Nursing Fundamentals & Patient Care Flashcards

Which site is preferred for intramuscular injection in adults to avoid the sciatic nerve?

Answer: Ventrogluteal site

The ventrogluteal site is the preferred IM injection site in adults because it is free of major nerves and blood vessels, has a thick muscle mass, and is easy to locate. The dorsogluteal site carries risk of sciatic nerve injury.

A patient's blood pressure reads 168/98 mmHg. According to JNC guidelines, this is classified as:

Answer: Hypertension Stage 2

Per ACC/AHA guidelines, Stage 2 hypertension is defined as systolic ≥140 mmHg or diastolic ≥90 mmHg. A reading of 168/98 mmHg exceeds both thresholds and requires prompt clinical evaluation and management.

What does a pulse oximetry reading of 88% SpO2 indicate in a previously healthy adult?

Answer: Significant hypoxemia requiring immediate oxygen therapy

Normal SpO2 in a healthy adult is 95–100%. An SpO2 of 88% represents significant hypoxemia. Supplemental oxygen should be applied immediately and the cause investigated. Target SpO2 is generally ≥94% for most patients.

Which action best demonstrates the principle of patient autonomy in nursing care?

Answer: Providing complete information so the patient can make an informed decision

Autonomy means the patient's right to self-determination. Nurses uphold this by ensuring patients receive complete, understandable information to make informed decisions. Overriding a patient's decision violates autonomy.

A nurse accidentally administers the wrong medication. What is the first priority action?

Answer: Assess the patient for adverse reactions and notify the physician

Patient safety is the first priority. The nurse must immediately assess the patient for harm, notify the physician for orders if needed, and then follow facility incident reporting procedures. Documentation follows patient stabilization.

What is the purpose of a nursing diagnosis (as defined by NANDA)?

Answer: To describe a clinical judgment about a human response to health conditions

A NANDA nursing diagnosis is a clinical judgment about a patient's, family's, or community's response to actual or potential health problems. It differs from a medical diagnosis, which identifies disease. Nursing diagnoses guide nursing interventions.