Fundamentals of Nursing 12th Edition P a g e | 1
Test Bank 1 – Fundamentals of Nursing 12th
Edition | Patricia A. Potter | Latest Update
2026 | Graded A+ Exam Prep
| GUARANTEED PASS
The health care provider has written the following orders. Which orders does the nurse need to clarify
before administering the medication?
Timoptic .25% solution 1 drop OD BID
Metoprolol 12.50 mg QD
Insulin Glargine 6 u SC twice a day
Enalapril 2.5 mg. PO three times a day, hold for systolic blood pressure <100 –
Correct Answer :The nurse needs to clarify all of the orders.
Rationale: Timoptic .25% solution 1 drop OD BID has a "naked" decimal point, and OD (right eye) could
be mistaken for AD (right ear). Metoprolol 12.50 mg QD has a trailing zero, and the dosage could be
mistaken for 1250 mg if the decimal point is not seen; it also has no route identified. Insulin Glargine 6
u SC twice a day includes the letter u, which means units but could be mistaken as the number 0 or 4,
and SC could be mistaken as SL. Enalapril 2.5 mg. PO three times a day, hold for systolic blood pressure
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, Fundamentals of Nursing 12th Edition P a g e | 2
<100 has a period after mg, which could be mistaken as the number 1, and the < sign could be
mistaken as greater than. The correctly written orders are
"Timoptic 0.25% solution 1 drop right eye BID.
Metoprolol 12.5 mg QD PO
Insulin glargine 6 units subcutaneous twice a day
Enalapril 2.5 mg PO three times a day, hold for systolic blood pressure less than 100."
Place the steps of administering an intradermal injection in the correct order.
1. Inject medication slowly
2. Note the presence of a bleb
3. Advance needle through epidermis to 3mm
4. Using nondominant hand, stretch skin over site with forefinger
5. Insert needle at a 5 to 15 degree angle into the skin until resistance is felt
6. Cleanse site with antiseptic swab –
Correct Answer :6, 4, 5, 3, 1, 2
Rationale: This is the correct sequence of steps to administer an intradermal injection.
After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's
burning and tingling where I got my injection." What should the nurse do next? (Select all that apply)
1. Assess the injection site
2. Administer an oral medication for pain
3. Notify the patient's health care provider of assessment findings
4. Document assessment findings and related interventions in the patient's medical record
5. This is a normal finding, so nothing needs to be done
6. Apply ice to the site for relief of burning pain –
Correct Answer :1, 3, 4
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, Fundamentals of Nursing 12th Edition P a g e | 3
Rationale: Assessing the injection site may reveal a sire reaction or induration from the injection. The
health care provider needs to be notified in case there is an adverse effect from the injection. The
nurse must always document adverse effects so that the site and patient can be monitored.
When administering medication intramuscularly, the nurse would document the intervention by
including which information? (Select all that apply)
1. Site of injection
2. The amount of medication injected
3. The name of the medication injected
4. The time the medication was prepared for injection
5. Confirmation that the medication was injected intramuscularly –
Correct Answer :1, 2, 3, 5
Rationale: Safe administration of medication requires appropriate documentation, which includes the
name, route, and amount of the medication; in the case of an injection, the site is also included. The
time the medication is given (not the time is was prepared) is included in the documentation.
A client who had surgery this morning has a distended bladder and is unable to void. Which nursing
interventions are most appropriate initially? Select all that apply.
1. Run warm water over the perineum
2. Have the client listen to the sound of running water
3. Obtain a prescription for an indwelling urinary catheter
4. Position the client on a bedpan with the head the bed elevated
5. Perform a bladder ultrasonography to evaluate the amount of urine left in the bladder –
Correct Answer :1, 2, 4, 5
Rationale: Before performing any interventions, the nurse should use a bladder ultrasonography to
obtain data about the amount of urine in the client's bladder. The nurse should first use conservative
methods such as maintaining a functional position with the head of the bed elevated, running warm
water over the perineum, and having the client listen to the sound of running water. If these
interventions are unsuccessful, the nurse should obtain a prescription for a straight catheterization.
