Saudi Prometric Nursing Fundamentals of Nursing 4 — Questions and Answers
Question 1: The nurse is preparing to perform a sterile dressing change. Which action breaks sterile technique?
- Reaching across the sterile field (Correct answer)
- Opening sterile packages away from the sterile field
- Keeping sterile items above waist level
- Wearing sterile gloves
Correct answer: Reaching across the sterile field
Reaching across a sterile field introduces contamination because the arm (non-sterile) passes over sterile items. Items must always be passed around, never over, a sterile field.
Question 2: A patient develops a stage 2 pressure injury. Which description best matches this stage?
- Partial-thickness skin loss with exposed dermis (Correct answer)
- Intact skin with non-blanchable erythema
- Full-thickness skin loss with visible subcutaneous fat
- Full-thickness tissue loss with exposed bone
Correct answer: Partial-thickness skin loss with exposed dermis
Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis. The wound bed is viable and may appear as a shallow open ulcer or intact/ruptured seroma. Stage 1 shows intact skin with non-blanchable redness.
Question 3: Which blood pressure reading would be classified as hypertension stage 1 according to current guidelines?
- 130–139/80–89 mmHg (Correct answer)
- 120–129/<80 mmHg
- <120/<80 mmHg
- ≥140/≥90 mmHg
Correct answer: 130–139/80–89 mmHg
According to updated cardiovascular guidelines, hypertension stage 1 is defined as systolic 130–139 mmHg or diastolic 80–89 mmHg. Elevated blood pressure is 120–129/<80, and stage 2 hypertension is ≥140/≥90.
Question 4: The nurse is caring for a post-operative patient with a nasogastric tube. Before administering tube feeding, the nurse should first:
- Verify tube placement by checking gastric pH and/or X-ray (Correct answer)
- Flush the tube with 30 mL of water
- Elevate the head of the bed to 30 degrees
- Check the patient's last bowel movement
Correct answer: Verify tube placement by checking gastric pH and/or X-ray
Verifying NG tube placement is the critical first step before any feeding to prevent aspiration. pH testing (gastric pH <5) and chest X-ray are the most reliable methods. Auscultation alone is no longer considered reliable.
Question 5: Which of the following is a NANDA-approved nursing diagnostic statement format?
- Risk for infection related to impaired skin integrity (Correct answer)
- Infection due to surgical wound
- Post-operative wound infection
- Infection secondary to incision
Correct answer: Risk for infection related to impaired skin integrity
NANDA nursing diagnoses follow the PES format (Problem + Etiology + Signs/Symptoms) or PE format for risk diagnoses. 'Risk for infection related to impaired skin integrity' correctly identifies a potential problem and its related factor.
Question 6: A patient's Glasgow Coma Scale score is 8. How should the nurse interpret this finding?
- Severe brain injury requiring immediate intervention (Correct answer)
- Mild confusion with intact orientation
- Moderate injury with expected full recovery
- Normal neurological status
Correct answer: Severe brain injury requiring immediate intervention
The Glasgow Coma Scale ranges from 3 (deep coma/brain death) to 15 (fully alert). A score of 8 or below indicates severe brain injury and typically necessitates airway management and urgent medical intervention.
Saudi Prometric Nursing Fundamentals of Nursing 4
The nurse is preparing to perform a sterile dressing change.
Which action breaks sterile technique?