Fundamentals of Nursing Flashcards

A nurse in a Saudi Ministry of Health hospital is preparing to perform a sterile dressing change on a patient with a stage III pressure injury. During the procedure, the nurse's sterile glove accidentally touches the outer edge of the sterile field border (2 cm from the edge). What is the most appropriate action?

Answer: Consider the glove contaminated and replace it before continuing

In sterile technique, a 2.5 cm (1-inch) border around the edges of a sterile field is considered contaminated. Since the glove touched within this border zone, it is considered contaminated regardless of how briefly or lightly contact occurred. The nurse must replace the glove immediately before continuing. Wiping with alcohol does not restore sterility, and there is no 'brief contact' exception in aseptic technique principles.

A nurse is performing a physical assessment on a post-operative Saudi patient and notes a capillary refill time of 4 seconds in the fingertips. The patient's SpO₂ is 97% and the room temperature is 18°C. How should the nurse interpret this finding?

Answer: Normal variant — ambient room temperature below 20°C can prolong capillary refill time in healthy individuals

Normal capillary refill time is less than 2 seconds in warm conditions. However, cold ambient temperatures (below 20°C) cause peripheral vasoconstriction that physiologically prolongs capillary refill time beyond 2–3 seconds without indicating true peripheral vascular compromise. With an SpO₂ of 97% and no other signs of circulatory impairment, the prolonged CRT in a cold room (18°C) is a normal environmental variant. The nurse should reassess in a warmer environment before escalating.

According to SCFHS nursing practice standards in Saudi Arabia, which of the following actions requires a nurse to document an incident report (تقرير الحوادث) in addition to the patient's medical record?

Answer: Administering a medication 30 minutes late due to a delayed pharmacy delivery

A medication administered 30 minutes late constitutes a medication administration error or deviation from the prescribed schedule, which requires both documentation in the medical record and completion of a formal incident report per SCFHS and CBAHI patient safety standards. IV infiltration with site change, informed patient refusal, and ordered restraint application are expected nursing interventions that are documented in the medical record only and do not constitute adverse events requiring a separate incident report.

A nurse is using the Braden Scale to assess pressure injury risk for a bedridden patient in a Saudi hospital. The patient scores: Sensory Perception 3, Moisture 2, Activity 1, Mobility 2, Nutrition 2, Friction and Shear 2. What is the correct total score interpretation?

Answer: Total score 12 — High Risk, requiring a specialty mattress and 2-hourly repositioning

Adding the subscores: 3+2+1+2+2+2 = 12. A Braden Scale total score of 13–14 indicates Mild Risk, 10–12 indicates High Risk, and ≤9 indicates Very High Risk. A score of 12 places this patient in the High Risk category. High-risk interventions include use of a pressure-redistributing specialty mattress and repositioning at minimum every 2 hours. Score 14 would be Mild Risk with less intensive intervention, and score 10 would require more aggressive intervention.

A nurse is preparing a critically ill patient for nasogastric tube (NGT) insertion. After insertion, which combination of confirmation methods is considered the gold standard per evidence-based nursing practice guidelines endorsed by SCFHS?

Answer: Radiographic confirmation (X-ray) combined with pH testing of aspirate (pH ≤ 5.5)

SCFHS and international evidence-based guidelines (including NICE and NPSA) identify radiographic (X-ray) confirmation as the definitive gold standard for NGT placement verification, particularly before first use in high-risk patients. pH testing of aspirate (pH ≤ 5.5 confirms gastric placement) is a validated bedside adjunct. The combination of both provides the highest accuracy. Auscultation of air insufflation alone is no longer considered reliable and has been associated with fatal misplacements. Capnography detects tracheal placement but cannot confirm correct gastric positioning. pH testing alone, while useful, is not considered the gold standard.

During handover in a Saudi tertiary hospital using the SBAR communication tool, a night nurse reports a patient has a urine output of 25 mL/hour for the past 3 hours. The patient weighs 80 kg and received 500 mL IV bolus 2 hours ago without improvement. Which component of the SBAR should include the nurse's clinical judgment that this likely represents oliguria requiring urgent medical review?

Answer: Assessment (A) — because this is the nurse's interpretation and clinical synthesis of the data

In the SBAR framework: Situation = the current presenting problem (e.g., 'patient has low urine output'); Background = relevant history and context (e.g., the IV bolus given without improvement); Assessment = the nurse's clinical interpretation and synthesis — 'I believe this represents oliguria and potentially developing acute kidney injury'; Recommendation = the specific action requested (e.g., 'Please review the patient and consider urinalysis and nephrology consult'). Clinical judgment — the interpretation of what the data means — belongs in Assessment. Confusion between Assessment and Recommendation is a common error; Assessment is 'what I think is happening,' Recommendation is 'what I think should be done.'