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 perform a sterile dressing change for a
client with a deep surgical wound. After establishing a sterile
field, the nurse accidentally drops a sterile gauze pad onto the
outer 1-inch border of the sterile drape. Which action should
the nurse take next?
A. Pick up the gauze pad with sterile forceps and use it for the
dressing change. B. Discard the gauze pad and continue using
the remaining sterile items on the field. C. Dispose of the entire
sterile field and start over with a new dressing kit. D. Pour
sterile normal saline over the dropped gauze pad to re-sterilize
it.
Correct Answer: B
Rationale: The outer 1-inch border of a sterile field is
considered contaminated. Any sterile item that touches this
border is no longer sterile and must be discarded to prevent
introducing microorganisms into the surgical wound. However,
if the rest of the sterile field remains uncompromised and
untouched by the contaminated object, the nurse does not
need to discard the entire field. The nurse should simply discard
the contaminated gauze pad and proceed with the remaining
sterile items. Sterile saline cannot re-sterilize an object once it
has been contaminated.
,Question 2
An assistive personnel (AP) reports to the charge nurse that a
client's electronic blood pressure reading is 158/94 mm Hg. The
client has no history of hypertension. Which action should the
charge nurse direct the AP to take first?
A. Recheck the blood pressure on the opposite arm using a
manual sphygmomanometer. B. Document the blood pressure
in the electronic health record and notify the health care
provider. C. Instruct the client to lie down flat in bed and rest
for 30 minutes before retesting. D. Administer a PRN dose of an
antihypertensive medication if available on the medication
administration record.
Correct Answer: A
Rationale: When an unexpected or abnormal vital sign reading
is obtained via an electronic device, the initial action is to verify
the accuracy of the reading. A manual sphygmomanometer
provides a more accurate assessment and eliminates potential
equipment errors associated with automated cuffs. The AP can
be directed to recheck the reading manually, or the nurse can
perform it. The reading should be verified before documenting
it as a definitive trend, notifying the provider, or modifying the
client's position or medication regimen. APs cannot administer
medications.
Question 3
, A nurse is caring for an older adult client who is at high risk for
skin breakdown due to immobility. Which intervention should
the nurse include in the client's care plan to minimize shearing
forces on the skin?
A. Keep the head of the bed elevated at 45 to 60 degrees at all
times. B. Use a friction-reducing slide sheet when repositioning
the client up in bed. C. Massage reddened bony prominences
vigorously during every turn. D. Apply a thick layer of cornstarch
to the client's perineum and sacrum.
Correct Answer: B
Rationale: Shearing forces occur when the skin adheres to a
surface (like bed sheets) while the skeletal structures slide
downward, causing damage to the deep subcutaneous tissue
and blood vessels. Utilizing a friction-reducing slide sheet
prevents the skin from dragging against the linens during
repositioning. Elevating the head of the bed above 30 degrees
increases shearing forces because it causes the client to slide
down in bed. Massaging reddened areas causes further tissue
damage and is contraindicated. Cornstarch can cake, hold
moisture, and promote friction and infection.
Question 4
A nurse is preparing to administer an intramuscular (IM)
injection of an oil-based medication to an adult client. Which
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 perform a sterile dressing change for a
client with a deep surgical wound. After establishing a sterile
field, the nurse accidentally drops a sterile gauze pad onto the
outer 1-inch border of the sterile drape. Which action should
the nurse take next?
A. Pick up the gauze pad with sterile forceps and use it for the
dressing change. B. Discard the gauze pad and continue using
the remaining sterile items on the field. C. Dispose of the entire
sterile field and start over with a new dressing kit. D. Pour
sterile normal saline over the dropped gauze pad to re-sterilize
it.
Correct Answer: B
Rationale: The outer 1-inch border of a sterile field is
considered contaminated. Any sterile item that touches this
border is no longer sterile and must be discarded to prevent
introducing microorganisms into the surgical wound. However,
if the rest of the sterile field remains uncompromised and
untouched by the contaminated object, the nurse does not
need to discard the entire field. The nurse should simply discard
the contaminated gauze pad and proceed with the remaining
sterile items. Sterile saline cannot re-sterilize an object once it
has been contaminated.
,Question 2
An assistive personnel (AP) reports to the charge nurse that a
client's electronic blood pressure reading is 158/94 mm Hg. The
client has no history of hypertension. Which action should the
charge nurse direct the AP to take first?
A. Recheck the blood pressure on the opposite arm using a
manual sphygmomanometer. B. Document the blood pressure
in the electronic health record and notify the health care
provider. C. Instruct the client to lie down flat in bed and rest
for 30 minutes before retesting. D. Administer a PRN dose of an
antihypertensive medication if available on the medication
administration record.
Correct Answer: A
Rationale: When an unexpected or abnormal vital sign reading
is obtained via an electronic device, the initial action is to verify
the accuracy of the reading. A manual sphygmomanometer
provides a more accurate assessment and eliminates potential
equipment errors associated with automated cuffs. The AP can
be directed to recheck the reading manually, or the nurse can
perform it. The reading should be verified before documenting
it as a definitive trend, notifying the provider, or modifying the
client's position or medication regimen. APs cannot administer
medications.
Question 3
, A nurse is caring for an older adult client who is at high risk for
skin breakdown due to immobility. Which intervention should
the nurse include in the client's care plan to minimize shearing
forces on the skin?
A. Keep the head of the bed elevated at 45 to 60 degrees at all
times. B. Use a friction-reducing slide sheet when repositioning
the client up in bed. C. Massage reddened bony prominences
vigorously during every turn. D. Apply a thick layer of cornstarch
to the client's perineum and sacrum.
Correct Answer: B
Rationale: Shearing forces occur when the skin adheres to a
surface (like bed sheets) while the skeletal structures slide
downward, causing damage to the deep subcutaneous tissue
and blood vessels. Utilizing a friction-reducing slide sheet
prevents the skin from dragging against the linens during
repositioning. Elevating the head of the bed above 30 degrees
increases shearing forces because it causes the client to slide
down in bed. Massaging reddened areas causes further tissue
damage and is contraindicated. Cornstarch can cake, hold
moisture, and promote friction and infection.
Question 4
A nurse is preparing to administer an intramuscular (IM)
injection of an oil-based medication to an adult client. Which