The use of an indwelling catheter places the client at risk for infection.
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, Fundamentals of Nursing 12th Edition P a g e | 4
The nurse would determine which factors as contributing to stress incontinence in a female client?
Select all that apply.
1. Obesity
2. Sneezing
3. Nulliparity
4. Decreased estrogen
5. Performing Kegel exercises
6. Voiding at frequent intervals –
Correct Answer :1, 2, 4
Rationale: Obesity contributes to stress incontinence by causing intra-abdominal pressure. Sneezing or
laughing often causes leakage of urine. A decrease in estrogen levels after menopause is also a factor.
Nulliparity is not a factor, but a history of having three or more vaginal births may be a factor.
Performing Kegel exercises is a means of strengthening muscle tone. Voiding at regular intervals, such
as every 2 hours, decreases urine storage in the bladder, lessening the chance of incontinence.
Which information is most appropriate for the nurse to include in client teaching regarding ostomy
care? Select all that apply
1. Change the appliance daily
2. Empty the pouch when 1/3 to 1/2 full
3. The stoma should be dry and pale pink
4. The stoma should be moist and pink to red
5. The skin barrier should be within 1/16 to 1/8 inch of the stoma
6. Change the appliance every 3 day or longer, or if it is leaking effluent –
Correct Answer :2, 4, 5, 6
Rationale: The pouch should be emptied when 1/3 to 1/2 full to prevent the weight of contents from
loosening the seal. The stoma should be moist and pink to red in color. Keeping the skin barrier to
within 1/16 the 1/8 inch of the base of the stoma prevents effluent from irritating the skin. With an
adequate seal, changing the appliance every 3 days is adequate and may be done as infrequently as 2
weeks. Changing the appliance daily would damage the skin around the stoma. A stoma that is dry and
pale pink is indicative of an unhealthy stoma.
P a g e 4 | 65
Test Bank 1 – Fundamentals of Nursing 12th
Edition | Patricia A. Potter | Latest Update
2026 | Graded A+ Exam Prep
| GUARANTEED PASS
The health care provider has written the following orders. Which orders does the nurse need to clarify
before administering the medication?
Timoptic .25% solution 1 drop OD BID
Metoprolol 12.50 mg QD
Insulin Glargine 6 u SC twice a day
Enalapril 2.5 mg. PO three times a day, hold for systolic blood pressure <100 –
Correct Answer :The nurse needs to clarify all of the orders.
Rationale: Timoptic .25% solution 1 drop OD BID has a "naked" decimal point, and OD (right eye) could
be mistaken for AD (right ear). Metoprolol 12.50 mg QD has a trailing zero, and the dosage could be
mistaken for 1250 mg if the decimal point is not seen; it also has no route identified. Insulin Glargine 6
u SC twice a day includes the letter u, which means units but could be mistaken as the number 0 or 4,
and SC could be mistaken as SL. Enalapril 2.5 mg. PO three times a day, hold for systolic blood pressure
P a g e 1 | 65
, Fundamentals of Nursing 12th Edition P a g e | 2
<100 has a period after mg, which could be mistaken as the number 1, and the < sign could be
mistaken as greater than. The correctly written orders are
"Timoptic 0.25% solution 1 drop right eye BID.
Metoprolol 12.5 mg QD PO
Insulin glargine 6 units subcutaneous twice a day
Enalapril 2.5 mg PO three times a day, hold for systolic blood pressure less than 100."
Place the steps of administering an intradermal injection in the correct order.
1. Inject medication slowly
2. Note the presence of a bleb
3. Advance needle through epidermis to 3mm
4. Using nondominant hand, stretch skin over site with forefinger
5. Insert needle at a 5 to 15 degree angle into the skin until resistance is felt
6. Cleanse site with antiseptic swab –
Correct Answer :6, 4, 5, 3, 1, 2
Rationale: This is the correct sequence of steps to administer an intradermal injection.
