Chapter 1 Assessment 1) A client on the medical/surgical unit complains of sudden chest pains. Which action will the nurse implement first? A) Call the healthcare provider. B) Administer pain medication. C) Reassess a new set of vital signs. D) Turn client from supine to lateral. Answer: C Explanation: A) The nurse will need to reassess the client first, before calling the healthcare provider. B) The nurse will need to reassess the client first, before administering pain medication. C) The nurse needs to implement a new set of vital signs first when there is a change in condition. D) 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: 2 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 1.1 | QSEN Competencies: Patient-Centered Care AACN Domains and Comps.: Domain 2: Person-Centered Care 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? A) Oral B) Rectal C) Scanner D) Tympanic Answer: A Explanation: A) The temperature of an unconscious client is never taken by mouth. The rectal, tympanic, or scanner method is preferred. B) The rectal, tympanic, or scanner method is preferred. C) The rectal, tympanic, or scanner method is preferred. D) The rectal, tympanic, or scanner method is preferred. Page Ref: 24 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Evaluation | Learning Outcome: 1.1 | QSEN Competencies: Safety AACN Domains and Comps.: Domain 5: Quality and Safety NLN Competencies: Quality & Safety