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 assessing four hospitalized clients at the beginning of
the shift. Which client should the nurse assess first?
A. A client reporting incisional pain rated 6/10 after receiving
analgesics 2 hours ago
B. A client with a blood pressure of 138/82 mm Hg requesting
assistance to the bathroom
C. A client who suddenly becomes confused and is attempting
to climb out of bed
D. A client scheduled for discharge who needs medication
teaching
Correct Answer: C
Rationale:
An acute change in mental status may indicate hypoxia,
infection, stroke, medication effects, or another life-threatening
condition. The confused client attempting to leave the bed is
also at immediate risk for injury. This client requires prompt
assessment and intervention. The other clients have important
but less urgent needs that can safely follow after addressing the
immediate safety concern.
Question 2
,A nurse is preparing to delegate tasks to an experienced
unlicensed assistive personnel (UAP). Which task is appropriate
to delegate?
A. Assess a client's response to pain medication
B. Reinforce teaching about insulin administration
C. Obtain routine vital signs for a stable client
D. Develop a nursing care plan
Correct Answer: C
Rationale:
Routine vital signs for a stable client may be delegated to
trained UAP. Nursing assessment, patient education, evaluation
of treatment effectiveness, and care planning require nursing
judgment and remain the responsibility of the registered nurse.
Question 3
A client states, "I don't think this treatment is helping me."
Which response by the nurse demonstrates therapeutic
communication?
A. "You shouldn't feel that way."
B. "Tell me more about what concerns you."
C. "The provider knows what is best."
D. "Let's discuss that after your next treatment."
Correct Answer: B
, Rationale:
Inviting the client to elaborate encourages open
communication, demonstrates empathy, and provides valuable
assessment information. Dismissing concerns, offering false
reassurance, or delaying the discussion may hinder the
therapeutic relationship.
Question 4
A nurse enters a client's room and discovers the client lying on
the floor. What is the nurse's priority action?
A. Return the client to bed immediately
B. Assess the client for injuries and level of consciousness
C. Complete an incident report
D. Notify the client's family
Correct Answer: B
Rationale:
The nurse should first assess the client's condition, including
airway, breathing, circulation, level of consciousness, pain, and
possible injuries before moving the client unless immediate
danger exists. Documentation, notifications, and reporting
occur after the client's immediate safety needs are addressed.
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 is assessing four hospitalized clients at the beginning of
the shift. Which client should the nurse assess first?
A. A client reporting incisional pain rated 6/10 after receiving
analgesics 2 hours ago
B. A client with a blood pressure of 138/82 mm Hg requesting
assistance to the bathroom
C. A client who suddenly becomes confused and is attempting
to climb out of bed
D. A client scheduled for discharge who needs medication
teaching
Correct Answer: C
Rationale:
An acute change in mental status may indicate hypoxia,
infection, stroke, medication effects, or another life-threatening
condition. The confused client attempting to leave the bed is
also at immediate risk for injury. This client requires prompt
assessment and intervention. The other clients have important
but less urgent needs that can safely follow after addressing the
immediate safety concern.
Question 2
,A nurse is preparing to delegate tasks to an experienced
unlicensed assistive personnel (UAP). Which task is appropriate
to delegate?
A. Assess a client's response to pain medication
B. Reinforce teaching about insulin administration
C. Obtain routine vital signs for a stable client
D. Develop a nursing care plan
Correct Answer: C
Rationale:
Routine vital signs for a stable client may be delegated to
trained UAP. Nursing assessment, patient education, evaluation
of treatment effectiveness, and care planning require nursing
judgment and remain the responsibility of the registered nurse.
Question 3
A client states, "I don't think this treatment is helping me."
Which response by the nurse demonstrates therapeutic
communication?
A. "You shouldn't feel that way."
B. "Tell me more about what concerns you."
C. "The provider knows what is best."
D. "Let's discuss that after your next treatment."
Correct Answer: B
, Rationale:
Inviting the client to elaborate encourages open
communication, demonstrates empathy, and provides valuable
assessment information. Dismissing concerns, offering false
reassurance, or delaying the discussion may hinder the
therapeutic relationship.
Question 4
A nurse enters a client's room and discovers the client lying on
the floor. What is the nurse's priority action?
A. Return the client to bed immediately
B. Assess the client for injuries and level of consciousness
C. Complete an incident report
D. Notify the client's family
Correct Answer: B
Rationale:
The nurse should first assess the client's condition, including
airway, breathing, circulation, level of consciousness, pain, and
possible injuries before moving the client unless immediate
danger exists. Documentation, notifications, and reporting
occur after the client's immediate safety needs are addressed.
Question 5
