER:
A
Explanation:g A)g Theg temperatureg ofg ang unconsciousg clientg isg neverg takeng byg mouth.g Th
egrectal,tympanic,g org scannerg methodg isg preferred.
B) Theg rectal,g tympanic,g org scannerg methodg isg preferred.
C) Theg rectal,g tympanic,g org scannerg methodg isg preferred.
D) Thegrectal,gtympanic,g orgscannerg methodgisg
preferred.Pageg Ref:g 24
Cognitiveg Level: Applying
Clientg Need/Sub:
Safeg andg Effectiveg CaregEnvironment:g Safetygandg Infectiong Controlg
Standards:g NursinggProcess:g Evaluationg |g Learningg Outcome:g 1.1g |gQSENg Competencies:
gSafetyAACNg Domainsg andg Comps.:g Domaing 5:g Qualityg andg Safety
NLNg Competencies: Qualityg &g Safety
1
, 3) Theg nurseg isg changingg ag 2-month-
oldg client'sg diaperg andg notesg theg clientg feelsg warmg togtouch.Whichg methodg shouldg theg n
urseg useg tog checkg theg baby'sg temperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanicgmembra
neiiANSWER:
C
Explanation: A)g Oralg isg usedg forg ageg 3g org older.
B) Theg rectalg routeg isg theg leastg desirable.
C) Theg axillaryg routeg mayg notg beg asg accurateg asg otherg routesg forg detectingg feversg ing children.
D) Thegtympanicg membraneg maygbeg usedg forg3g monthsg or
golder.Pageg Ref:g 29
Cognitiveg Level: Applying
Clientg Need/Sub: Physiologicalg Integrity:g Reductiong ofg Riskg Potential
Standards:g Nursingg Process:g Evaluatingg |g Learningg Outcome:g 1.2g |g QSENg Competencies:
gSafetyAACNg Domainsg andg Comps.:g Domaing 5:g Qualityg andg Safety
NLNg Competencies: Qualityg &g Safety
4) Ag clientg comesg ing withg exacerbationg ofg chronicg obstructiveg pulmonarygdiseaseg (COPD
).gWhichiinoninvasiveg diagnosticg testg willg theg nurseg implementg tog knowg thatg theg clientg is
greceivingg enoughg oxygen?
A) Chestg x-ray
B) Pulseg oximeter
C) Arterialg bloodg gasses
D) Assessmentgofgrespiratory
grateiiANSWER:g B
Explanation:g g g A)g Ag chestg x-rayg isg notg ang interventiong ag nurseg completes.
B) Agpulsegoximetergprovidesgagnoninvasivegmethodgofgmeasuringgoxygenation,gorgox
ygengsaturation,gingthegbloodgandgprovidesgagpulsegreading,gwhichgisgespeciallyghelpfu
lg forg theg clientiiwithg ag respiratorygillnessg org disease.
C) Arterialg bloodg gasesg areg ang invasiveg diagnosticg test.
D) Assessingg ag respiratoryg rateg isg importantg forg theg nurseg tog implement;g however,g i
tgisg notg aiidiagnosticg test.
Pageg Ref:g 21
Cognitiveg Level: Applying
Clientg Need/Sub:
Physiologicalg Integrity:g Reductiong ofgRiskg PotentialgStand
ards:g Nursingg Process:g Implementationg |g Learningg Outcome:g 1.3g |g QSENgCo
mpetencies:Informatics
AACNg Domainsg andg Comps.:g Domaing 5:g Qualitygandg Safetyg
NLNg Competencies:g Qualityg&g Safety
2
