Fundamentals of Nursing and Basic Care
Fundamentals of Nursing and Basic Care tests safe, competent performance of core nursing actions: hygiene, mobility, skin and wound care, infection control, nutrition, elimination, vital signs, oxygenation, and basic documentation. Items often ask for the first action, the safest technique, or the finding that requires escalation.
Core rules and concepts
- Infection control. Hand hygiene is the single most effective prevention measure. Perform it before and after patient contact, after body fluids, and before aseptic tasks. Medical asepsis reduces organisms; surgical asepsis keeps objects sterile. In a sterile field, keep items above waist level, do not turn your back, and treat the outer 2.5 cm (1 inch) as unsterile.
- Vital signs. For a resting adult, oral temperature is about 36.5–37.5 °C, pulse 60–100/min, respirations 12–20/min, blood pressure below 120/80 mmHg, and SpO2 at least 95% on room air. Reassess after an abnormal finding and before calling for help, but do not delay urgent escalation.
- Skin and mobility. Reposition at-risk patients at least every 2 hours, keep skin clean and dry, use pressure-redistributing surfaces, and provide nutrition and hydration. Stage 1 pressure injury is nonblanchable erythema; stage 2 is partial-thickness loss; stage 3 extends to subcutaneous tissue; stage 4 exposes fascia, muscle, or bone.
- Nutrition and elimination. Aspiration precautions include upright positioning, small bites, and thickened fluids for dysphagia. Monitor intake and output, bowel sounds, and bladder distention. Prevent catheter-associated urinary tract infection by avoiding unnecessary catheters and maintaining closed drainage.
- Oxygenation. Match the device to the oxygen need and reassess. Nasal cannula is low-flow; a nonrebreather delivers high concentration. Never adjust oxygen without reassessing the patient.
Worked example
A postoperative patient becomes restless and confused, with SpO2 88% on room air. The nurse should sit the patient upright, open the airway, apply oxygen per protocol, check vital signs and lung sounds, and notify the provider. Restlessness and confusion can be early hypoxia, so the nurse should not simply reorient the patient or assume pain.
Traps that cost marks
- Documenting a task before completing it.
- Touching the sterile field with ungloved hands or reaching over it.
- Treating an abnormal vital sign without reassessment or escalation.
- Using restraints or a catheter for convenience rather than a documented clinical need.