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 intramuscular injection to
a 2-year-old child. Which muscle site is the most appropriate
choice for this patient?
A. Deltoid B. Dorsogluteal C. Vastus lateralis D. Ventrogluteal
Correct Answer: C
Rationale: The vastus lateralis is the preferred and safest site for
intramuscular injections in infants and toddlers because it is
well-developed and lacks major nerves or blood vessels. The
deltoid is not sufficiently developed in a 2-year-old for routine
deep IM injections. The dorsogluteal site should be avoided in
all patients due to the high risk of sciatic nerve injury. The
ventrogluteal site can be used once the child has been walking
for a year or more, but the vastus lateralis remains the primary
choice for this age group in general pediatric guidelines.
Question 2
While reviewing a client's electronic health record, a nurse
notes an order for "Acetaminophen 650 mg PO q4h PRN for
pain." The nurse realizes the route is missing from the original
handwritten order sheet. Which action should the nurse take
first?
,A. Call the healthcare provider to clarify and verify the route. B.
Administer the medication orally as indicated by the electronic
record. C. Contact the pharmacist to confirm how the
medication was dispensed. D. Document the omission as a
medication error in the safety reporting system.
Correct Answer: A
Rationale: When any component of a medication order is
missing, unclear, or incomplete, the nurse must directly contact
the prescribing healthcare provider for clarification before
administering the drug. Relying on the electronic health record
without verifying the source of the discrepancy compromises
patient safety. Contacting the pharmacist or documenting an
error does not resolve the immediate clinical need to safely
clarify the prescription for the patient.
Question 3
A nurse enters a patient's room and finds a small fire burning in
a trash can. Using the RACE acronym, which action should the
nurse perform first?
A. Extinguish the fire using a nearby pass-rated extinguisher. B.
Close the door to the patient's room to contain the smoke. C.
Pull the fire alarm lever at the nearest pull station. D. Move the
patient out of the room to a safe location.
Correct Answer: D
, Rationale: The RACE acronym stands for Rescue, Alarm,
Confine, Extinguish/Evacuate. The nurse's first priority is always
to rescue and protect patients who are in immediate danger
from the fire. Once the patient is safely removed from the
room, the nurse can pull the fire alarm, close the door to
confine the fire, and attempt to extinguish it if it is small and
manageable.
Question 4
A nurse is caring for an older adult patient who is at high risk for
skin breakdown. Which intervention should the nurse
implement to prevent pressure injury development?
A. Massage reddened bony prominences daily. B. Maintain the
head of the bed at a 45-degree angle. C. Reposition the patient
at least every 2 hours. D. Place a plastic-lined chuck directly
under the patient.
Correct Answer: C
Rationale: Frequent repositioning (at least every 2 hours)
redistributes pressure and minimizes prolonged ischemia to
vulnerable tissues. Massaging reddened areas causes deep
tissue damage and is contraindicated. Keeping the head of the
bed at or below 30 degrees reduces shear and friction forces.
Plastic-lined pads trap moisture against the skin, increasing the
risk of maceration and breakdown.
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 intramuscular injection to
a 2-year-old child. Which muscle site is the most appropriate
choice for this patient?
A. Deltoid B. Dorsogluteal C. Vastus lateralis D. Ventrogluteal
Correct Answer: C
Rationale: The vastus lateralis is the preferred and safest site for
intramuscular injections in infants and toddlers because it is
well-developed and lacks major nerves or blood vessels. The
deltoid is not sufficiently developed in a 2-year-old for routine
deep IM injections. The dorsogluteal site should be avoided in
all patients due to the high risk of sciatic nerve injury. The
ventrogluteal site can be used once the child has been walking
for a year or more, but the vastus lateralis remains the primary
choice for this age group in general pediatric guidelines.
Question 2
While reviewing a client's electronic health record, a nurse
notes an order for "Acetaminophen 650 mg PO q4h PRN for
pain." The nurse realizes the route is missing from the original
handwritten order sheet. Which action should the nurse take
first?
,A. Call the healthcare provider to clarify and verify the route. B.
Administer the medication orally as indicated by the electronic
record. C. Contact the pharmacist to confirm how the
medication was dispensed. D. Document the omission as a
medication error in the safety reporting system.
Correct Answer: A
Rationale: When any component of a medication order is
missing, unclear, or incomplete, the nurse must directly contact
the prescribing healthcare provider for clarification before
administering the drug. Relying on the electronic health record
without verifying the source of the discrepancy compromises
patient safety. Contacting the pharmacist or documenting an
error does not resolve the immediate clinical need to safely
clarify the prescription for the patient.
Question 3
A nurse enters a patient's room and finds a small fire burning in
a trash can. Using the RACE acronym, which action should the
nurse perform first?
A. Extinguish the fire using a nearby pass-rated extinguisher. B.
Close the door to the patient's room to contain the smoke. C.
Pull the fire alarm lever at the nearest pull station. D. Move the
patient out of the room to a safe location.
Correct Answer: D
, Rationale: The RACE acronym stands for Rescue, Alarm,
Confine, Extinguish/Evacuate. The nurse's first priority is always
to rescue and protect patients who are in immediate danger
from the fire. Once the patient is safely removed from the
room, the nurse can pull the fire alarm, close the door to
confine the fire, and attempt to extinguish it if it is small and
manageable.
Question 4
A nurse is caring for an older adult patient who is at high risk for
skin breakdown. Which intervention should the nurse
implement to prevent pressure injury development?
A. Massage reddened bony prominences daily. B. Maintain the
head of the bed at a 45-degree angle. C. Reposition the patient
at least every 2 hours. D. Place a plastic-lined chuck directly
under the patient.
Correct Answer: C
Rationale: Frequent repositioning (at least every 2 hours)
redistributes pressure and minimizes prolonged ischemia to
vulnerable tissues. Massaging reddened areas causes deep
tissue damage and is contraindicated. Keeping the head of the
bed at or below 30 degrees reduces shear and friction forces.
Plastic-lined pads trap moisture against the skin, increasing the
risk of maceration and breakdown.
