Fundamentals of Nursing Flashcards

The nurse is performing a physical assessment and notices the patient has clubbing of the fingers. This finding is most commonly associated with:

Answer: Chronic hypoxia

Digital clubbing is associated with chronic hypoxia, most commonly due to chronic lung diseases (e.g., COPD, cystic fibrosis) or cyanotic heart disease. The mechanism involves chronic tissue hypoxia causing soft tissue proliferation.

Which nursing intervention is most important when caring for a patient with increased intracranial pressure (ICP)?

Answer: Elevate the head of the bed to 30 degrees and maintain neutral head alignment

Elevating the head of the bed to 30 degrees and keeping the head in neutral alignment facilitates venous drainage from the brain, helping to reduce ICP. Flat positioning increases ICP by impeding venous outflow.

A nurse receives a verbal order from a physician. The nurse should:

Answer: Read back the order to the physician to confirm accuracy, then document it

Verbal orders should be repeated back (read-back) to confirm accuracy, then documented as a verbal order with the nurse's signature, physician's name, date, and time. This reduces transcription errors.

Which nursing action best prevents catheter-associated urinary tract infections (CAUTIs)?

Answer: Remove the urinary catheter as soon as it is no longer clinically indicated

The most effective CAUTI prevention strategy is prompt removal of urinary catheters when no longer needed. Every additional day of catheterization increases infection risk by 3–7%. Maintaining closed drainage and below-bladder positioning are also important.

The nurse is assessing a patient with a new colostomy. Which finding should be reported immediately to the physician?

Answer: Dark purple, dusky stoma

A dark purple or dusky stoma indicates impaired blood supply and possible necrosis, which is a surgical emergency. A healthy stoma should be moist, pink-red, and slightly raised. Any sign of ischemia requires immediate reporting.

Which of the following demonstrates the correct technique for measuring blood pressure?

Answer: Patient seated, arm at heart level, cuff covers 80% of arm circumference

Accurate BP measurement requires the patient to be seated with feet flat on the floor, the arm supported at heart level, and the cuff bladder covering 80% of the arm circumference. The patient should have rested for at least 5 minutes.