Test Bank for Clinical Nursing Skills:
ii ii
m ii
m mii ii
A Concept-Based Approach
ii ii
m ii
4th Edition Volume III
ii ii ii
by Pearson Education Chapters 1 - 16
mii ii mi i ii mi i mii
,Testm Bankm formClinicalmNursingm Skills:m Am Concept-
Basedm Approachm 4thm EditionmPearsonii
,Clinicalm Nursingm Skills:m Am Concept-
Basedm Approach,m 4em (Pearson)mEducationm TestmBankiiChapterm 1:m Assessment
1) A m client m onm them medical/surgicalm unit m complainsm of m suddenm chest m pains.m Whichm acti
onmwillm theiinursem implement m first?
A) Callm them healthcarem provider.
B) Administerm painm medication.
C) Reassessm am new m set m of m vitalm signs.
D) Turnmclient mfrommsupinemto
mlateral.iiANSWER:m C
Explanation:m A)m Them nursem willm need m tom reassessm them client m first,m beforem callingm themheal
thcareprovider.
B) Them nursem willm need m tom reassessm them client m first,m beforem administeringm painm medication.
C) Them nursem needsm tom implement m am new m set m of m vitalm signsm first m whenm therem is
m amchangem iniicondition.
D) Them nursem willm need m tom reassessm them client m first,m beforem movingm them client,m tom avo
id mmakingmtheiichangem inm client'sm conditionm worse.
Pagem Ref:m 2
Cognitivem Level: Applying
Client m Need/Sub:
Physiologicalm Integrity:m Reductionm of mRiskm Potentialm
Standards:m Nursingm Process:m Assessment m |m Learningm Outcome:m 1.1m |m QSE
NmCompetencies:Patient-Centered m Care
AACN m Domainsm and m Comps.:m Domainm 2:m Person-
Centered mCareiiNLN m Competencies:m Relationshipm Centered m Car
e
2) Them nursem ism observingm them UAPm takingm them temperaturem of m anm unconsciousm clie
nt.mWhichm routeiiwillm them nursem questionm them UAPm using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
iiANSWER:
A
Explanation:m A)m Them temperaturem of m anm unconsciousm client m ism neverm takenm bym mouth.m T
hemrectal,tympanic,m orm scannerm method m ism preferred.
B) Them rectal,m tympanic,m orm scannerm method m ism preferred.
C) Them rectal,m tympanic,m orm scannerm method m ism preferred.
D) Themrectal,mtympanic,m ormscannerm method mis
mpreferred.Pagem Ref:m 24
Cognitivem Level: Applying
Client m Need/Sub:
Safem and m Effectivem CaremEnvironment:m Safetymand m Infectionm Controlm
Standards:m NursingmProcess:m Evaluationm |m Learningm Outcome:m 1.1m |mQSEN m Competencies
:mSafetyAACN m Domainsm and m Comps.:m Domainm 5:m Qualitym and m Safety
NLN m Competencies: Qualitym &m Safety
1
, 3) Them nursem ism changingm am 2-month-
old m client'sm diaperm and m notesm them client m feelsm warmm tomtouch.Whichm method m should m them
nursem usem tom checkm them baby'sm temperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanicmmembra
neiiANSWER:
C
Explanation: A)m Oralm ism used m form agem 3m orm older.
B) Them rectalm routem ism them least m desirable.
C) Them axillarym routem maym not m bem asm accuratem asm otherm routesm form detectingm feversm inm children.
D) Themtympanicm membranem maymbem used m form3m monthsm o
rmolder.Pagem Ref:m 29
Cognitivem Level: Applying
Client m Need/Sub: Physiologicalm Integrity:m Reductionm of m Riskm Potential
Standards:m Nursingm Process:m Evaluatingm |m Learningm Outcome:m 1.2m |m QSEN m Competencies
:mSafetyAACN m Domainsm and m Comps.:m Domainm 5:m Qualitym and m Safety
NLN m Competencies: Qualitym &m Safety
4) A m client m comesm inm withm exacerbationm of m chronicm obstructivem pulmonarymdiseasem (COP
D).mWhichiinoninvasivem diagnosticm test m willm them nursem implement m tom know m that m them client
m ismreceivingm enoughm oxygen?
A) Chest m x-ray
B) Pulsem oximeter
C) Arterialm blood m gasses
D) Assessment mof mrespiratory
mrateiiANSWER:m B
Explanation:m m m A)m Am chest m x-raym ism not m anm interventionm am nursem completes.
B) A mpulsemoximetermprovidesmamnoninvasivemmethod mof mmeasuringmoxygenation,mormo
xygenmsaturation,minmthemblood mand mprovidesmampulse mreading,mwhichmismespeciallymhel
pfulm form them client iiwithm am respiratorymillnessm orm disease.
C) Arterialm blood m gasesm arem anm invasivem diagnosticm test.
D) Assessingm am respiratorym ratem ism important m form them nursem tom implement;m however,
m it mism not m aiidiagnosticm test.
