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 client's room and finds the client lying on the
floor next to the bed. What is the nurse's priority action?
A. Assist the client back to bed immediately
B. Assess the client for injuries and level of consciousness
C. Complete an incident report
D. Notify the health care provider
Correct Answer: B
Rationale:
The nurse should first assess the client for injuries,
responsiveness, pain, and potential complications before
moving the client. Assessment is the priority because
movement could worsen an undetected injury. After
assessment and ensuring safety, the nurse can notify the
provider, assist the client as appropriate, and complete required
documentation.
Question 2
A nurse is caring for a client who is at risk for pressure injuries.
Which intervention is most appropriate?
A. Massage reddened bony prominences every shift
B. Reposition the client at least every 2 hours
C. Keep the head of the bed elevated above 60 degrees
D. Use a donut-shaped cushion under the sacrum
,Correct Answer: B
Rationale:
Regular repositioning reduces prolonged pressure on tissues
and promotes circulation. Massaging reddened areas can cause
tissue damage. Excessive head-of-bed elevation increases shear
forces. Donut-shaped devices may impair circulation and
increase pressure injury risk.
Question 3
A nurse is teaching a client about proper hand hygiene. Which
statement by the client indicates understanding?
A. "I only need to wash my hands when they look dirty."
B. "Hand hygiene is important before and after contact with
patients."
C. "Alcohol-based sanitizer should be used only after soap and
water."
D. "Gloves eliminate the need for hand hygiene."
Correct Answer: B
Rationale:
Hand hygiene should be performed before and after patient
contact to reduce transmission of microorganisms. Hands
should be cleaned even when not visibly soiled. Alcohol-based
hand rubs are effective in many situations and do not require
, prior soap-and-water washing unless hands are visibly dirty or
contaminated. Gloves do not replace hand hygiene.
Question 4
A nurse delegates ambulation of a stable postoperative client to
an assistive personnel (AP). Which action requires nurse follow-
up?
A. The AP reports dizziness during ambulation
B. The AP documents the distance walked
C. The AP assists the client with nonskid footwear
D. The AP encourages the client during ambulation
Correct Answer: A
Rationale:
Dizziness is an unexpected finding that requires nursing
assessment and clinical judgment. Documentation, use of safety
measures, and encouragement are appropriate tasks for AP. The
nurse remains responsible for evaluating and responding to
changes in client condition.
Question 5
A client states, "I'm worried that my surgery will not go well."
Which response by the nurse demonstrates therapeutic
communication?
A. "You shouldn't worry about that."
B. "Everything will be fine."
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 lying on the
floor next to the bed. What is the nurse's priority action?
A. Assist the client back to bed immediately
B. Assess the client for injuries and level of consciousness
C. Complete an incident report
D. Notify the health care provider
Correct Answer: B
Rationale:
The nurse should first assess the client for injuries,
responsiveness, pain, and potential complications before
moving the client. Assessment is the priority because
movement could worsen an undetected injury. After
assessment and ensuring safety, the nurse can notify the
provider, assist the client as appropriate, and complete required
documentation.
Question 2
A nurse is caring for a client who is at risk for pressure injuries.
Which intervention is most appropriate?
A. Massage reddened bony prominences every shift
B. Reposition the client at least every 2 hours
C. Keep the head of the bed elevated above 60 degrees
D. Use a donut-shaped cushion under the sacrum
,Correct Answer: B
Rationale:
Regular repositioning reduces prolonged pressure on tissues
and promotes circulation. Massaging reddened areas can cause
tissue damage. Excessive head-of-bed elevation increases shear
forces. Donut-shaped devices may impair circulation and
increase pressure injury risk.
Question 3
A nurse is teaching a client about proper hand hygiene. Which
statement by the client indicates understanding?
A. "I only need to wash my hands when they look dirty."
B. "Hand hygiene is important before and after contact with
patients."
C. "Alcohol-based sanitizer should be used only after soap and
water."
D. "Gloves eliminate the need for hand hygiene."
Correct Answer: B
Rationale:
Hand hygiene should be performed before and after patient
contact to reduce transmission of microorganisms. Hands
should be cleaned even when not visibly soiled. Alcohol-based
hand rubs are effective in many situations and do not require
, prior soap-and-water washing unless hands are visibly dirty or
contaminated. Gloves do not replace hand hygiene.
Question 4
A nurse delegates ambulation of a stable postoperative client to
an assistive personnel (AP). Which action requires nurse follow-
up?
A. The AP reports dizziness during ambulation
B. The AP documents the distance walked
C. The AP assists the client with nonskid footwear
D. The AP encourages the client during ambulation
Correct Answer: A
Rationale:
Dizziness is an unexpected finding that requires nursing
assessment and clinical judgment. Documentation, use of safety
measures, and encouragement are appropriate tasks for AP. The
nurse remains responsible for evaluating and responding to
changes in client condition.
Question 5
A client states, "I'm worried that my surgery will not go well."
Which response by the nurse demonstrates therapeutic
communication?
A. "You shouldn't worry about that."
B. "Everything will be fine."
