Fundamentals of Nursing 12th Edition P a g e | 1
Test Bank 2 – Fundamentals of Nursing 12th
Edition | Patricia A. Potter | Latest Update
2026 | Graded A+ Exam Prep
| GUARANTEED PASS
A nursing diagnosis is written as: "Impaired skin integrity related to immobility as evidenced by a stage
2 pressure injury on the sacrum." Which format does this follow?
A. SOAP
B. PES (Problem, Etiology, Signs/symptoms)
C. SMART
D. DAR
B. PES (Problem, Etiology, Signs/symptoms)
Rationale: PES format states the Problem, related Etiology, and the Signs/symptoms (as evidenced by)
that support the diagnosis.
Ch7.5. Which of the following goals is written correctly using SMART criteria?
A. "Client will feel better about their diagnosis."
B. "Client will ambulate 50 feet in the hallway with a walker by the end of the shift."
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C. "Client will understand their medications eventually."
D. "Client will try to eat more."
B. "Client will ambulate 50 feet in the hallway with a walker by the end of the shift."
Rationale: A SMART goal is specific, measurable, attainable, realistic, and time-limited — the hallway
ambulation goal meets all of these criteria.
Ch7.6. A nurse repositions a client every 2 hours to prevent skin breakdown, based on evidence and
nursing judgment rather than a provider's order. This is an example of which type of intervention?
A. Provider-initiated (dependent)
B. Nurse-initiated (independent)
C. Collaborative
D. Delegated-only
B. Nurse-initiated (independent)
Rationale: Nurse-initiated/independent interventions are autonomous actions based on nursing
knowledge and scope of practice, not requiring a provider's order.
Ch12.1. A nurse is caring for an alert, oriented client with a history of falls who is sitting on the bedside
commode. Which action is most appropriate?
A. Apply a belt restraint while the client is on the commode
B. Stay with the client or check on them frequently, and ensure the call light is within reach
C. Raise all four side rails after leaving the room
D. Ask the client to call out loudly if they need help instead of using the call light
B. Stay with the client or check on them frequently, and ensure the call light is within reach
Rationale: Least restrictive measures come first for a client who is alert, oriented, and cooperative —
restraints are not appropriate here, and skipping the call light removes a key safety tool.
Ch12.2. A client with a history of multiple falls this week is being cared for by a nurse. What is the
nurse's priority action?
A. Educate the client's family about fall risks
B. Complete a fall-risk assessment
C. Move all furniture out of the room
D. Apply a bed alarm without further assessment
B. Complete a fall-risk assessment
Rationale: A fall-risk assessment should be completed first to individualize the plan of care; other
interventions follow from its findings.
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Ch12.3. While caring for a client having a generalized seizure, which action should the nurse take?
A. Insert a padded tongue depressor into the client's mouth
B. Restrain the client's arms and legs to prevent injury
C. Lower the client to the floor or bed, turn them to one side, and protect the head
D. Leave the room briefly to get help and lock the door for privacy
C. Lower the client to the floor or bed, turn them to one side, and protect the head
Rationale: During a seizure, the nurse should never put anything in the client's mouth or restrain them;
instead, protect the client from injury, position them on their side, and stay with them while calling for
help.
Ch12.4. A provider prescribes wrist restraints for an agitated client who is pulling at an IV line. Which of
the following is true regarding this order?
A. The order may be written as a standing PRN order
B. The order may authorize restraint use for up to 4 hours for this adult client before requiring renewal
C. Restraints may be tied directly to the bed's side rails for quick release
D. No provider order is needed if the nurse believes the client is at risk
B. The order may authorize restraint use for up to 4 hours for this adult client before requiring renewal
Rationale: Adult restraint orders are limited to 4 hours before requiring renewal (2 hours for ages 9-17,
1 hour under age 9). PRN restraint orders are never allowed, and restraints must be secured to the
bed frame, not the side rails.
Ch12.5. A nurse notices smoke coming from underneath a supply closet door on the unit. Following
the RACE protocol, what should the nurse do first?
A. Extinguish the fire with the nearest fire extinguisher
B. Activate the fire alarm
C. Move clients who are in close proximity to the fire to safety
D. Close all doors and windows on the unit
C. Move clients who are in close proximity to the fire to safety
Rationale: RACE begins with Rescue — moving people who are in immediate danger — before Alarm,
Confine, and Extinguish.
