Fundamentals of Nursing Flashcards

A nurse in a Saudi MOH hospital is preparing to perform a sterile dressing change. While opening the sterile field, the outer edge of the sterile drape falls below the level of the trolley surface. Which principle of surgical asepsis has been violated, and what is the correct action?

Answer: The 2.5 cm border rule is violated; discard and open a new drape because the dependent edge is considered contaminated

In surgical asepsis, any part of the sterile drape that falls below the level of the sterile field (or below the trolley surface) is considered contaminated. The 2.5 cm (1-inch) border around the edge of a sterile field is also considered non-sterile. Since the drape has been compromised, the entire setup must be discarded and a new sterile field established. The principle violated is that 'sterile objects become contaminated if they fall below the waist or table level.'

A patient on a medical ward in a Saudi hospital has a nasogastric tube in situ for enteral feeding. Before administering the 08:00 feeding, the nurse aspirates 280 mL of gastric residual volume (GRV). According to evidence-based practice guidelines endorsed by SCFHS, what is the most appropriate nursing action?

Answer: Return the aspirate, hold the feeding, reassess GRV after one hour, and notify the physician if it remains elevated

Current evidence-based guidelines (reflected in SCFHS Prometric content) recommend returning the gastric aspirate to prevent electrolyte loss, temporarily holding the feeding, reassessing GRV after approximately one hour, and notifying the physician if the GRV remains ≥250–500 mL on repeat measurement. Discarding the aspirate risks fluid and electrolyte imbalance. Proceeding with feeding when GRV is this high risks aspiration. A GRV of 280 mL alone is not an emergency requiring immediate physician notification before reassessment.

A nurse is caring for a post-operative Saudi patient who is receiving a blood transfusion. Fifteen minutes into the transfusion of packed red blood cells, the patient develops back pain, haematuria, and a sudden drop in blood pressure. The nurse correctly identifies this as an acute haemolytic transfusion reaction. Placing the actions in correct priority order, which sequence is MOST appropriate?

Answer: Stop the transfusion → maintain IV access with normal saline → notify the physician and blood bank → send urine and blood samples

In an acute haemolytic transfusion reaction (ABO incompatibility), the priority sequence is: (1) Stop the transfusion immediately to limit the volume of incompatible blood infused. (2) Maintain IV access with normal saline using new IV tubing to prevent further exposure to residual blood in the line. (3) Notify the physician and blood bank simultaneously. (4) Send required samples (urine for haemoglobinuria, blood for repeat crossmatch) and return the blood bag and tubing to the blood bank. Removing the IV line is incorrect — access is needed for fluid resuscitation. Antihistamines are for allergic/urticarial reactions, not haemolytic ones.

During a routine ward round in a Saudi hospital, a nurse notes that a patient's surgical wound shows the following: wound edges are well-approximated, slight serous drainage is present, and a thin, pale-pink layer of epithelium is visible across the wound surface. No sutures remain. This presentation is best described as which phase and type of wound healing?

Answer: Proliferative phase; healing by primary intention

The proliferative phase of wound healing (days 3–24) is characterised by the formation of granulation tissue, collagen synthesis, angiogenesis, and epithelialisation — visible here as the thin pink epithelial layer migrating across the wound. Well-approximated wound edges with a clean suture line indicate primary intention healing (wound edges are surgically closed). Secondary intention involves an open wound healing from the base with significant granulation. Tertiary intention (delayed primary closure) involves a wound left open initially then closed later. The maturation phase would show a contracted, pale, avascular scar.

A Saudi nurse is performing urinary catheterisation on a male patient using an indwelling Foley catheter. After inserting the catheter approximately 17–20 cm and observing urine return, the nurse inflates the balloon with 10 mL of sterile water. The patient immediately reports severe suprapubic pain. What is the most likely cause and correct immediate action?

Answer: The catheter tip is still in the urethra; deflate the balloon immediately and advance the catheter a further 5 cm before re-inflating

Severe suprapubic pain immediately upon balloon inflation strongly indicates the balloon is being inflated within the urethra rather than the bladder. This can cause urethral rupture. The immediate action is to deflate the balloon completely, advance the catheter further (ensuring urine drains freely from the catheter lumen before re-inflating), and then reinflate. In male patients, the catheter is typically advanced to the bifurcation/hub (or at least 5 cm beyond the point of urine return) before balloon inflation to ensure placement in the bladder. Over-inflation with only 10 mL (standard for a Foley balloon rated for 10 mL) would not present this way.

A nurse working in a Saudi MOH general hospital is assigned to care for a patient under transmission-based contact precautions for carbapenem-resistant Enterobacteriaceae (CRE). The nurse must perform a head-to-toe assessment and wound dressing. Applying the correct donning sequence for PPE and considering SCFHS infection control standards, which order is correct?

Answer: Gown → mask/respirator → goggles/face shield → gloves

The WHO and CDC donning sequence — adopted by SCFHS infection control guidelines — is: (1) Gown first, to protect clothing and skin; (2) Mask or respirator, to protect mucous membranes of the mouth and nose; (3) Goggles or face shield, to protect eyes (placed over the mask); (4) Gloves last, extending over the gown cuffs. Gloves are donned last because they are the outermost barrier and must cover the gown cuffs to prevent contamination of exposed wrists. For CRE (contact precautions), a surgical mask is sufficient (not an N95), unless aerosol-generating procedures are performed. Donning gloves before the gown leaves wrist skin exposed during gown tying.