FUNDAMENTALS OF NURSING
12TH EDITION
• AUTHOR(S)PATRICIA A. POTTER;
ANNE G. PERRY; PATRICIA A.
STOCKERT; AMY HALL; WENDY
R. OSTENDORF
TEST BANK
,Question 1
A nurse is preparing to administer an enteral feeding to a
patient with a nasogastric tube. Which action should the nurse
take first to ensure patient safety?
A. Flush the tube with 30 mL of air to confirm placement.
B. Verify tube placement by aspirating gastric contents and
checking pH.
C. Elevate the head of the bed to a semi-Fowler's position.
D. Check the residual volume to assess for delayed gastric
emptying.
Correct Answer: B
Rationale:
Verifying tube placement is the priority safety action before
initiating an enteral feeding to prevent accidental pulmonary
administration. While auscultation of injected air is no longer a
reliable method, aspiration of gastric contents with pH testing
provides a more accurate indicator of placement. Elevating the
head of the bed is important to prevent aspiration but should
follow placement verification. Residual checks and flushing are
appropriate but are secondary to confirming correct tube
location.
,Question 2
A patient who is postoperative reports a pain level of 7 on a 0-
to-10 scale. The nurse administers a prescribed analgesic. Thirty
minutes later, the patient reports the pain is still a 7. What is
the nurse's priority action?
A. Administer another dose of the same analgesic as prescribed.
B. Notify the healthcare provider immediately.
C. Reassess the patient using a different pain scale.
D. Perform a comprehensive pain reassessment, including
location, quality, and characteristics.
Correct Answer: D
Rationale:
The priority is to perform a thorough reassessment of the pain.
This includes evaluating the characteristics of the pain,
determining if the analgesic was effective or if there are new or
different symptoms, and assessing for potential complications.
This reassessment guides the next intervention and
communication with the healthcare provider. Administering
another dose without reassessment could lead to over-sedation
or mask a serious condition.
Question 3
, A nurse is educating a patient with diabetes mellitus about foot
care. Which statement by the patient indicates a correct
understanding of the teaching?
A. "I will soak my feet in hot water every day to help with
circulation."
B. "I should apply moisturizer between my toes to prevent
cracking."
C. "It is safe to use a heating pad on my feet if they feel cold."
D. "I will cut my toenails straight across and file the edges."
Correct Answer: D
Rationale:
Cutting toenails straight across and filing the edges prevents
ingrown toenails, which can lead to infection and complications
in patients with diabetes. Soaking feet in hot water and using
heating pads can cause burns due to decreased sensation.
Applying moisturizer between the toes increases the risk of
fungal infections because moisture promotes microbial growth
in those areas.
Question 4
The nurse is providing oral care to a patient who is unconscious.
Which intervention is essential to prevent aspiration?
A. Place the patient in a supine position with a rolled towel
under the neck.
12TH EDITION
• AUTHOR(S)PATRICIA A. POTTER;
ANNE G. PERRY; PATRICIA A.
STOCKERT; AMY HALL; WENDY
R. OSTENDORF
TEST BANK
,Question 1
A nurse is preparing to administer an enteral feeding to a
patient with a nasogastric tube. Which action should the nurse
take first to ensure patient safety?
A. Flush the tube with 30 mL of air to confirm placement.
B. Verify tube placement by aspirating gastric contents and
checking pH.
C. Elevate the head of the bed to a semi-Fowler's position.
D. Check the residual volume to assess for delayed gastric
emptying.
Correct Answer: B
Rationale:
Verifying tube placement is the priority safety action before
initiating an enteral feeding to prevent accidental pulmonary
administration. While auscultation of injected air is no longer a
reliable method, aspiration of gastric contents with pH testing
provides a more accurate indicator of placement. Elevating the
head of the bed is important to prevent aspiration but should
follow placement verification. Residual checks and flushing are
appropriate but are secondary to confirming correct tube
location.
,Question 2
A patient who is postoperative reports a pain level of 7 on a 0-
to-10 scale. The nurse administers a prescribed analgesic. Thirty
minutes later, the patient reports the pain is still a 7. What is
the nurse's priority action?
A. Administer another dose of the same analgesic as prescribed.
B. Notify the healthcare provider immediately.
C. Reassess the patient using a different pain scale.
D. Perform a comprehensive pain reassessment, including
location, quality, and characteristics.
Correct Answer: D
Rationale:
The priority is to perform a thorough reassessment of the pain.
This includes evaluating the characteristics of the pain,
determining if the analgesic was effective or if there are new or
different symptoms, and assessing for potential complications.
This reassessment guides the next intervention and
communication with the healthcare provider. Administering
another dose without reassessment could lead to over-sedation
or mask a serious condition.
Question 3
, A nurse is educating a patient with diabetes mellitus about foot
care. Which statement by the patient indicates a correct
understanding of the teaching?
A. "I will soak my feet in hot water every day to help with
circulation."
B. "I should apply moisturizer between my toes to prevent
cracking."
C. "It is safe to use a heating pad on my feet if they feel cold."
D. "I will cut my toenails straight across and file the edges."
Correct Answer: D
Rationale:
Cutting toenails straight across and filing the edges prevents
ingrown toenails, which can lead to infection and complications
in patients with diabetes. Soaking feet in hot water and using
heating pads can cause burns due to decreased sensation.
Applying moisturizer between the toes increases the risk of
fungal infections because moisture promotes microbial growth
in those areas.
Question 4
The nurse is providing oral care to a patient who is unconscious.
Which intervention is essential to prevent aspiration?
A. Place the patient in a supine position with a rolled towel
under the neck.
