DOH Nursing Nursing Fundamentals & Patient Care 1 — Questions and Answers
Question 1: What is the correct order of the nursing process?
- Assessment, Diagnosis, Planning, Implementation, Evaluation (Correct answer)
- Diagnosis, Assessment, Planning, Evaluation, Implementation
- Planning, Assessment, Diagnosis, Implementation, Evaluation
- Assessment, Planning, Diagnosis, Implementation, Evaluation
Correct 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.
Question 2: Which vital sign is considered the 'fifth vital sign' in modern nursing practice?
- Pain (Correct answer)
- Blood pressure
- Oxygen saturation
- Respiratory rate
Correct 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.
Question 3: A patient's urine output over 8 hours is 160 mL. How should the nurse interpret this finding?
- Oliguria, requiring immediate reporting (Correct answer)
- Normal output for 8 hours
- Polyuria, indicating fluid overload
- Anuria, a critical emergency
Correct 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.
Question 4: When performing hand hygiene using an alcohol-based hand rub, how long should the rubbing procedure take?
- 20–30 seconds (Correct answer)
- 5–10 seconds
- 60–90 seconds
- 10–15 seconds
Correct 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.
Question 5: Which position is most appropriate for a patient experiencing respiratory distress?
- High Fowler's (90°) (Correct answer)
- Supine
- Trendelenburg
- Prone
Correct 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.
Question 6: What does the acronym SBAR stand for in clinical communication?
- Situation, Background, Assessment, Recommendation (Correct answer)
- Safety, Background, Action, Response
- Situation, Brief, Action, Report
- Status, Background, Assessment, Response
Correct 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.
DOH Nursing Nursing Fundamentals & Patient Care 1
What is the correct order of the nursing process?