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 the room of a client who is attempting to climb
over the side rails of the bed and appears confused. Which
action should the nurse take first?
A. Apply wrist restraints to prevent injury.
B. Lower the bed, stay with the client, and assess the cause of
the behavior.
C. Ask the nursing assistant to monitor the client while the
nurse finishes documentation.
D. Raise all four side rails to keep the client in bed.
Correct Answer: B
Rationale:
The priority is immediate client safety while assessing the
reason for the behavior. Lowering the bed reduces injury risk if
a fall occurs, remaining with the client provides supervision, and
assessment may identify reversible causes such as pain,
hypoxia, medication effects, or the need to use the restroom.
Restraints should only be used as a last resort when less
restrictive interventions fail. Raising all four side rails may be
considered a restraint and can increase injury risk if the client
attempts to climb over them.
Question 2
,A nurse is teaching a client how to use an incentive spirometer
after surgery. Which statement by the client indicates correct
understanding?
A. "I will blow into the device as hard as I can."
B. "I should inhale slowly and deeply through the mouthpiece."
C. "I only need to use the device if I become short of breath."
D. "I should exhale into the mouthpiece after each breath."
Correct Answer: B
Rationale:
An incentive spirometer promotes lung expansion through slow,
deep inhalation. Clients should inhale slowly through the
mouthpiece, hold their breath briefly at maximal inspiration,
and then exhale normally. Blowing into the device is incorrect
because it is designed for inhalation, not exhalation. Regular
use, even without symptoms, helps prevent postoperative
pulmonary complications.
Question 3
A nurse is caring for a client with limited mobility. Which
intervention is most effective for reducing the risk of pressure
injuries?
A. Massage reddened bony prominences.
B. Reposition the client at regular intervals and inspect the skin.
, C. Place the client in a high-Fowler position continuously.
D. Limit fluid intake to decrease episodes of incontinence.
Correct Answer: B
Rationale:
Frequent repositioning and routine skin assessment are key
evidence-based interventions to prevent pressure injuries.
Massaging reddened skin may increase tissue damage.
Prolonged high-Fowler positioning increases pressure over the
sacrum. Adequate hydration supports skin integrity and should
not be restricted without a clinical indication.
Question 4
A nurse delegates care to an experienced unlicensed assistive
personnel (UAP). Which task is appropriate to delegate?
A. Assess a client's pain after medication administration.
B. Teach a client how to use a walker safely.
C. Measure and record a stable client's intake and output.
D. Evaluate a client's response to discharge teaching.
Correct Answer: C
Rationale:
Measuring and documenting intake and output for a stable
client is within the role of trained UAP. Assessment, teaching,
and evaluation require nursing judgment and remain the
responsibility of the registered nurse.
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 the room of a client who is attempting to climb
over the side rails of the bed and appears confused. Which
action should the nurse take first?
A. Apply wrist restraints to prevent injury.
B. Lower the bed, stay with the client, and assess the cause of
the behavior.
C. Ask the nursing assistant to monitor the client while the
nurse finishes documentation.
D. Raise all four side rails to keep the client in bed.
Correct Answer: B
Rationale:
The priority is immediate client safety while assessing the
reason for the behavior. Lowering the bed reduces injury risk if
a fall occurs, remaining with the client provides supervision, and
assessment may identify reversible causes such as pain,
hypoxia, medication effects, or the need to use the restroom.
Restraints should only be used as a last resort when less
restrictive interventions fail. Raising all four side rails may be
considered a restraint and can increase injury risk if the client
attempts to climb over them.
Question 2
,A nurse is teaching a client how to use an incentive spirometer
after surgery. Which statement by the client indicates correct
understanding?
A. "I will blow into the device as hard as I can."
B. "I should inhale slowly and deeply through the mouthpiece."
C. "I only need to use the device if I become short of breath."
D. "I should exhale into the mouthpiece after each breath."
Correct Answer: B
Rationale:
An incentive spirometer promotes lung expansion through slow,
deep inhalation. Clients should inhale slowly through the
mouthpiece, hold their breath briefly at maximal inspiration,
and then exhale normally. Blowing into the device is incorrect
because it is designed for inhalation, not exhalation. Regular
use, even without symptoms, helps prevent postoperative
pulmonary complications.
Question 3
A nurse is caring for a client with limited mobility. Which
intervention is most effective for reducing the risk of pressure
injuries?
A. Massage reddened bony prominences.
B. Reposition the client at regular intervals and inspect the skin.
, C. Place the client in a high-Fowler position continuously.
D. Limit fluid intake to decrease episodes of incontinence.
Correct Answer: B
Rationale:
Frequent repositioning and routine skin assessment are key
evidence-based interventions to prevent pressure injuries.
Massaging reddened skin may increase tissue damage.
Prolonged high-Fowler positioning increases pressure over the
sacrum. Adequate hydration supports skin integrity and should
not be restricted without a clinical indication.
Question 4
A nurse delegates care to an experienced unlicensed assistive
personnel (UAP). Which task is appropriate to delegate?
A. Assess a client's pain after medication administration.
B. Teach a client how to use a walker safely.
C. Measure and record a stable client's intake and output.
D. Evaluate a client's response to discharge teaching.
Correct Answer: C
Rationale:
Measuring and documenting intake and output for a stable
client is within the role of trained UAP. Assessment, teaching,
and evaluation require nursing judgment and remain the
responsibility of the registered nurse.
