Fundamentals of Nursing: Process, Vital Signs, and Safe Basic Care
What this domain tests
Questions test the nursing process, vital signs, basic care, safety, and the nurse's scope of practice.
Core rules and concepts
- Nursing process: Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE). The diagnosis is a nursing diagnosis, not a medical diagnosis.
- Adult resting ranges: pulse 60–100/min, respirations 12–20/min, oral temperature 36.5–37.5°C, blood pressure about 120/80 mmHg, SpO2 95–100% on room air.
- Hand hygiene is the single most important infection-prevention action. Wash before and after patient contact and after body-fluid exposure.
- Use the recovery position for an unconscious breathing patient without suspected spinal injury.
- Fowler's position (head elevated 45–60°) helps breathing; Trendelenburg is head-down and is not routine.
Worked example
An adult has temperature 38.6°C, pulse 112/min, respirations 26/min, BP 100/60 mmHg. Reasoning: fever, tachycardia, and tachypnoea suggest infection or dehydration; low-normal BP may indicate fluid deficit. The nurse should reassess, check SpO2 and urine output, offer fluids if not contraindicated, and report persistent values. Do not give antipyretics without an order.
Traps that cost marks
- Counting respirations for 15 seconds and multiplying by 4 is inaccurate; count 30 seconds and double, or a full minute if irregular.
- Calling a nursing diagnosis a medical diagnosis.
- Taking BP immediately after exercise or smoking; wait and rest.
- Documenting a value you did not measure.