Fundamentals of Nursing and Basic Care
Domain 2 - Fundamentals of Nursing and Basic Care
This domain tests the safe, dignified delivery of core nursing care: vital signs, hygiene, mobility, pressure injury prevention, nutrition and hydration, elimination, comfort, and the documentation that proves care happened. Questions often ask which observation, technique or nursing measure is correct, or which finding must be escalated.
Core rules
- Adult normal ranges: temperature 36.5–37.5 °C, pulse 60–100/min, respirations 12–20/min, SpO2 95% or above on room air, systolic BP below 120 mmHg. Record and act on trends, not single readings.
- Measure correctly: patient seated and rested 5 minutes, cuff at heart level, correct cuff size; count respirations for a full minute without telling the patient; avoid oral temperature immediately after a hot drink; confirm a low SpO2 by checking probe placement and the patient.
- Pressure injury: use a validated risk score, reposition at least two-hourly or according to assessment, offload heels, keep skin clean and dry, manage moisture and nutrition, and document stage and site. Stage 1 is non-blanchable erythema of intact skin.
- Fluid balance: record every intake and output, including drains and insensible losses; adult urine output below 0.5 mL/kg/hour (about 30 mL/hour) must be reported.
- Falls prevention: bed low and braked, call bell in reach, non-slip footwear, orientation, adequate lighting, and supervision for high-risk patients.
- Aseptic non-touch technique for invasive procedures, and hand hygiene before and after every contact.
- Post-operative care includes deep breathing and early mobilisation to prevent atelectasis and thrombosis.
Worked example
A 68-year-old admitted with pneumonia has: temperature 38.4 °C, pulse 118, respirations 26, BP 92/56, SpO2 92% on room air, new confusion. Reasoning: this is not a single abnormal value but a deteriorating pattern suggesting sepsis and hypoxia. Correct response: stay with the patient, call for senior review using the early warning score, sit him upright, give oxygen to the target range, obtain IV access and take cultures and bloods as ordered, start antibiotics within one hour, monitor every 15 minutes, and document. Reassuring him and rechecking in four hours would be unsafe.
Traps
- Estimating rather than counting respirations.
- Blaming a low reading on the equipment without assessing the patient.
- Recording 'skin intact' without inspecting pressure areas.
- Leaving a patient on a bedpan or in one position for hours because they 'did not ask'.
- Omitting fluid output from drains in the balance chart.