12TH EDITION
• AUTHOR(S)PATRICIA A. POTTER;
ANNE G. PERRY; PATRICIA A.
STOCKERT; AMY HALL; WENDY
R. OSTENDORF
TEST BANK
,Question 1
A nurse enters a client's room and finds the client sitting on the
floor next to the bed. What is the nurse's priority action?
A. Assist the client back into bed immediately.
B. Assess the client for injuries and level of consciousness.
C. Complete an incident report before notifying the provider.
D. Ask the client why they got out of bed.
Correct Answer: B
Rationale:
The priority is to assess the client for injuries and determine
physiologic stability before moving the client. A rapid
assessment includes level of consciousness, pain, obvious
injuries, and vital signs as indicated. The client should not be
moved until it is safe to do so. Incident reports are completed
after appropriate patient care and notification. Asking why the
client got out of bed is appropriate later but is not the priority.
Question 2
A nurse is preparing to administer an oral medication. Which
action best supports safe medication administration?
,A. Compare the medication label with the medication
administration record before giving the medication.
B. Ask another nurse to administer the medication.
C. Leave the medication at the bedside if the client is asleep.
D. Administer the medication before confirming the client's
identity.
Correct Answer: A
Rationale:
Comparing the medication label with the medication
administration record and verifying the correct patient using
approved identifiers are essential safety practices. Medications
should not be left unattended unless specifically ordered and
appropriate. Identity must always be confirmed before
administration.
Question 3
A hospitalized client says, "I'm worried about my surgery
tomorrow." Which response by the nurse demonstrates
therapeutic communication?
A. "There's nothing to worry about."
B. "Tell me more about what concerns you."
C. "Everyone feels nervous before surgery."
D. "You should focus on thinking positively."
Correct Answer: B
, Rationale:
Inviting the client to express concerns promotes therapeutic
communication, encourages exploration of feelings, and helps
the nurse identify specific fears. Responses that minimize
feelings or offer false reassurance can hinder communication.
Question 4
A nurse is caring for four clients. Which client should the nurse
assess first?
A. A client reporting sudden shortness of breath.
B. A client requesting assistance to the bathroom.
C. A client scheduled for discharge later in the day.
D. A client requesting pain medication for chronic back pain.
Correct Answer: A
Rationale:
Sudden shortness of breath may indicate a life-threatening
condition requiring immediate assessment. Airway and
breathing concerns take priority over routine requests,
discharge planning, and chronic pain management.
Question 5
A nurse is teaching a client about proper hand hygiene. Which
statement by the client indicates understanding?
A. "I should clean my hands before eating and after using the
restroom."