TEST BANK
CLINICAL NURSING SKILLS:
A Concept-Based Approach
4th Edition, Pearson Education
SO
LU
TI
O
N
S
TEST BANK
,Table of Contents
Chapter 1. Assessment
Chapter 2. Caring Interventions
Chapter 3. Comfort
Chapter 4. Elimination
Chapter 5. Fluids and Electrolytes
Chapter 6. Infection
Chapter 7. Intracranial Regulation
Chapter 8. Metabolism
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Chapter 9. Mobility
Chapter 10. Nutrition
Chapter 11. Oxygenation
Chapter 12. Perfusion
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Chapter 13. Perioperative Care
Chapter 14. Reproduction
Chapter 15. Safety
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Chapter 16. Tissue Integrity
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N
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,Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Education
Complete 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.
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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
LU
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
TI
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?
O
A) Oral
B) Rectal
C) Scanner
N
D) Tympanic
Answer: A
Explanation: A) The temperature of an unconscious client is never taken by mouth. The rectal,
S
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
SO
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
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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
TI
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
O
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.
N
D) Assessing a respiratory rate is important for the nurse to implement; however, it is not a
diagnostic test.
Page Ref: 21
S
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
CLINICAL NURSING SKILLS:
A Concept-Based Approach
4th Edition, Pearson Education
SO
LU
TI
O
N
S
TEST BANK
,Table of Contents
Chapter 1. Assessment
Chapter 2. Caring Interventions
Chapter 3. Comfort
Chapter 4. Elimination
Chapter 5. Fluids and Electrolytes
Chapter 6. Infection
Chapter 7. Intracranial Regulation
Chapter 8. Metabolism
SO
Chapter 9. Mobility
Chapter 10. Nutrition
Chapter 11. Oxygenation
Chapter 12. Perfusion
LU
Chapter 13. Perioperative Care
Chapter 14. Reproduction
Chapter 15. Safety
TI
Chapter 16. Tissue Integrity
O
N
S
,Clinical Nursing Skills: A Concept-Based Approach, 4e (Pearson) Education
Complete 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.
SO
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
LU
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
TI
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?
O
A) Oral
B) Rectal
C) Scanner
N
D) Tympanic
Answer: A
Explanation: A) The temperature of an unconscious client is never taken by mouth. The rectal,
S
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
SO
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
LU
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
TI
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
O
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.
N
D) Assessing a respiratory rate is important for the nurse to implement; however, it is not a
diagnostic test.
Page Ref: 21
S
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
