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 enters a patient's room and finds the patient lying on
the floor beside the bed. What is the nurse's priority action?
A. Assist the patient back into bed immediately.
B. Assess the patient for responsiveness and injuries.
C. Notify the health care provider.
D. Complete an incident report.
Correct Answer: B
Rationale:
The nurse's first priority is to assess the patient for
responsiveness, airway, breathing, circulation, and evidence of
injury before moving the patient. Moving the patient before
assessment may worsen an undetected injury. After
assessment, appropriate interventions, provider notification,
documentation, and completion of an incident report should
follow according to agency policy.
Question 2
A patient receiving opioid pain medication reports increasing
drowsiness and is difficult to arouse. Which nursing action is
most appropriate?
,A. Encourage the patient to drink fluids.
B. Assess the patient's respiratory rate and oxygen saturation
immediately.
C. Administer the next scheduled dose later than prescribed.
D. Ask the patient to walk in the hallway.
Correct Answer: B
Rationale:
Opioids can depress respiratory function. The priority
assessment is respiratory status, including respiratory rate,
depth, oxygen saturation, and level of consciousness. This
assessment determines whether immediate intervention is
needed. Delaying medication or encouraging fluids does not
address the immediate safety concern.
Question 3
A nurse is preparing to administer an oral medication. The
patient states, "That pill doesn't look like the one I usually take."
What should the nurse do first?
A. Tell the patient the pharmacy verifies all medications.
B. Administer the medication as ordered.
C. Compare the medication with the prescription and
investigate the discrepancy.
D. Document that the patient questioned the medication.
Correct Answer: C
, Rationale:
Any discrepancy between the prescribed medication and the
medication available must be investigated before
administration. Nurses are responsible for verifying medication
accuracy and should never administer a medication when
uncertainty exists. Patient concerns can help prevent
medication errors.
Question 4
A nurse is caring for a postoperative patient who has been on
bed rest for two days. Which intervention best helps prevent
venous thromboembolism?
A. Restrict fluid intake.
B. Encourage early and frequent ambulation.
C. Limit lower extremity movement.
D. Keep the patient's knees flexed while in bed.
Correct Answer: B
Rationale:
Early ambulation promotes venous return and significantly
reduces the risk of venous thromboembolism. Adequate
hydration, leg exercises, and compression devices may also be
appropriate. Flexing the knees continuously and limiting
movement impede circulation.
Question 5
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 patient's room and finds the patient lying on
the floor beside the bed. What is the nurse's priority action?
A. Assist the patient back into bed immediately.
B. Assess the patient for responsiveness and injuries.
C. Notify the health care provider.
D. Complete an incident report.
Correct Answer: B
Rationale:
The nurse's first priority is to assess the patient for
responsiveness, airway, breathing, circulation, and evidence of
injury before moving the patient. Moving the patient before
assessment may worsen an undetected injury. After
assessment, appropriate interventions, provider notification,
documentation, and completion of an incident report should
follow according to agency policy.
Question 2
A patient receiving opioid pain medication reports increasing
drowsiness and is difficult to arouse. Which nursing action is
most appropriate?
,A. Encourage the patient to drink fluids.
B. Assess the patient's respiratory rate and oxygen saturation
immediately.
C. Administer the next scheduled dose later than prescribed.
D. Ask the patient to walk in the hallway.
Correct Answer: B
Rationale:
Opioids can depress respiratory function. The priority
assessment is respiratory status, including respiratory rate,
depth, oxygen saturation, and level of consciousness. This
assessment determines whether immediate intervention is
needed. Delaying medication or encouraging fluids does not
address the immediate safety concern.
Question 3
A nurse is preparing to administer an oral medication. The
patient states, "That pill doesn't look like the one I usually take."
What should the nurse do first?
A. Tell the patient the pharmacy verifies all medications.
B. Administer the medication as ordered.
C. Compare the medication with the prescription and
investigate the discrepancy.
D. Document that the patient questioned the medication.
Correct Answer: C
, Rationale:
Any discrepancy between the prescribed medication and the
medication available must be investigated before
administration. Nurses are responsible for verifying medication
accuracy and should never administer a medication when
uncertainty exists. Patient concerns can help prevent
medication errors.
Question 4
A nurse is caring for a postoperative patient who has been on
bed rest for two days. Which intervention best helps prevent
venous thromboembolism?
A. Restrict fluid intake.
B. Encourage early and frequent ambulation.
C. Limit lower extremity movement.
D. Keep the patient's knees flexed while in bed.
Correct Answer: B
Rationale:
Early ambulation promotes venous return and significantly
reduces the risk of venous thromboembolism. Adequate
hydration, leg exercises, and compression devices may also be
appropriate. Flexing the knees continuously and limiting
movement impede circulation.
Question 5
