Nursing Fundamentals,
Patient Safety, and
Basic Care Concepts
(Part 2)
### 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.
💫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.
,💫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 due to the large muscle mass and low risk of nerve injury.
💫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."
B. "Keep pathways clear of clutter and secure electrical cords."
C. "Install dim lighting to reduce glare."
D. "Wear socks without grips for comfort."
💫RATIONALE✔️✔️: Keeping pathways clear of clutter and securing electrical cords reduces the risk
of falls. Other safety measures include adequate lighting, removal of throw rugs, and wearing non-skid
footwear. Dim lighting increases fall risk.
💫ANSWER✔️✔️: B. "Keep pathways clear of clutter and secure electrical cords."
---
### Question 5
The nurse is assessing a patient's peripheral vascular status. Which technique should the nurse use to
assess capillary refill?
A. Palpate the radial pulse for 30 seconds
B. Apply pressure to the nail bed until it blanches
C. Inspect the skin for color and temperature
D. Measure the circumference of the extremities
💫RATIONALE✔️✔️: Capillary refill is assessed by applying pressure to the nail bed until it blanches,
then releasing the pressure and noting the time for color to return. Normal capillary refill is less than 2
seconds. Prolonged refill (>3 seconds) indicates decreased perfusion.
Patient Safety, and
Basic Care Concepts
(Part 2)
### 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.
💫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.
,💫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 due to the large muscle mass and low risk of nerve injury.
💫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."
B. "Keep pathways clear of clutter and secure electrical cords."
C. "Install dim lighting to reduce glare."
D. "Wear socks without grips for comfort."
💫RATIONALE✔️✔️: Keeping pathways clear of clutter and securing electrical cords reduces the risk
of falls. Other safety measures include adequate lighting, removal of throw rugs, and wearing non-skid
footwear. Dim lighting increases fall risk.
💫ANSWER✔️✔️: B. "Keep pathways clear of clutter and secure electrical cords."
---
### Question 5
The nurse is assessing a patient's peripheral vascular status. Which technique should the nurse use to
assess capillary refill?
A. Palpate the radial pulse for 30 seconds
B. Apply pressure to the nail bed until it blanches
C. Inspect the skin for color and temperature
D. Measure the circumference of the extremities
💫RATIONALE✔️✔️: Capillary refill is assessed by applying pressure to the nail bed until it blanches,
then releasing the pressure and noting the time for color to return. Normal capillary refill is less than 2
seconds. Prolonged refill (>3 seconds) indicates decreased perfusion.
