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 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
1
, 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch.
Which amethod ashould athe anurse ause ato acheck athe ababy's atemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
amembraneaANSWER:
aC
Explanation: a A) aOral ais aused afor aage a3 aor aolder.
B) The arectal aroute ais athe aleast adesirable.
C) The aaxillary aroute amay anot abe aas aaccurate aas aother aroutes afor adetecting afevers ain achildren.
D) The atympanic amembrane amay abe aused afor a3 amonths aor
aolder.aPage aRef: a29
Cognitive aLevel: a Applying
Client aNeed/Sub: a Physiological aIntegrity: aReduction aof aRisk aPotential
Standards: a Nursing aProcess: aEvaluating a| aLearning aOutcome: a1.2 a| aQSEN aCompetencies:
aSafetyaAACN aDomains aand aComps.: a Domain a5: aQuality aand aSafety
NLN aCompetencies: a Quality a& aSafety
4) A aclient acomes ain awith aexacerbation aof achronic aobstructive apulmonary adisease a(COPD).
aWhichanoninvasive adiagnostic atest awill athe anurse aimplement ato aknow athat athe aclient ais
areceiving aenough aoxygen?
A) Chest ax-ray
B) Pulse aoximeter
C) Arterial ablood agasses
D) Assessment aof arespiratory
arateaANSWER: a B
Explanation: a A) aA achest ax-ray ais anot aan aintervention aa anurse acompletes.
B) A apulse aoximeter aprovides aa anoninvasive amethod aof ameasuring aoxygenation, aor
aoxygen asaturation, ain athe ablood aand aprovides aa apulse areading, awhich ais aespecially
ahelpful afor athe aclientawith aa arespiratory aillness aor adisease.
C) Arterial ablood agases aare aan ainvasive adiagnostic atest.
D) Assessing aa arespiratory arate ais aimportant afor athe anurse ato aimplement; ahowever, ait
ais anot aaadiagnostic atest.
Page aRef: a21
Cognitive aLevel: a Applying
Client aNeed/Sub: a Physiological aIntegrity: aReduction aof aRisk aPotential
Standards: aNursing aProcess: aImplementation a| aLearning aOutcome: a1.3 a| aQSEN
aCompetencies:aInformatics
AACN aDomains aand aComps.: a Domain a5: aQuality aand aSafety
aNLN aCompetencies: a Quality a& aSafety
2
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 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
1
, 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch.
Which amethod ashould athe anurse ause ato acheck athe ababy's atemperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
amembraneaANSWER:
aC
Explanation: a A) aOral ais aused afor aage a3 aor aolder.
B) The arectal aroute ais athe aleast adesirable.
C) The aaxillary aroute amay anot abe aas aaccurate aas aother aroutes afor adetecting afevers ain achildren.
D) The atympanic amembrane amay abe aused afor a3 amonths aor
aolder.aPage aRef: a29
Cognitive aLevel: a Applying
Client aNeed/Sub: a Physiological aIntegrity: aReduction aof aRisk aPotential
Standards: a Nursing aProcess: aEvaluating a| aLearning aOutcome: a1.2 a| aQSEN aCompetencies:
aSafetyaAACN aDomains aand aComps.: a Domain a5: aQuality aand aSafety
NLN aCompetencies: a Quality a& aSafety
4) A aclient acomes ain awith aexacerbation aof achronic aobstructive apulmonary adisease a(COPD).
aWhichanoninvasive adiagnostic atest awill athe anurse aimplement ato aknow athat athe aclient ais
areceiving aenough aoxygen?
A) Chest ax-ray
B) Pulse aoximeter
C) Arterial ablood agasses
D) Assessment aof arespiratory
arateaANSWER: a B
Explanation: a A) aA achest ax-ray ais anot aan aintervention aa anurse acompletes.
B) A apulse aoximeter aprovides aa anoninvasive amethod aof ameasuring aoxygenation, aor
aoxygen asaturation, ain athe ablood aand aprovides aa apulse areading, awhich ais aespecially
ahelpful afor athe aclientawith aa arespiratory aillness aor adisease.
C) Arterial ablood agases aare aan ainvasive adiagnostic atest.
D) Assessing aa arespiratory arate ais aimportant afor athe anurse ato aimplement; ahowever, ait
ais anot aaadiagnostic atest.
Page aRef: a21
Cognitive aLevel: a Applying
Client aNeed/Sub: a Physiological aIntegrity: aReduction aof aRisk aPotential
Standards: aNursing aProcess: aImplementation a| aLearning aOutcome: a1.3 a| aQSEN
aCompetencies:aInformatics
AACN aDomains aand aComps.: a Domain a5: aQuality aand aSafety
aNLN aCompetencies: a Quality a& aSafety
2
