Fundamentals of Nursing Flashcards

The nurse is preparing to perform a sterile dressing change. Which action breaks sterile technique?

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.

A patient develops a stage 2 pressure injury. Which description best matches this stage?

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.

Which blood pressure reading would be classified as hypertension stage 1 according to current guidelines?

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.

The nurse is caring for a post-operative patient with a nasogastric tube. Before administering tube feeding, the nurse should first:

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.

Which of the following is a NANDA-approved nursing diagnostic statement format?

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.

A patient's Glasgow Coma Scale score is 8. How should the nurse interpret this finding?

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.