Fundamentals of Nursing Flashcards

A client's urine output over 8 hours is 200 mL. The nurse should recognize this as:

Answer: Oliguria

Oliguria is defined as urine output less than 400 mL in 24 hours (or less than 30 mL/hour).

Which action should a nurse take when a patient's peripheral IV site shows redness, warmth, and swelling?

Answer: Discontinue the IV and start a new site

Signs of phlebitis (redness, warmth, swelling) require immediate discontinuation of the IV and insertion at a new site.

A nurse must document a medication error. Which entry is most appropriate?

Answer: 'Wrong medication given; incident report filed; physician notified; patient assessed'

Accurate documentation of a medication error includes the facts, interventions taken, notifications, and patient assessment.

Which type of isolation precaution is required for a patient with active pulmonary tuberculosis?

Answer: Airborne precautions

Pulmonary TB is transmitted via airborne particles (droplet nuclei <5 microns), requiring airborne precautions and a negative-pressure room.

When assessing a patient's pain, which tool is most appropriate for a non-verbal patient?

Answer: FLACC Behavioral Scale

The FLACC scale assesses pain through observable behaviors (face, legs, activity, cry, consolability) in non-verbal patients.

A nurse is preparing to transfer a patient from bed to wheelchair. Which action is the priority?

Answer: Lock the wheelchair wheels

Locking the wheelchair wheels is the priority safety action to prevent it from rolling during transfer.