,TestBank for Clinical Nursing Skills: A Concept-Based Approach 4th Edition Pearson
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Education
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Table of Contents
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Chapter1. Assessment
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Chapter2. Caring Interventions
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Chapter3. Comfort
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Chapter4. Elimination
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Chapter5. Fluids and Electrolytes
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Chapter6. Infection
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Chapter7. Intracranial Regulation
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Chapter8. Metabolism
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Chapter9. Mobility
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Chapter10. Nutrition
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Chapter11. Oxygenation
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Chapter12. Perfusion
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Chapter13. Perioperative Care
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Chapter14. Reproduction
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Chapter15. Safety
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Chapter16. Tissue Integrity
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,ClinicalNursingSkills:A Concept-Based Approach, 4e(Pearson)Education Test BankChapter
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1: Assessment
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1) Aclient on themedical/surgical unit complains of sudden chest pains. Which action will the
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nurse implement first?
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A) Call the healthcareprovider. r r r
B) Administerpain medication. r r
C) Reassess anew set of vital signs. r r r r r r
D) Turnclientfromsupinetolateral. r r r r r
Answer: C
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Explanation: A)Thenursewill need toreassess the client first, beforecallingthe healthcare r r r r r r r r r r r r r
provider.
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B) Thenursewill need to reassess the client first, before administering pain medication.
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C) Thenurseneeds to implement anewset ofvital signs first when thereis achangein
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condition.
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D) Thenursewill needto reassess theclient first, beforemovingthe client, to avoid makingthe
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change in client's condition worse.
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PageRef: 2 r r
Cognitive Level: Applying r
ClientNeed/Sub: Physiological Integrity: Reduction ofRisk Potential
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Standards: NursingProcess: Assessment |LearningOutcome: 1.1 |QSEN Competencies: r r r r r r rr r
Patient-Centered Care
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AACNDomainsandComps.: Domain2:Person-Centered Care
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NLN Competencies: Relationship Centered Care
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2) Thenurseis observingthe UAP takingthe temperatureofan unconscious client. Which routewill
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the nurse question the UAP using?
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A) Oral
B) Rectal
C) Scanner
D) Tympanic
Answer: A
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Explanation: A)Thetemperatureofanunconscious client is nevertaken bymouth. Therectal, tympanic,or r r r r r r r r r r r r r r r
scanner method is preferred.
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B) The rectal, tympanic, or scanner method is preferred.
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C) Therectal, tympanic, or scanner method is preferred.
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D) Therectal,tympanic,orscannermethodispreferred.
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Page Ref: 24
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Cognitive Level: Applying r
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards:
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Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: Safety AACN
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Domains and Comps.: Domain 5: Quality and Safety
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NLNCompetencies: Quality & Safety
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1
, 3) Thenurseis changinga2-month-old client's diaperand notesthe client feels warm to touch.
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Which method should the nurse use to check the baby's temperature?
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A) Oral
B) Rectal
C) Axillary
D) Tympanicmembrane
Answer: C
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Explanation: A)Oral is used for age 3 or older. r r r r r r r r
B) The rectal route is the least desirable.
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C) Theaxillaryroutemaynot be as accurate as other routes for detecting fevers in children.
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D) Thetympanicmembranemaybeusedfor3months or older.
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Page Ref: 29
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Cognitive Level: Applying r
ClientNeed/Sub: Physiological Integrity: Reduction ofRisk Potential
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Standards: NursingProcess: Evaluating |LearningOutcome: 1.2 |QSEN Competencies: Safety r r rr r r r r r r
AACN Domains and Comps.: Domain 5: Quality and Safety
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NLNCompetencies: Quality & Safety
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4) Aclient comesinwith exacerbation of chronic obstructivepulmonarydisease(COPD). Which
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noninvasive diagnostic test will the nurse implement to know that the client is receiving enough
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oxygen?
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A) Chest x-ray r
B) Pulseoximeter r
C) Arterialblood gasses r r
D) Assessmentofrespiratoryrate
Answer: B
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Explanation: A) A chest x-rayis not an intervention a nurse completes. r r r r r r r r r r
B) A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen
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saturation,intheblood and provides apulsereading, which is especiallyhelpful forthe clientwith
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a respiratory illness or disease.
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C) Arterial blood gases arean invasive diagnostic test. r r r r r r r
D) Assessingarespiratoryrate is important forthe nurseto implement; however, it is not a
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diagnostic test.
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PageRef: 21 r r
Cognitive Level: Applying r
ClientNeed/Sub: Physiological Integrity: Reduction ofRisk Potential
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Standards: NursingProcess: Implementation |LearningOutcome: 1.3 |QSENCompetencies: Informatics r r rr r r rr r r
AACNDomainsandComps.: Domain5:QualityandSafety
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NLN Competencies: Quality & Safety
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2
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