FUNDAMENTALS OF NURSING
12TH EDITION
• AUTHOR(S)PATRICIA A. POTTER;
ANNE G. PERRY; PATRICIA A.
STOCKERT; AMY HALL; WENDY
R. OSTENDORF
TEST BANK
,rationale for Question 20.
Question 1
A nurse is caring for a client who is prescribed a 24-hour urine
collection. Which of the following actions should the nurse take
to ensure accurate collection?
A. Instruct the client to void at the start time and discard that
urine.
B. Keep the collection container at room temperature
throughout the collection.
C. Place the urine collection container in the client's bathroom
for easy access.
D. Collect all urine from the start time until the end time,
including the final void.
Correct Answer: A
Rationale:
The correct procedure for a 24-hour urine collection is to have
the client void completely at the start time and discard that
specimen, as it represents urine produced before the collection
period. The collection then begins with the next void, and all
subsequent urine is collected, including the final void at the end
of the 24-hour period. The container should be kept
refrigerated or on ice to prevent bacterial growth and
,breakdown of urine components, not at room temperature. For
safety and to prevent contamination, the container should be
stored in a designated area, such as a biohazard refrigerator,
not in the client's bathroom.
Question 2
A client newly diagnosed with diabetes mellitus is learning to
self-administer insulin. The client accurately draws up the
correct dose but then asks, "Why do I have to wipe the top of
the vial with alcohol if it's already clean?" Which of the
following is the most appropriate nursing response?
A. "The alcohol helps to lubricate the needle for easier insertion
into the vial."
B. "It is a standard precaution to destroy any bacteria that may
be on the rubber stopper."
C. "This step is only necessary if the vial has been used before."
D. "It ensures that the insulin concentration is not diluted by
the needle."
Correct Answer: B
Rationale:
Wiping the rubber stopper of an insulin vial with an alcohol
swab is a crucial aseptic technique to reduce the risk of
infection by destroying microorganisms on the surface. This
standard precaution is performed each time the vial is accessed
to maintain sterility and prevent contamination of the
, medication. It does not lubricate the needle, is not only for
previously used vials, and does not affect the concentration of
the insulin.
Question 3
The nurse is preparing to administer a tube feeding to a client
via a nasogastric (NG) tube. Which of the following actions
should the nurse take first?
A. Flush the tube with 30 mL of water.
B. Check the placement of the tube by aspirating gastric
contents.
C. Verify the tube feeding prescription with the medication
administration record (MAR).
D. Position the client in a supine position.
Correct Answer: C
Rationale:
The first action in any medication or treatment administration is
to verify the prescription against the MAR to ensure the right
client, right route, right dose, right time, and right solution. This
is a critical patient safety step. After verification, the nurse
would then assess tube placement by checking the pH of
aspirated contents and confirm tube position, flush the tube,
and position the client in a semi-Fowler's or high-Fowler's
position to prevent aspiration, not supine.
12TH EDITION
• AUTHOR(S)PATRICIA A. POTTER;
ANNE G. PERRY; PATRICIA A.
STOCKERT; AMY HALL; WENDY
R. OSTENDORF
TEST BANK
,rationale for Question 20.
Question 1
A nurse is caring for a client who is prescribed a 24-hour urine
collection. Which of the following actions should the nurse take
to ensure accurate collection?
A. Instruct the client to void at the start time and discard that
urine.
B. Keep the collection container at room temperature
throughout the collection.
C. Place the urine collection container in the client's bathroom
for easy access.
D. Collect all urine from the start time until the end time,
including the final void.
Correct Answer: A
Rationale:
The correct procedure for a 24-hour urine collection is to have
the client void completely at the start time and discard that
specimen, as it represents urine produced before the collection
period. The collection then begins with the next void, and all
subsequent urine is collected, including the final void at the end
of the 24-hour period. The container should be kept
refrigerated or on ice to prevent bacterial growth and
,breakdown of urine components, not at room temperature. For
safety and to prevent contamination, the container should be
stored in a designated area, such as a biohazard refrigerator,
not in the client's bathroom.
Question 2
A client newly diagnosed with diabetes mellitus is learning to
self-administer insulin. The client accurately draws up the
correct dose but then asks, "Why do I have to wipe the top of
the vial with alcohol if it's already clean?" Which of the
following is the most appropriate nursing response?
A. "The alcohol helps to lubricate the needle for easier insertion
into the vial."
B. "It is a standard precaution to destroy any bacteria that may
be on the rubber stopper."
C. "This step is only necessary if the vial has been used before."
D. "It ensures that the insulin concentration is not diluted by
the needle."
Correct Answer: B
Rationale:
Wiping the rubber stopper of an insulin vial with an alcohol
swab is a crucial aseptic technique to reduce the risk of
infection by destroying microorganisms on the surface. This
standard precaution is performed each time the vial is accessed
to maintain sterility and prevent contamination of the
, medication. It does not lubricate the needle, is not only for
previously used vials, and does not affect the concentration of
the insulin.
Question 3
The nurse is preparing to administer a tube feeding to a client
via a nasogastric (NG) tube. Which of the following actions
should the nurse take first?
A. Flush the tube with 30 mL of water.
B. Check the placement of the tube by aspirating gastric
contents.
C. Verify the tube feeding prescription with the medication
administration record (MAR).
D. Position the client in a supine position.
Correct Answer: C
Rationale:
The first action in any medication or treatment administration is
to verify the prescription against the MAR to ensure the right
client, right route, right dose, right time, and right solution. This
is a critical patient safety step. After verification, the nurse
would then assess tube placement by checking the pH of
aspirated contents and confirm tube position, flush the tube,
and position the client in a semi-Fowler's or high-Fowler's
position to prevent aspiration, not supine.
