Fundamentals of Nursing Flashcards

A nurse is preparing to administer a blood transfusion to a patient in a Saudi MOH hospital. After confirming the patient's identity using two identifiers, the nurse notes the blood unit was issued 28 minutes ago. The patient's baseline vital signs are: BP 118/76 mmHg, HR 82 bpm, Temp 37.1°C. Fifteen minutes into the transfusion, the patient reports lower back pain and the nurse notes haemoglobinuria. Which action is the highest priority?

Answer: Stop the transfusion immediately, keep the IV line open with normal saline, and notify the physician and blood bank

Lower back pain and haemoglobinuria are hallmark signs of an acute haemolytic transfusion reaction (AHTR), the most dangerous transfusion reaction caused by ABO incompatibility. Per SCFHS nursing standards and Saudi MOH haemovigilance protocols, the nurse must immediately stop the transfusion, maintain IV access with 0.9% NaCl via new tubing, notify the physician and blood bank, and return the blood unit with a fresh patient sample for re-crossmatch. Slowing the rate or administering antihistamines is appropriate for allergic reactions, not haemolytic ones, and delays life-saving intervention.

A nurse working in a general medical ward in Riyadh is caring for a 68-year-old male patient with chronic kidney disease (CKD) Stage 4. The physician prescribes enemas until clear for bowel preparation before a diagnostic procedure. After the third enema, the patient becomes increasingly lethargic and his serum sodium returns at 128 mEq/L. Which physiological mechanism best explains this complication?

Answer: Absorption of hypotonic tap water through the colonic mucosa leading to dilutional hyponatraemia

In CKD patients, the kidneys cannot excrete free water efficiently. Repeated tap water enemas result in absorption of hypotonic fluid across the colonic mucosa, expanding intravascular volume and diluting serum sodium — producing dilutional (hypotonic) hyponatraemia. This is particularly dangerous in CKD Stage 4 where GFR is 15–29 mL/min/1.73m². SCFHS guidelines emphasise caution with volume-expanding procedures in renally impaired patients. Sodium is not lost in significant quantities through stool, and aldosterone/ADH mechanisms described in the other options do not account for the primary pathophysiology here.

Under the Saudi Health Information National Center (SHINC) standards adopted by SCFHS, a nurse documenting in an electronic health record (EHR) discovers a charting error made 2 hours ago — she incorrectly documented a patient's pain score as 2/10 when it was actually 8/10, which led to delayed analgesia. What is the correct procedure to handle this electronic documentation error?

Answer: Add a late entry notation with the current date/time, correct the pain score, state the reason for the amendment, and co-sign with the nursing supervisor

Saudi MOH and SCFHS documentation standards — aligned with SHINC's EHR governance framework — require that errors in health records never be deleted or backdated. The correct approach is to add a clearly labelled late entry with the actual current date and time, document the corrected information, provide a reason for the amendment, and have a supervisor co-sign when the error had clinical consequences. Deleting or overwriting original entries constitutes falsification of medical records, a violation of the Saudi Health Professions Licensure Law and grounds for disciplinary action by SCFHS.

A nurse is performing wound care for a patient with a Stage III pressure injury over the sacrum. The wound bed shows 70% yellow slough and 30% granulation tissue. There is no clinical sign of infection. The physician orders wet-to-dry dressing changes three times daily. Based on current evidence-based wound care principles aligned with Saudi SCFHS competency standards, what should the nurse do?

Answer: Clarify the order with the physician and advocate for moist wound healing dressings such as hydrocolloid or foam, as wet-to-dry dressings are non-selective and damage granulation tissue

Evidence-based practice — endorsed by SCFHS and aligned with international wound care guidelines adopted in Saudi MOH facilities — indicates that wet-to-dry dressings are non-selective debridement methods that remove viable granulation tissue along with slough, causing pain and impairing healing. For Stage III pressure injuries with slough, moist wound healing using autolytic debridement agents (hydrocolloid, foam, or alginate dressings) is preferred. The nurse has both a professional and ethical obligation under SCFHS Code of Ethics to advocate for evidence-based care and clarify orders that may cause patient harm. Povidone-iodine is cytotoxic to granulation tissue; bedside sharp debridement requires specific credentialing beyond standard nursing scope.

A 52-year-old female patient is admitted to a Saudi hospital with suspected pulmonary embolism. She is on a therapeutic heparin infusion at 1,200 units/hour. Her most recent aPTT result is 210 seconds (therapeutic range: 60–100 seconds). The patient is now requesting to get up independently to use the bathroom. Concurrently, you note she has developed a petechial rash on both forearms. What is your priority nursing action?

Answer: Hold the heparin infusion, keep the patient on strict bed rest, notify the physician immediately with the aPTT result and new rash findings

An aPTT of 210 seconds is critically supratherapeutic (>3× the upper therapeutic limit), indicating severe anticoagulation with high bleeding risk. The petechial rash on the forearms suggests early bleeding manifestation, possibly early heparin-induced thrombocytopenia (HIT) or coagulopathy. Per SCFHS-aligned critical value protocols, a critically supratherapeutic aPTT is a medical emergency requiring immediate cessation of heparin, full bed rest to minimise trauma risk, and urgent physician notification. Ambulating this patient — even with assistance — risks a catastrophic intracranial haemorrhage or internal bleed. Adjusting the rate independently or delaying notification is a scope-of-practice violation in Saudi MOH facilities.

A nurse working in a Saudi hospital ICU is suctioning the endotracheal tube (ETT) of a mechanically ventilated patient using a closed inline suction system. Midway through suctioning, the cardiac monitor alarms and shows a ventricular rate of 38 bpm with wide, bizarre complexes. SpO₂ drops from 97% to 79%. The patient's eyes open and she appears distressed. Which sequence of actions reflects correct prioritisation?

Answer: Immediately withdraw the suction catheter, re-oxygenate the patient via the ventilator at 100% FiO₂, call for emergency assistance, and assess for return to baseline before documenting

Vagal stimulation from deep suctioning can cause severe hypoxia and vasovagal bradycardia. The correct priority sequence per SCFHS critical care nursing competencies is: (1) immediately cease suctioning and withdraw the catheter — prolonging suction worsens hypoxia; (2) restore oxygenation by delivering 100% FiO₂ through the closed circuit or ventilator hyperoxgenation; (3) activate the emergency response team. The bradycardia and desaturation are suction-induced, not primary cardiac events, so the most effective intervention is stopping the triggering cause and restoring oxygen. Completing the suction pass or increasing PEEP independently without addressing the immediate hypoxic-vagal crisis escalates the risk of cardiac arrest. Manual BMV disconnects PEEP and risks VAP in this context.