Test Bank for Clinical Nursing Skills:
p p p p p
A Concept-Based Approach
p p p
4th Edition Volume III
p p p
by Pearson Education Chapters 1 - 16
p p p p p p
,Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Pearson
p p p p p p p p p p p p
,Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Education Test
p p p p p p p p p
BankChapter 1: Assessment
p p p p
1) A client on the medical/surgical unit complains of sudden chest pains. Which action will
p p p p p p p p p p p p p
thenurse implement first?
p p p p
A) Call the healthcare provider. p p p
B) Administer pain medication. p p
C) Reassess a new set of vital signs. p p p p p p
D) Turn client from supine to p p p p
lateral.ANSWER: C
p p p
Explanation: A) The nurse will need to reassess the client first, before calling thep p p p p p p p p p p p p
healthcareprovider.
p p
B) The nurse will need to reassess the client first, before administering pain medication.
p p p p p p p p p p p p
C) The nurse needs to implement a new set of vital signs first when there is a change
p p p p p p p p p p p p p p p p
incondition.
p p
D) The nurse will need to reassess the client first, before moving the client, to avoid making
p p p p p p p p p p p p p p p
thechange in client's condition worse.
p p p p p p
Page Ref: 2 p p
Cognitive Level: Applying p p
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
p p p p p p p
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN p p p p p p p p p
Competencies:Patient-Centered Care
p p p
AACN Domains and Comps.: Domain 2: Person-Centered
p p p p p p
CareNLN Competencies: Relationship Centered Care
p p p p p p
2) The nurse is observing the UAP taking the temperature of an unconscious client. Which routewill
p p p p p p p p p p p p p p p
the nurse question the UAP using?
p p p p p p
A) Oral
B) Rectal
C) Scanner
D) Tympanic p
ANSWER:
A
p
Explanation: A) The temperature of an unconscious client is never taken by mouth. The
p p p p p p p p p p p p p
rectal,tympanic, or scanner method is preferred.
p p p p p p p
B) The rectal, tympanic, or scanner method is preferred.
p p p p p p p
C) The rectal, tympanic, or scanner method is preferred.
p p p p p p p
D) The rectal, tympanic, or scanner method is
p p p p p p
preferred.Page Ref: 24
p p p p
Cognitive Level: Applying p p
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards:
p pp p p p p p p p p p p
Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: SafetyAACN
p p p p p p p p p p p p
Domains and Comps.: Domain 5: Quality and Safety
p p p p p p p p
NLN Competencies: Quality & Safety
p p p p
1
, 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to
p p p p p p p p p p p p p p
touch.Which method should the nurse use to check the baby's temperature?
p p p p p p p p p p p p
A) Oral
B) Rectal
C) Axillary
D) Tympanic
membraneANSWER: C
p p p
Explanation: A) Oral is used for age 3 or older. p p p p p p p p p
B) The rectal route is the least desirable.
p p p p p p
C) The axillary route may not be as accurate as other routes for detecting fevers in children.
p p p p p p p p p p p p p p p
D) The tympanic membrane may be used for 3 months or
p p p p p p p p p
older.Page Ref: 29
p p p p
Cognitive Level: Applying p p
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
p p p p p p p
Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies:
p p p p p p p p p p
SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
p p p p p p p p p p
NLN Competencies: Quality & Safety
p p p p
4) A client comes in with exacerbation of chronic obstructive pulmonary disease (COPD).
p p p p p p p p p p p
Whichnoninvasive diagnostic test will the nurse implement to know that the client is receiving
p p p p p p p p p p p p p p p
enough oxygen?
p p
A) Chest x-ray p
B) Pulse oximeter p
C) Arterial blood gasses p p
D) Assessment of respiratory p p
rateANSWER: B
p p p
Explanation: A) A chest x-ray is not an intervention a nurse completes. p p p p p p p p p p p
B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen
p p p p p p p p p p p
saturation, in the blood and provides a pulse reading, which is especially helpful for the clientwith
p p p p p p p p p p p p p p p p p
a respiratory illness or disease.
p p p p p
C) Arterial blood gases are an invasive diagnostic test. p p p p p p p
D) Assessing a respiratory rate is important for the nurse to implement; however, it is not
p p p p p p p p p p p p p p
adiagnostic test.