Ch12.6. When using a fire extinguisher, which sequence follows the PASS technique?
A. Squeeze, Aim, Pull, Sweep
B. Pull, Aim, Squeeze, Sweep
C. Aim, Pull, Sweep, Squeeze
D. Sweep, Pull, Aim, Squeeze
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B. Pull, Aim, Squeeze, Sweep
Rationale: PASS stands for Pull the pin, Aim at the base of the fire, Squeeze the handle, and Sweep
side to side.
Ch12.7. Which nursing actions are appropriate when caring for a client in bilateral wrist restraints?
(Select all that apply.)
A. Secure the restraints to the movable bed frame
B. Assess skin integrity approximately every 2 hours
C. Ensure two fingers fit comfortably between the restraint and the client's skin
D. Leave the restraints in place until the provider's order expires without reassessment
E. Offer range-of-motion exercises and toileting assistance regularly
A, B, C, E
Rationale: Restraints should be tied to the movable bed frame (not side rails), checked for a proper 2-
finger fit, monitored via regular skin checks, and paired with ROM/hygiene care. The need for restraints
must be reassessed on an ongoing basis, not left unexamined until the order expires.
Ch14.1. Which statement by a newly hired nursing assistant indicates a correct understanding of body
mechanics?
A. "I should keep my feet close together for better balance."
B. "The lower my center of gravity, the more stable I'll be."
C. "My line of gravity should fall outside my base of support."
D. "I should hold heavy objects away from my body to protect my back."
B. "The lower my center of gravity, the more stable I'll be."
Rationale: Lowering the center of gravity (bending hips/knees) increases stability. The base of support
should be widened (not feet together), the line of gravity should fall inside the base of support, and
objects should be held close to the body.
Ch14.2. When pulling a heavy cart, which action demonstrates correct body mechanics?
A. Moving the front foot forward
B. Moving the rear leg backward
C. Keeping both feet stationary and twisting the torso
D. Bending only at the waist while keeping the legs straight
B. Moving the rear leg backward
Rationale: When pulling, the rear leg moves back (the front foot moves forward for pushing); twisting
the spine and waist-only bending both increase injury risk.
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Test Bank 2 – Fundamentals of Nursing 12th
Edition | Patricia A. Potter | Latest Update
2026 | Graded A+ Exam Prep
| GUARANTEED PASS
A nursing diagnosis is written as: "Impaired skin integrity related to immobility as evidenced by a stage
2 pressure injury on the sacrum." Which format does this follow?
A. SOAP
B. PES (Problem, Etiology, Signs/symptoms)
C. SMART
D. DAR
B. PES (Problem, Etiology, Signs/symptoms)
Rationale: PES format states the Problem, related Etiology, and the Signs/symptoms (as evidenced by)
that support the diagnosis.
Ch7.5. Which of the following goals is written correctly using SMART criteria?
A. "Client will feel better about their diagnosis."
B. "Client will ambulate 50 feet in the hallway with a walker by the end of the shift."
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C. "Client will understand their medications eventually."
D. "Client will try to eat more."
B. "Client will ambulate 50 feet in the hallway with a walker by the end of the shift."
Rationale: A SMART goal is specific, measurable, attainable, realistic, and time-limited — the hallway
ambulation goal meets all of these criteria.
Ch7.6. A nurse repositions a client every 2 hours to prevent skin breakdown, based on evidence and
nursing judgment rather than a provider's order. This is an example of which type of intervention?
A. Provider-initiated (dependent)
B. Nurse-initiated (independent)
C. Collaborative
D. Delegated-only
B. Nurse-initiated (independent)
Rationale: Nurse-initiated/independent interventions are autonomous actions based on nursing
knowledge and scope of practice, not requiring a provider's order.
Ch12.1. A nurse is caring for an alert, oriented client with a history of falls who is sitting on the bedside
commode. Which action is most appropriate?
A. Apply a belt restraint while the client is on the commode
B. Stay with the client or check on them frequently, and ensure the call light is within reach
C. Raise all four side rails after leaving the room
D. Ask the client to call out loudly if they need help instead of using the call light
B. Stay with the client or check on them frequently, and ensure the call light is within reach
Rationale: Least restrictive measures come first for a client who is alert, oriented, and cooperative —
restraints are not appropriate here, and skipping the call light removes a key safety tool.
