Nursing Fundamentals
and Basic Care
Concepts (Part 3)
### Question 1
The nurse is preparing to insert a Foley catheter on a female patient. Which action is essential for
preventing a catheter-associated urinary tract infection (CAUTI)?
A. Use sterile technique during insertion
B. Clean the perineal area with soap and water
C. Inflate the balloon with 30 mL of sterile water
D. Apply lubricant to the catheter tip
,💫RATIONALE✔️✔️: Using sterile technique during insertion is essential for preventing CAUTI. All
aspects of catheter insertion must be sterile, including the catheter, gloves, drapes, and lubricant. The
balloon should be inflated with 10 mL of sterile water for a Foley catheter. Perineal cleaning should be
done with sterile solution, not soap and water.
💫ANSWER✔️✔️: A. Use sterile technique during insertion
---
### Question 2
A patient who is 2 days post-operative from abdominal surgery reports feeling "something give way"
in the incision site. The nurse observes a small amount of serosanguineous drainage on the dressing.
Which action should the nurse take first?
A. Apply an abdominal binder
B. Assess the wound for dehiscence
C. Notify the healthcare provider
D. Place the patient in a supine position
💫RATIONALE✔️✔️: The sensation of "something giving way" in the incision site with
serosanguineous drainage is a classic sign of wound dehiscence. The nurse should immediately assess
the wound by inspecting it with a sterile gloved hand to determine if dehiscence or evisceration has
occurred. If evisceration is present, the nurse should cover the wound with sterile saline-soaked gauze
and notify the healthcare provider.
💫ANSWER✔️✔️: B. Assess the wound for dehiscence
, ---
### Question 3
The nurse is preparing to administer an intramuscular injection in the ventrogluteal site. Which action
is essential for proper site identification?
A. Place the patient in a prone position with the toes pointing inward
B. Locate the greater trochanter and the anterior superior iliac spine
C. Use the palm of the hand to locate the injection site
D. Identify the midpoint of the vastus lateralis muscle
💫RATIONALE✔️✔️: To locate the ventrogluteal site, the nurse identifies the greater trochanter
and the anterior superior iliac spine. The injection site is in the center of the triangle formed by these
landmarks. This site is preferred for IM injections due to the large muscle mass and low risk of nerve
injury. The patient may be in a side-lying or supine position.
💫ANSWER✔️✔️: B. Locate the greater trochanter and the anterior superior iliac spine
---
### Question 4
A patient with a history of falls is being discharged to home. Which instruction should the nurse
include in the discharge teaching to promote safety?
A. "Use throw rugs to prevent slipping on hardwood floors."
and Basic Care
Concepts (Part 3)
### Question 1
The nurse is preparing to insert a Foley catheter on a female patient. Which action is essential for
preventing a catheter-associated urinary tract infection (CAUTI)?
A. Use sterile technique during insertion
B. Clean the perineal area with soap and water
C. Inflate the balloon with 30 mL of sterile water
D. Apply lubricant to the catheter tip
,💫RATIONALE✔️✔️: Using sterile technique during insertion is essential for preventing CAUTI. All
aspects of catheter insertion must be sterile, including the catheter, gloves, drapes, and lubricant. The
balloon should be inflated with 10 mL of sterile water for a Foley catheter. Perineal cleaning should be
done with sterile solution, not soap and water.
💫ANSWER✔️✔️: A. Use sterile technique during insertion
---
### Question 2
A patient who is 2 days post-operative from abdominal surgery reports feeling "something give way"
in the incision site. The nurse observes a small amount of serosanguineous drainage on the dressing.
Which action should the nurse take first?
A. Apply an abdominal binder
B. Assess the wound for dehiscence
C. Notify the healthcare provider
D. Place the patient in a supine position
💫RATIONALE✔️✔️: The sensation of "something giving way" in the incision site with
serosanguineous drainage is a classic sign of wound dehiscence. The nurse should immediately assess
the wound by inspecting it with a sterile gloved hand to determine if dehiscence or evisceration has
occurred. If evisceration is present, the nurse should cover the wound with sterile saline-soaked gauze
and notify the healthcare provider.
💫ANSWER✔️✔️: B. Assess the wound for dehiscence
, ---
### Question 3
The nurse is preparing to administer an intramuscular injection in the ventrogluteal site. Which action
is essential for proper site identification?
A. Place the patient in a prone position with the toes pointing inward
B. Locate the greater trochanter and the anterior superior iliac spine
C. Use the palm of the hand to locate the injection site
D. Identify the midpoint of the vastus lateralis muscle
💫RATIONALE✔️✔️: To locate the ventrogluteal site, the nurse identifies the greater trochanter
and the anterior superior iliac spine. The injection site is in the center of the triangle formed by these
landmarks. This site is preferred for IM injections due to the large muscle mass and low risk of nerve
injury. The patient may be in a side-lying or supine position.
💫ANSWER✔️✔️: B. Locate the greater trochanter and the anterior superior iliac spine
---
### Question 4
A patient with a history of falls is being discharged to home. Which instruction should the nurse
include in the discharge teaching to promote safety?
A. "Use throw rugs to prevent slipping on hardwood floors."
