Test Bank - Clinical Nursing Skills: A Concept-Based Approach, 4th Edition (Callahan, 2023) Chapter 1-16 | All Chapters Completely Covered.

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v AConcept-BasedApproach
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4thEditionVolume III
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byPearsonEducationChapters1-16
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,Test Bank for ClinicalNursing Skills: A Concept-Based Approach 4th Edition Pearson
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,Clinical Nursing Skills:A Concept-Based Approach, 4e (Pearson)Education Test BankChapter
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1: Assessment
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1) A client on the medical/surgical unit complains of sudden chest pains. Which action will
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thenurse implement first?
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A) Call the healthcare provider. v v v




B) Administerpain medication. v v




C) Reassess a new set of vital signs. v v v v v v




D) Turnclientfrom supineto v v v v




lateral.ANSWER: C
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Explanation: A) The nurse will need to reassess the client first, before calling the v v v v v v v v v v v v v




healthcareprovider.
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B) The nurse will need to reassess the client first, before administeringpain medication.
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C) The nurse needs to implement a new set of vital signs first when there is a change
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incondition.
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D) The nurse will need to reassess the client first, before movingthe client, to avoid making
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thechange in client's condition worse.
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Page Ref: 2 v v




Cognitive Level: Applying v v




Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN v v v v v v v v v




Competencies:Patient-Centered Care
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AACN Domains and Comps.: Domain 2: Person-Centered CareNLN
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Competencies: Relationship Centered Care
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2) The nurse is observing the UAP taking the temperature of an unconscious client. Which routewill
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the nurse question the UAP using?
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A) Oral
B) Rectal
C) Scanner
D) Tympanic v




ANSWER: A v




Explanation: A) The temperature of an unconscious client is never taken by mouth. The v v v v v v v v v v v v v




rectal,tympanic, or scanner method is preferred.
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B) The rectal, tympanic, or scanner method is preferred.
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C) The rectal, tympanic, or scanner method is preferred.
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D) Therectal, tympanic, or scanner method is v v v v v v




preferred.Page Ref: 24
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Cognitive Level: Applying v v




Client Need/Sub: Safe and Effective Care Environment: Safetyand Infection Control Standards:
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NursingProcess: Evaluation | Learning Outcome: 1.1 |QSEN Competencies: SafetyAACN Domains
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and Comps.: Domain 5: Quality and Safety
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NLN Competencies: Quality & Safety
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1

, 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to
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touch.Which method should the nurse use to check the baby's temperature?
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A) Oral
B) Rectal
C) Axillary
D) Tympanic
membraneANSWER: C
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Explanation: A)Oral is used for age 3 or older. v v v v v v v v v




B) The rectal route is the least desirable.
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C) The axillaryroute maynot be as accurate as other routes for detecting fevers in children.
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D) The tympanic membrane maybe used for 3 months or
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older.Page Ref: 29
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Cognitive Level: Applying v v




Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: NursingProcess: Evaluating | Learning Outcome: 1.2 | QSEN Competencies:
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SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
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NLN Competencies: Quality & Safety
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4) A client comes in with exacerbation of chronic obstructive pulmonarydisease (COPD).
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Whichnoninvasive diagnostic test will the nurse implement to know that the client is receiving
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enough oxygen?
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A) Chest x-ray v




B) Pulse oximeter v




C) Arterialblood gasses v v




D) Assessmentofrespiratory v v




rateANSWER: B
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Explanation: A)A chest x-rayis not an intervention a nurse completes. v v v v v v v v v v v




B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen
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saturation, in the blood and provides a pulse reading, which is especiallyhelpful for the clientwith
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a respiratoryillness or disease.
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C) Arterial blood gases are an invasive diagnostic test. v v v v v v v




D) Assessinga respiratory rate is important for the nurse to implement; however, it is not v v v v v v v v v v v v v v




adiagnostic test.
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Page Ref: 21 v v




Cognitive Level: Applying v v




Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
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Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN v v v v v v v v v




Competencies:Informatics
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AACN Domains and Comps.: Domain 5: Quality and SafetyNLN
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Competencies: Quality& Safety
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