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 preparing to administer a scheduled antihypertensive
medication. Before giving the medication, the nurse finds the
patient's blood pressure is significantly lower than previous
readings. What is the nurse's priority action?
A. Administer the medication as prescribed.
B. Withhold the medication and notify the provider after
assessing the patient.
C. Ask another nurse to administer the medication.
D. Document the blood pressure after administering the
medication.
Correct Answer: B
Rationale:
The nurse should assess the patient, compare the current
findings with previous values, and withhold the medication if
administration may place the patient at risk. The provider
should then be notified for further instructions. Administering
the medication without evaluating the change could worsen
hypotension. Delegating the decision to another nurse is
inappropriate, and documentation alone does not address
patient safety.
Question 2
,A postoperative patient tells the nurse, "My pain is getting
worse even though I received medication an hour ago." What is
the nurse's best initial response?
A. "The medication needs more time to work."
B. "Rate your pain on a scale from 0 to 10 and describe where it
hurts."
C. "You should try to sleep until your next dose."
D. "Pain is expected after surgery."
Correct Answer: B
Rationale:
The nurse should reassess the patient's pain before determining
the next intervention. A comprehensive assessment includes
intensity, location, quality, and associated symptoms.
Reassessing supports clinical judgment and guides appropriate
pain management. Assuming the medication simply needs
more time or dismissing the patient's concerns is not patient-
centered.
Question 3
A nurse is caring for a patient who is at high risk for falls. Which
intervention is most appropriate?
A. Raise all four side rails at all times.
B. Keep the bed in the lowest position and ensure the call light
is within reach.
, C. Encourage the patient to walk independently.
D. Apply wrist restraints during the night.
Correct Answer: B
Rationale:
Keeping the bed low and the call light accessible promotes
safety while encouraging patient independence. Raising all side
rails may be considered a restraint and can increase injury risk.
Restraints should not be used for fall prevention except under
specific circumstances. Encouraging independent ambulation
without assistance increases fall risk.
Question 4
A nurse is caring for a patient with limited mobility. Which
assessment finding requires the most immediate intervention?
A. Mild redness over the sacrum that blanches with pressure.
B. Dry skin on both lower legs.
C. An open area over the heel with visible subcutaneous tissue.
D. Thickened toenails.
Correct Answer: C
Rationale:
An open wound with visible subcutaneous tissue indicates
significant tissue injury requiring prompt intervention to
prevent infection and further deterioration. Blanchable redness
requires preventive measures but is less urgent. Dry skin and
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 preparing to administer a scheduled antihypertensive
medication. Before giving the medication, the nurse finds the
patient's blood pressure is significantly lower than previous
readings. What is the nurse's priority action?
A. Administer the medication as prescribed.
B. Withhold the medication and notify the provider after
assessing the patient.
C. Ask another nurse to administer the medication.
D. Document the blood pressure after administering the
medication.
Correct Answer: B
Rationale:
The nurse should assess the patient, compare the current
findings with previous values, and withhold the medication if
administration may place the patient at risk. The provider
should then be notified for further instructions. Administering
the medication without evaluating the change could worsen
hypotension. Delegating the decision to another nurse is
inappropriate, and documentation alone does not address
patient safety.
Question 2
,A postoperative patient tells the nurse, "My pain is getting
worse even though I received medication an hour ago." What is
the nurse's best initial response?
A. "The medication needs more time to work."
B. "Rate your pain on a scale from 0 to 10 and describe where it
hurts."
C. "You should try to sleep until your next dose."
D. "Pain is expected after surgery."
Correct Answer: B
Rationale:
The nurse should reassess the patient's pain before determining
the next intervention. A comprehensive assessment includes
intensity, location, quality, and associated symptoms.
Reassessing supports clinical judgment and guides appropriate
pain management. Assuming the medication simply needs
more time or dismissing the patient's concerns is not patient-
centered.
Question 3
A nurse is caring for a patient who is at high risk for falls. Which
intervention is most appropriate?
A. Raise all four side rails at all times.
B. Keep the bed in the lowest position and ensure the call light
is within reach.
, C. Encourage the patient to walk independently.
D. Apply wrist restraints during the night.
Correct Answer: B
Rationale:
Keeping the bed low and the call light accessible promotes
safety while encouraging patient independence. Raising all side
rails may be considered a restraint and can increase injury risk.
Restraints should not be used for fall prevention except under
specific circumstances. Encouraging independent ambulation
without assistance increases fall risk.
Question 4
A nurse is caring for a patient with limited mobility. Which
assessment finding requires the most immediate intervention?
A. Mild redness over the sacrum that blanches with pressure.
B. Dry skin on both lower legs.
C. An open area over the heel with visible subcutaneous tissue.
D. Thickened toenails.
Correct Answer: C
Rationale:
An open wound with visible subcutaneous tissue indicates
significant tissue injury requiring prompt intervention to
prevent infection and further deterioration. Blanchable redness
requires preventive measures but is less urgent. Dry skin and