Ch12.2. A client with a history of multiple falls this week is being cared for by a nurse. What is the
nurse's priority action?
A. Educate the client's family about fall risks
B. Complete a fall-risk assessment
C. Move all furniture out of the room
D. Apply a bed alarm without further assessment
B. Complete a fall-risk assessment
Rationale: A fall-risk assessment should be completed first to individualize the plan of care; other
interventions follow from its findings.
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Ch12.3. While caring for a client having a generalized seizure, which action should the nurse take?
A. Insert a padded tongue depressor into the client's mouth
B. Restrain the client's arms and legs to prevent injury
C. Lower the client to the floor or bed, turn them to one side, and protect the head
D. Leave the room briefly to get help and lock the door for privacy
C. Lower the client to the floor or bed, turn them to one side, and protect the head
Rationale: During a seizure, the nurse should never put anything in the client's mouth or restrain them;
instead, protect the client from injury, position them on their side, and stay with them while calling for
help.
Ch12.4. A provider prescribes wrist restraints for an agitated client who is pulling at an IV line. Which of
the following is true regarding this order?
A. The order may be written as a standing PRN order
B. The order may authorize restraint use for up to 4 hours for this adult client before requiring renewal
C. Restraints may be tied directly to the bed's side rails for quick release
D. No provider order is needed if the nurse believes the client is at risk
B. The order may authorize restraint use for up to 4 hours for this adult client before requiring renewal
Rationale: Adult restraint orders are limited to 4 hours before requiring renewal (2 hours for ages 9-17,
1 hour under age 9). PRN restraint orders are never allowed, and restraints must be secured to the
bed frame, not the side rails.
Ch12.5. A nurse notices smoke coming from underneath a supply closet door on the unit. Following
the RACE protocol, what should the nurse do first?
A. Extinguish the fire with the nearest fire extinguisher
B. Activate the fire alarm
C. Move clients who are in close proximity to the fire to safety
D. Close all doors and windows on the unit
C. Move clients who are in close proximity to the fire to safety
Rationale: RACE begins with Rescue — moving people who are in immediate danger — before Alarm,
Confine, and Extinguish.
Ch12.6. When using a fire extinguisher, which sequence follows the PASS technique?
A. Squeeze, Aim, Pull, Sweep
B. Pull, Aim, Squeeze, Sweep
C. Aim, Pull, Sweep, Squeeze
D. Sweep, Pull, Aim, Squeeze
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B. Pull, Aim, Squeeze, Sweep
Rationale: PASS stands for Pull the pin, Aim at the base of the fire, Squeeze the handle, and Sweep
side to side.
Ch12.7. Which nursing actions are appropriate when caring for a client in bilateral wrist restraints?
(Select all that apply.)
A. Secure the restraints to the movable bed frame
B. Assess skin integrity approximately every 2 hours
C. Ensure two fingers fit comfortably between the restraint and the client's skin
D. Leave the restraints in place until the provider's order expires without reassessment
E. Offer range-of-motion exercises and toileting assistance regularly
A, B, C, E
Rationale: Restraints should be tied to the movable bed frame (not side rails), checked for a proper 2-
finger fit, monitored via regular skin checks, and paired with ROM/hygiene care. The need for restraints
must be reassessed on an ongoing basis, not left unexamined until the order expires.
Ch14.1. Which statement by a newly hired nursing assistant indicates a correct understanding of body
mechanics?
A. "I should keep my feet close together for better balance."
B. "The lower my center of gravity, the more stable I'll be."
C. "My line of gravity should fall outside my base of support."
D. "I should hold heavy objects away from my body to protect my back."
B. "The lower my center of gravity, the more stable I'll be."
Rationale: Lowering the center of gravity (bending hips/knees) increases stability. The base of support
should be widened (not feet together), the line of gravity should fall inside the base of support, and
objects should be held close to the body.
Ch14.2. When pulling a heavy cart, which action demonstrates correct body mechanics?
A. Moving the front foot forward
B. Moving the rear leg backward
C. Keeping both feet stationary and twisting the torso
D. Bending only at the waist while keeping the legs straight
B. Moving the rear leg backward
Rationale: When pulling, the rear leg moves back (the front foot moves forward for pushing); twisting
the spine and waist-only bending both increase injury risk.
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