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