Pearson Education, Inc. Clinical Nursing Skills: A Concept-Based Approach, 3e

Clinical Nursing Skills: A Concept-Based Approach, 3e

Chapter 1 Assessment 1) A client on the medical/surgical unit complains of sudden chest pains. Which is the first action the nurse will implement?

• Call the health care provider.
• Administer pain medication.
• Reassess a new set of vital signs.
• Turn client from supine to lateral.

Answer: C

Explanation: A) The nurse will need to reassess the client first, before calling the healthcare provider.

• The nurse will need to reassess the client first, before administering pain medication.
• The nurse needs to implement a new set of vital signs first when there is a change in

condition.

• 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: 3

Cognitive Level: Applying

Client Need/Sub: Reduction of Risk Potential: System Specific Assessments Standards: Nursing Process: Implementation | Learning Outcome: 1.1 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice

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?

• Oral
• Rectal
• Scanner
• Tympanic

Answer: A

Explanation: A) The temperature of an unconscious client is never taken by mouth. The rectal, tympanic, or scanner method is preferred.

• The rectal, tympanic, or scanner method is preferred.
• The rectal, tympanic, or scanner method is preferred.
• The rectal, tympanic, or scanner method is preferred.

Page Ref: 24

Cognitive Level: Remembering

Client Need/Sub: Management of Care: Assignment, Delegation, and Supervision Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice

NLN Competencies: Quality and Safety

Clinical Nursing Skills A Concept-Based Approach, 3e Barbara Callahan (Test Bank, All Chapters 100% Original Verified, A+ Grade)

2 Copyright © 2019 Pearson Education, Inc.3) The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch.Which is the best method for checking this baby's temperature?

• Oral
• Rectal
• Axillary
• Tympanic membrane

Answer: C

Explanation: A) Oral is used for age 3 or older.

• The rectal route is the least desirable.
• The tympanic membrane route may be more accurate in determining temperature in febrile

newborns or infants.

• The tympanic membrane may be used for 3 months or older.

Page Ref: 29

Cognitive Level: Understanding

Client Need/Sub: Reduction of Risk Potential: Diagnostic Tests Standards: Nursing Process: Evaluating | Learning Outcome: 1.2 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice

NLN Competencies: Quality and Safety

4) A client comes in with exacerbation of chronic obstructive pulmonary disease (COPD). Which noninvasive diagnostic test will the nurse implement to know that the client is receiving enough oxygen?

• Chest x-ray
• Pulse oximeter
• Arterial blood gasses
• Assessment of respiratory rate

Answer: B

Explanation: A) A chest x-ray is not an intervention a nurse completes.

• A pulse oximeter provides a noninvasive method of measuring oxygenation, or oxygen

saturation, in the blood and provides a pulse reading, which is especially helpful for the client with a respiratory illness or disease.

• Arterial blood gases are an invasive diagnostic test.
• Assessing a respiratory rate is important for the nurse to implement; however, it is not a

diagnostic test.

Page Ref: 21

Cognitive Level: Applying

Client Need/Sub: Reduction of Risk Potential: Diagnostic Tests Standards: Nursing Process: Implementation | Learning Outcome: 1.3 | QSEN Competencies: Informatics AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice

NLN Competencies: Quality and Safety

3 Copyright © 2019 Pearson Education, Inc.5) Which is the most important question the nurse should ask a client before performing a routine musculoskeletal assessment?

• "Do you exercise every day?"
• "Do you have a history of any sports injuries?"
• "Do you take a hot bath to relax your muscles?"
• "Do you want pain medication before I begin?"

Answer: B

Explanation: A) Knowing if a client exercises is an important question but knowing if there are any sports injuries to know about first, is most important before doing a routine musculoskeletal assessment.

• It is important to note if the client has a history of any sports injuries first to know what the

client will or will not be able to do during a routine musculoskeletal assessment.

• Knowing if the client takes a hot bath to relax the muscles is not the most important to ask

before performing a routine musculoskeletal assessment.

• To know if a client is experiencing any pain is an important question; however, this question

is assuming the client is in pain by asking if the client wants a pain medication before beginning a routine musculoskeletal assessment.

Page Ref: 62

Cognitive Level: Analyzing

Client Need/Sub: Safety and Infection Control: Accident/Error/Injury Prevention Standards: Nursing Process: Assessment | Learning Outcome: 1.5 | QSEN Competencies: Safety AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice

NLN Competencies: Quality and Safety

6) A client's daughter mentions to the nurse that her mom seems to have a decline in mental status and seems to be forgetting many things in their conversation since this hospitalization.Which is the best response by the nurse?

• "Give your mom time, because it will take her a little longer when answering questions."
• "Let me check the cranial nerve function to see if there is a defect in her mental status."
• "You do not need to worry. This decline is part of the normal process of aging."
• "If you bring some things from her home, it might reduce the confusion."

Answer: D

Explanation: A) This is expected to give some older adults time to respond, but the daughter is concerned about her forgetting, not the length of the response.

• Cranial nerve function is an assessment of the cranial nerves and not the mental status of a

client.

• A decline in mental status is not a normal result of aging, so this response is not true.
• The stress of being in unfamiliar situations can cause confusion in some older adults.

Page Ref: 68

Cognitive Level: Analyzing

Client Need/Sub: Psychosocial Integrity: Therapeutic Environment Standards: Nursing Process: Planning | Learning Outcome: 1.6 | QSEN Competencies: Patient- Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice

NLN Competencies: Context and Environment

4 Copyright © 2019 Pearson Education, Inc.7) The nurse coming on duty received in report that the client's lung sounds were clear to auscultation in all lobes. The nurse coming on heard moderate-intensity and moderate-pitch "blowing" sounds between the scapulae and lateral to the sternum at the first and second intercostal spaces when doing her own assessment. Which should the nurse do next?

• Encourage the client to cough and deep breathe.
• Notify the healthcare provider of abnormal breath sounds.
• Document assessment findings as normal breath sounds.
• Raise the head of the bed to allow maximum air excursion.

Answer: C

Explanation: A) The nurse would implement this if these were adventitious lung sounds; however, these are bronchovesicular sounds.

• The nurse would notify the healthcare provider if these were adventitious lung sounds;

however, these are bronchovesicular sounds.

• This is correct, because these are bronchovesicular sounds.
• The nurse would implement this if these were adventitious lung sounds; however, these are

bronchovesicular sounds.

Page Ref: 88

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.7 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice

NLN Competencies: Context and Environment

8) A new client came to the clinic complaining of shortness of breath and fever. How long should the triage nurse count the peripheral pulse?

• 15 seconds
• 30 seconds
• 1 minute
• 2 minutes

Answer: C

Explanation: A) Count for a full minute if taking a client's pulse for the first time.

• Count for a full minute if taking a client's pulse for the first time.
• Count for a full minute if taking a client's pulse for the first time.
• Count for a full minute if taking a client's pulse for the first time.

Page Ref: 19

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: Nursing Process: Assessment | Learning Outcome: 1.8 | QSEN Competencies: Patient-Centered Care AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice

NLN Competencies: Quality and Safety