Nursing Fundamentals & Patient Care Flashcards

What is the correct order of the nursing process?

Answer: Assessment, Diagnosis, Planning, Implementation, Evaluation

The nursing process follows the sequence: Assessment (data collection), Diagnosis (identifying problems), Planning (setting goals), Implementation (carrying out interventions), and Evaluation (measuring outcomes). This ADPIE framework is universally accepted.

Which vital sign is considered the 'fifth vital sign' in modern nursing practice?

Answer: Pain

Pain is widely recognized as the fifth vital sign because it requires routine assessment alongside temperature, pulse, respiration, and blood pressure. The Joint Commission mandates regular pain assessment in accredited facilities.

A patient's urine output over 8 hours is 160 mL. How should the nurse interpret this finding?

Answer: Oliguria, requiring immediate reporting

Normal urine output is 0.5–1 mL/kg/hr or at least 30 mL/hr. Over 8 hours, minimum expected output is 240 mL. A reading of 160 mL (20 mL/hr) constitutes oliguria and must be reported promptly.

When performing hand hygiene using an alcohol-based hand rub, how long should the rubbing procedure take?

Answer: 20–30 seconds

WHO guidelines specify that alcohol-based hand rub should be applied and rubbed for 20–30 seconds covering all hand surfaces until hands are dry. This duration ensures adequate antimicrobial contact time.

Which position is most appropriate for a patient experiencing respiratory distress?

Answer: High Fowler's (90°)

High Fowler's position (head of bed at 90°) maximizes diaphragm excursion and lung expansion by using gravity to lower abdominal organs away from the diaphragm, reducing the work of breathing.

What does the acronym SBAR stand for in clinical communication?

Answer: Situation, Background, Assessment, Recommendation

SBAR (Situation, Background, Assessment, Recommendation) is a standardized communication framework used during patient handoffs and critical communications to ensure complete and concise information transfer.