Fundamentals of Nursing Flashcards

Which vital sign finding should be reported to the charge nurse immediately in an adult patient?

Answer: Heart rate of 112 beats per minute

A heart rate of 112 bpm indicates tachycardia, which is above the normal adult range of 60–100 bpm and requires prompt assessment.

A nurse is preparing to perform hand hygiene. According to the CDC, how long should hands be scrubbed with soap and water?

Answer: At least 20 seconds

The CDC recommends scrubbing hands with soap and water for at least 20 seconds to effectively reduce microbial load.

When documenting in a patient's medical record, which principle is most important?

Answer: Record entries that are accurate, timely, and objective

Accurate, timely, and objective documentation is the legal and professional standard for medical recordkeeping.

A patient is placed in Fowler's position. At what angle is the head of the bed elevated?

Answer: 45–60 degrees

Fowler's position elevates the head of the bed to 45–60 degrees, which is the standard angle for this semi-upright position.

Which action best demonstrates respect for a patient's autonomy?

Answer: Allowing the patient to refuse treatment after being informed of the risks

Patient autonomy means the right to make informed decisions about their own care, including the right to refuse treatment.

A nurse is preparing to give an injection. Which site is most appropriate for an intramuscular (IM) injection in an adult?

Answer: Ventrogluteal muscle

The ventrogluteal site is the preferred IM injection site in adults because it has the fewest major nerves and blood vessels and consistently thick muscle mass.

What is the primary purpose of the nursing process?

Answer: To provide a systematic framework for individualized patient care

The nursing process (ADPIE) provides a systematic, evidence-based framework to deliver individualized, patient-centered care.