Pagem Ref:m 21
Cognitivem Level: Applying
Client m Need/Sub:
Physiologicalm Integrity:m Reductionm of mRiskm PotentialmStan
dards:m Nursingm Process:m Implementationm |m Learningm Outcome:m 1.3m |m QSEN mC
ompetencies:Informatics
AACN m Domainsm and m Comps.:m Domainm 5:m Qualitymand m Safetym
NLN m Competencies:m Qualitym&m Safety
2
ii ii
m ii
m mii ii
A Concept-Based Approach
ii ii
m ii
4th Edition Volume III
ii ii ii
by Pearson Education Chapters 1 - 16
mii ii mi i ii mi i mii
,Testm Bankm formClinicalmNursingm Skills:m Am Concept-
Basedm Approachm 4thm EditionmPearsonii
,Clinicalm Nursingm Skills:m Am Concept-
Basedm Approach,m 4em (Pearson)mEducationm TestmBankiiChapterm 1:m Assessment
1) A m client m onm them medical/surgicalm unit m complainsm of m suddenm chest m pains.m Whichm acti
onmwillm theiinursem implement m first?
A) Callm them healthcarem provider.
B) Administerm painm medication.
C) Reassessm am new m set m of m vitalm signs.
D) Turnmclient mfrommsupinemto
mlateral.iiANSWER:m C
Explanation:m A)m Them nursem willm need m tom reassessm them client m first,m beforem callingm themheal
thcareprovider.
B) Them nursem willm need m tom reassessm them client m first,m beforem administeringm painm medication.
C) Them nursem needsm tom implement m am new m set m of m vitalm signsm first m whenm therem is
m amchangem iniicondition.
D) Them nursem willm need m tom reassessm them client m first,m beforem movingm them client,m tom avo
id mmakingmtheiichangem inm client'sm conditionm worse.
Pagem Ref:m 2
Cognitivem Level: Applying
Client m Need/Sub:
Physiologicalm Integrity:m Reductionm of mRiskm Potentialm
Standards:m Nursingm Process:m Assessment m |m Learningm Outcome:m 1.1m |m QSE
NmCompetencies:Patient-Centered m Care
AACN m Domainsm and m Comps.:m Domainm 2:m Person-
Centered mCareiiNLN m Competencies:m Relationshipm Centered m Car
e
2) Them nursem ism observingm them UAPm takingm them temperaturem of m anm unconsciousm clie
nt.mWhichm routeiiwillm them nursem questionm them UAPm using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic
iiANSWER:
A
Explanation:m A)m Them temperaturem of m anm unconsciousm client m ism neverm takenm bym mouth.m T
hemrectal,tympanic,m orm scannerm method m ism preferred.
B) Them rectal,m tympanic,m orm scannerm method m ism preferred.
C) Them rectal,m tympanic,m orm scannerm method m ism preferred.
D) Themrectal,mtympanic,m ormscannerm method mis
mpreferred.Pagem Ref:m 24
Cognitivem Level: Applying
Client m Need/Sub:
Safem and m Effectivem CaremEnvironment:m Safetymand m Infectionm Controlm
Standards:m NursingmProcess:m Evaluationm |m Learningm Outcome:m 1.1m |mQSEN m Competencies
:mSafetyAACN m Domainsm and m Comps.:m Domainm 5:m Qualitym and m Safety
NLN m Competencies: Qualitym &m Safety
1
, 3) Them nursem ism changingm am 2-month-
old m client'sm diaperm and m notesm them client m feelsm warmm tomtouch.Whichm method m should m them
nursem usem tom checkm them baby'sm temperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanicmmembra
neiiANSWER:
C
Explanation: A)m Oralm ism used m form agem 3m orm older.
B) Them rectalm routem ism them least m desirable.
C) Them axillarym routem maym not m bem asm accuratem asm otherm routesm form detectingm feversm inm children.
D) Themtympanicm membranem maymbem used m form3m monthsm o
rmolder.Pagem Ref:m 29
Cognitivem Level: Applying
Client m Need/Sub: Physiologicalm Integrity:m Reductionm of m Riskm Potential
Standards:m Nursingm Process:m Evaluatingm |m Learningm Outcome:m 1.2m |m QSEN m Competencies
:mSafetyAACN m Domainsm and m Comps.:m Domainm 5:m Qualitym and m Safety
NLN m Competencies: Qualitym &m Safety
4) A m client m comesm inm withm exacerbationm of m chronicm obstructivem pulmonarymdiseasem (COP
D).mWhichiinoninvasivem diagnosticm test m willm them nursem implement m tom know m that m them client
m ismreceivingm enoughm oxygen?
A) Chest m x-ray
B) Pulsem oximeter
C) Arterialm blood m gasses
D) Assessment mof mrespiratory
mrateiiANSWER:m B
Explanation:m m m A)m Am chest m x-raym ism not m anm interventionm am nursem completes.
B) A mpulsemoximetermprovidesmamnoninvasivemmethod mof mmeasuringmoxygenation,mormo
xygenmsaturation,minmthemblood mand mprovidesmampulse mreading,mwhichmismespeciallymhel
pfulm form them client iiwithm am respiratorymillnessm orm disease.
C) Arterialm blood m gasesm arem anm invasivem diagnosticm test.
D) Assessingm am respiratorym ratem ism important m form them nursem tom implement;m however,
m it mism not m aiidiagnosticm test.
Pagem Ref:m 21
Cognitivem Level: Applying
Client m Need/Sub:
Physiologicalm Integrity:m Reductionm of mRiskm PotentialmStan
dards:m Nursingm Process:m Implementationm |m Learningm Outcome:m 1.3m |m QSEN mC
ompetencies:Informatics
AACN m Domainsm and m Comps.:m Domainm 5:m Qualitymand m Safetym
NLN m Competencies:m Qualitym&m Safety
2