After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's
burning and tingling where I got my injection." What should the nurse do next? (Select all that apply)
1. Assess the injection site
2. Administer an oral medication for pain
3. Notify the patient's health care provider of assessment findings
4. Document assessment findings and related interventions in the patient's medical record
5. This is a normal finding, so nothing needs to be done
6. Apply ice to the site for relief of burning pain –
Correct Answer :1, 3, 4
P a g e 2 | 65
, Fundamentals of Nursing 12th Edition P a g e | 3
Rationale: Assessing the injection site may reveal a sire reaction or induration from the injection. The
health care provider needs to be notified in case there is an adverse effect from the injection. The
nurse must always document adverse effects so that the site and patient can be monitored.
When administering medication intramuscularly, the nurse would document the intervention by
including which information? (Select all that apply)
1. Site of injection
2. The amount of medication injected
3. The name of the medication injected
4. The time the medication was prepared for injection
5. Confirmation that the medication was injected intramuscularly –
Correct Answer :1, 2, 3, 5
Rationale: Safe administration of medication requires appropriate documentation, which includes the
name, route, and amount of the medication; in the case of an injection, the site is also included. The
time the medication is given (not the time is was prepared) is included in the documentation.
A client who had surgery this morning has a distended bladder and is unable to void. Which nursing
interventions are most appropriate initially? Select all that apply.
1. Run warm water over the perineum
2. Have the client listen to the sound of running water
3. Obtain a prescription for an indwelling urinary catheter
4. Position the client on a bedpan with the head the bed elevated
5. Perform a bladder ultrasonography to evaluate the amount of urine left in the bladder –
Correct Answer :1, 2, 4, 5
Rationale: Before performing any interventions, the nurse should use a bladder ultrasonography to
obtain data about the amount of urine in the client's bladder. The nurse should first use conservative
methods such as maintaining a functional position with the head of the bed elevated, running warm
water over the perineum, and having the client listen to the sound of running water. If these
interventions are unsuccessful, the nurse should obtain a prescription for a straight catheterization.
The use of an indwelling catheter places the client at risk for infection.
P a g e 3 | 65
, Fundamentals of Nursing 12th Edition P a g e | 4
The nurse would determine which factors as contributing to stress incontinence in a female client?
Select all that apply.
1. Obesity
2. Sneezing
3. Nulliparity
4. Decreased estrogen
5. Performing Kegel exercises
6. Voiding at frequent intervals –
Correct Answer :1, 2, 4
Rationale: Obesity contributes to stress incontinence by causing intra-abdominal pressure. Sneezing or
laughing often causes leakage of urine. A decrease in estrogen levels after menopause is also a factor.
Nulliparity is not a factor, but a history of having three or more vaginal births may be a factor.
Performing Kegel exercises is a means of strengthening muscle tone. Voiding at regular intervals, such
as every 2 hours, decreases urine storage in the bladder, lessening the chance of incontinence.
Which information is most appropriate for the nurse to include in client teaching regarding ostomy
care? Select all that apply
1. Change the appliance daily
2. Empty the pouch when 1/3 to 1/2 full
3. The stoma should be dry and pale pink
4. The stoma should be moist and pink to red
5. The skin barrier should be within 1/16 to 1/8 inch of the stoma
6. Change the appliance every 3 day or longer, or if it is leaking effluent –
Correct Answer :2, 4, 5, 6
Rationale: The pouch should be emptied when 1/3 to 1/2 full to prevent the weight of contents from
loosening the seal. The stoma should be moist and pink to red in color. Keeping the skin barrier to
within 1/16 the 1/8 inch of the base of the stoma prevents effluent from irritating the skin. With an
adequate seal, changing the appliance every 3 days is adequate and may be done as infrequently as 2
weeks. Changing the appliance daily would damage the skin around the stoma. A stoma that is dry and
pale pink is indicative of an unhealthy stoma.
P a g e 4 | 65
