Fundamentals of Nursing: Nursing Process, Vital Signs and Asepsis
What this domain tests
Fundamentals of Nursing covers the nursing process, vital signs, asepsis and infection control, positioning, admission and discharge, and documentation. The exam favours applied questions: you are given a patient cue and must choose the safest first action.
Core rules
- Nursing process: Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE). Assessment comes before any intervention.
- Adult resting values: oral temperature 36.5–37.5 °C; pulse 60–100/min; respirations 12–20/min; blood pressure around 120/80 mmHg; SpO2 95% or above on room air.
- Hand hygiene is the single most effective infection-control measure. Perform it before patient contact, after body-fluid exposure, and after touching surroundings.
- Sterile field: only sterile items touch it; edges about 2.5 cm (1 inch) are considered unsterile; never turn your back or reach over it.
- Document objectively: time, measurement, action, response, and notification.
Worked example
A 45-year-old patient has oral temperature 38.9 °C, pulse 104/min, respirations 24/min, BP 118/76 mmHg. Reason it out: the temperature indicates fever; pulse above 100 is tachycardia; respirations above 20 are tachypnea; BP is acceptable. First reassess with a correct technique, check for rigors and hydration, apply prescribed antipyretic and tepid sponging if ordered, encourage fluids, and inform the nurse-in-charge or doctor. Recheck vitals after 30–60 minutes and document.
Traps
- Taking an oral temperature immediately after a hot drink; wait 15–30 minutes.
- Using a cuff that is too small, which falsely raises BP.
- Telling the patient you are counting respirations, which alters the rate.
- Calling a field sterile after it touches a nonsterile edge.