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 |method |should |the |nurse |use |to |check |the |baby's |temperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
|membrane|ANSWER: | 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
|rate|ANSWER: | 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
|client|with |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 |a|diagnostic |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 |Safety|NLN
|Competencies: | Quality |& |Safety
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 |method |should |the |nurse |use |to |check |the |baby's |temperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic
|membrane|ANSWER: | 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
|rate|ANSWER: | 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
|client|with |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 |a|diagnostic |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 |Safety|NLN
|Competencies: | Quality |& |Safety
2
