Fundamentals of Nursing Flashcards

A nurse is preparing to perform a sterile dressing change. Which action would contaminate the sterile field?

Answer: Reaching across the sterile field to retrieve an item on the opposite side

Reaching across a sterile field contaminates it because the nurse's arm passes over the field, which is not considered sterile.

When performing a head-to-toe assessment, the nurse auscultates bowel sounds and hears high-pitched, gurgling sounds every 5–15 seconds. How should the nurse document this finding?

Answer: Normal bowel sounds

Normal bowel sounds occur every 5–30 seconds and are described as high-pitched, gurgling sounds.

A patient's urinary output over 8 hours is 200 mL. The nurse recognizes this as:

Answer: Oliguria

Oliguria is defined as urine output less than 30 mL/hour; 200 mL over 8 hours equals 25 mL/hour, which is oliguria.

Which position is most appropriate for a patient experiencing dyspnea?

Answer: High Fowler's (90°)

High Fowler's position maximizes diaphragmatic excursion and lung expansion, relieving dyspnea.

The nurse is about to administer a medication and the patient states, 'That pill looks different than usual.' What is the nurse's priority action?

Answer: Hold the medication and verify the order

Patient statements about medication appearance are a safety cue; the nurse must hold and verify before administering.

A nurse is teaching a patient about diaphragmatic breathing. Which instruction is correct?

Answer: Place one hand on the chest and one on the abdomen; the abdomen should rise more

In diaphragmatic breathing, abdominal rise should predominate over chest rise, indicating proper use of the diaphragm.

Which finding indicates that a patient's nasogastric tube is correctly placed in the stomach?

Answer: Aspiration of gastric contents with a pH of 1–4

Gastric aspirate with a pH of 1–4 confirms correct placement in the stomach before administering feedings.