1) A5client5on5the5medical/surgical5unit5complains5of5sudden5chest5pains.5Which5action5will5t
he5nurse5implement5first?
A) Call5the5healthcare5provider.
B) Administer5pain5medication.
C) Reassess5a5new5set5of5vital5signs.
D) Turn5client5from5supine5to5lateral
.5ANSWER:5 C
Explanation:5A)5The5nurse5will5need5to5reassess5the5client5first,5before5calling5the5healthcar
e5provider.
B) The5nurse5will5need5to5reassess5the5client5first,5before5administering5pain5medication.
C) The5nurse5needs5to5implement5a5new5set5of5vital5signs5first5when5there5is5a5change
5in5condition.
2) The5nurse5is5observing5the5UAP5taking5the5temperature5of5an5unconscious5client.5Which5rou
te5will5the5nurse5question5the5UAP5using?
A) Oral
B) Rectal
C) Scanner
D) Tympanic5
ANSWER:5 A
Explanation:5A)5The5temperature5of5an5unconscious5client5is5never5taken5by5mouth.5The5rectal,5
tympanic,5or5scanner5method5is5preferred.
B) The5rectal,5tympanic,5or5scanner5method5is5preferred.
C) The5rectal,5tympanic,5or5scanner5method5is5preferred.
D) The5rectal,5tympanic,5or5scanner5method5is5preferre
d.5Page5Ref:524
Cognitive5Level:5 Applying
Client5Need/Sub:555 Safe5and5Effective5Care5Environment:5Safety5and5Infection5Control5Standard
s:5 Nursing5Process:5Evaluation5|5Learning5Outcome:51.15|5QSEN5Competencies:5Safety5AACN5Do
mains5and5Comps.:5 Domain55:5Quality5and5Safety
NLN5Competencies:5 Quality5&5Safety
1
, 3) The5nurse5is5changing5a52-month-
old5client's5diaper5and5notes5the5client5feels5warm5to5touch.5Which5method5should5the5nurse5
use5to5check5the5baby's5temperature?
A) Oral
B) Rectal
C) Axillary
D) Tympanic5membran
e5ANSWER:5 C
Explanation:5 A)5Oral5is5used5for5age535or5older.
B) The5rectal5route5is5the5least5desirable.
C) The5axillary5route5may5not5be5as5accurate5as5other5routes5for5detecting5fevers5in5children.
D) The5tympanic5membrane5may5be5used5for535months5or5old
er.5Page5Ref:529
Cognitive5Level:5 Applying
Client5Need/Sub:5 Physiological5Integrity:5Reduction5of5Risk5Potential
Standards:5 Nursing5Process:5Evaluating5|5Learning5Outcome:51.25|5QSEN5Competencies:5Safety5
AACN5Domains5and5Comps.:5 Domain55:5Quality5and5Safety
NLN5Competencies:5 Quality5&5Safety
4) A5client5comes5in5with5exacerbation5of5chronic5obstructive5pulmonary5disease5(COPD).5Whic
h5noninvasive5diagnostic5test5will5the5nurse5implement5to5know5that5the5client5is5receiving5enou
gh5oxygen?
A) Chest5x-ray
B) Pulse5oximeter
C) Arterial5blood5gasses
D) Assessment5of5respiratory5rat
e5ANSWER:5 B
Explanation:5 A)5A5chest5x-ray5is5not5an5intervention5a5nurse5completes.
B) A5pulse5oximeter5provides5a5noninvasive5method5of5measuring5oxygenation,5or5oxygen5s
aturation,5in5the5blood5and5provides5a5pulse5reading,5which5is5especially5helpful5for5the5clie
nt5with5a5respiratory5illness5or5disease.
C) Arterial5blood5gases5are5an5invasive5diagnostic5test.
D) Assessing5a5respiratory5rate5is5important5for5the5nurse5to5implement;5however,5it5is5n
ot5a5diagnostic5test.
Page5Ref:521
Cognitive5Level:5 Applying
Client5Need/Sub:5 Physiological5Integrity:5Reduction5of5Risk5Potential
Standards:5Nursing5Process:5Implementation5|5Learning5Outcome:51.35|5QSEN5Competencies:5I
nformatics
AACN5Domains5and5Comps.:5 Domain55:5Quality5and5Safety5NLN5C
ompetencies:5 Quality5&5Safety
2
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