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