p p p
Page Ref: 21 p p
Cognitive Level: Applying p p
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
p p p p p p p
Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN
p p p p p p p p p
Competencies:Informatics
p p
AACN Domains and Comps.: Domain 5: Quality and SafetyNLN
p p p p p p p p p
Competencies: Quality & Safety
p p p p
2
p p p p p
A Concept-Based Approach
p p p
4th Edition Volume III
p p p
by Pearson Education Chapters 1 - 16
p p p p p p
,Test Bank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Pearson
p p p p p p p p p p p p
,Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Education Test
p p p p p p p p p
BankChapter 1: Assessment
p p p p
1) A client on the medical/surgical unit complains of sudden chest pains. Which action will
p p p p p p p p p p p p p
thenurse implement first?
p p p p
A) Call the healthcare provider. p p p
B) Administer pain medication. p p
C) Reassess a new set of vital signs. p p p p p p
D) Turn client from supine to p p p p
lateral.ANSWER: C
p p p
Explanation: A) The nurse will need to reassess the client first, before calling thep p p p p p p p p p p p p
healthcareprovider.
p p
B) The nurse will need to reassess the client first, before administering pain medication.
p p p p p p p p p p p p
C) The nurse needs to implement a new set of vital signs first when there is a change
p p p p p p p p p p p p p p p p
incondition.
p p
D) The nurse will need to reassess the client first, before moving the client, to avoid making
p p p p p p p p p p p p p p p
thechange in client's condition worse.
p p p p p p
Page Ref: 2 p p
Cognitive Level: Applying p p
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
p p p p p p p
Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN p p p p p p p p p
Competencies:Patient-Centered Care
p p p
AACN Domains and Comps.: Domain 2: Person-Centered
p p p p p p
CareNLN Competencies: Relationship Centered Care
p p p p p p
2) The nurse is observing the UAP taking the temperature of an unconscious client. Which routewill
p p p p p p p p p p p p p p p
the nurse question the UAP using?
p p p p p p
A) Oral
B) Rectal
C) Scanner
D) Tympanic p
ANSWER:
A
p
Explanation: A) The temperature of an unconscious client is never taken by mouth. The
p p p p p p p p p p p p p
rectal,tympanic, or scanner method is preferred.
p p p p p p p
B) The rectal, tympanic, or scanner method is preferred.
p p p p p p p
C) The rectal, tympanic, or scanner method is preferred.
p p p p p p p
D) The rectal, tympanic, or scanner method is
p p p p p p
preferred.Page Ref: 24
p p p p
Cognitive Level: Applying p p
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards:
p pp p p p p p p p p p p
Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: SafetyAACN
p p p p p p p p p p p p
Domains and Comps.: Domain 5: Quality and Safety
p p p p p p p p
NLN Competencies: Quality & Safety
p p p p
1
, 3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to
p p p p p p p p p p p p p p
touch.Which method should the nurse use to check the baby's temperature?
p p p p p p p p p p p p
A) Oral
B) Rectal
C) Axillary
D) Tympanic
membraneANSWER: C
p p p
Explanation: A) Oral is used for age 3 or older. p p p p p p p p p
B) The rectal route is the least desirable.
p p p p p p
C) The axillary route may not be as accurate as other routes for detecting fevers in children.
p p p p p p p p p p p p p p p
D) The tympanic membrane may be used for 3 months or
p p p p p p p p p
older.Page Ref: 29
p p p p
Cognitive Level: Applying p p
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
p p p p p p p
Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies:
p p p p p p p p p p
SafetyAACN Domains and Comps.: Domain 5: Quality and Safety
p p p p p p p p p p
NLN Competencies: Quality & Safety
p p p p
4) A client comes in with exacerbation of chronic obstructive pulmonary disease (COPD).
p p p p p p p p p p p
Whichnoninvasive diagnostic test will the nurse implement to know that the client is receiving
p p p p p p p p p p p p p p p
enough oxygen?
p p
A) Chest x-ray p
B) Pulse oximeter p
C) Arterial blood gasses p p
D) Assessment of respiratory p p
rateANSWER: B
p p p
Explanation: A) A chest x-ray is not an intervention a nurse completes. p p p p p p p p p p p
B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen
p p p p p p p p p p p
saturation, in the blood and provides a pulse reading, which is especially helpful for the clientwith
p p p p p p p p p p p p p p p p p
a respiratory illness or disease.
p p p p p
C) Arterial blood gases are an invasive diagnostic test. p p p p p p p
D) Assessing a respiratory rate is important for the nurse to implement; however, it is not
p p p p p p p p p p p p p p
adiagnostic test.
p p p
Page Ref: 21 p p
Cognitive Level: Applying p p
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
p p p p p p p
Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN
p p p p p p p p p
Competencies:Informatics
p p
AACN Domains and Comps.: Domain 5: Quality and SafetyNLN
p p p p p p p p p
Competencies: Quality & Safety
p p p p
2
