Bullets (Funda)

8/6/2019 Bullets (Funda)

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Fundamentals of Nursingaffected extremity.

To fit a supine patient for crutches,the nurse should measure from theaxilla to the sole and add 2" (5 cm) tothat measurement.

Assessment begins with the nursesfirst encounter with the patient andcontinues throughout the patients stay.The nurse obtains assessment datathrough the health history, physicalexamination, and review of diagnosticstudies.

Residual urine is urine that remainsin the bladder after voiding. The amountof residual urine is normally 50 to 100ml.

The five stages of the nursingprocess are assessment, nursingdiagnosis, planning, implementation,and evaluation.

Assessment is the stage of thenursing process in which the nursecontinuously collects data to identify apatients actual and potential healthneeds.

Nursing diagnosis is the stage of thenursing process in which the nursemakes a clinical judgment aboutindividual, family, or community

responses to actual or potential healthproblems or life processes.

Planning is the stage of the nursingprocess in which the nurse assignspriorities to nursing diagnoses, definesshort-term and long-term goals andexpected outcomes, and establishesthe nursing care plan.

Normal room humidity is 30% to60%.

Implementation is the stage of thenursing process in which the nurse puts

the nursing care plan into action,delegates specific nursing interventionsto members of the nursing team, andcharts patient responses to nursinginterventions.

Evaluation is the stage of the nursingprocess in which the nurse comparesobjective and subjective data with theoutcome criteria and, if needed,modifies the nursing care plan.

Before administering any asneeded pain medication, the nurseshould ask the patient to indicate thelocation of the pain.

Jehovahs Witnesses believe thatthey shouldnt receive bloodcomponents donated by other people.

To test visual acuity, the nurseshould ask the patient to cover eacheye separately and to read the eyechart with glasses and without, as

appropriate.

When providing oral care for anunconscious patient, to minimize therisk of aspiration, the nurse shouldposition the patient on the side.

During assessment of distancevision, the patient should stand 20' (6.1m) from the chart.

For a geriatric patient or one who isextremely ill, the ideal roomtemperature is 66 to 76 F (18.8 to24.4 C).

Electrolytes in a solution aremeasured in milliequivalents per liter(mEq/L). A milliequivalent is the numberof milligrams per 100 milliliters of a

solution. Hand washing is the single bestmethod of limiting the spread ofmicroorganisms. Once gloves are

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Fundamentals of Nursingremoved after routine contact with apatient, hands should be washed for 10to 15 seconds.

To perform catheterization, the nurseshould place a woman in the dorsal

recumbent position.

A positive Homans sign mayindicate thrombophlebitis.

Metabolism occurs in two phases:anabolism (the constructive phase) andcatabolism (the destructive phase).

The basal metabolic rate is theamount of energy needed to maintainessential body functions. Its measuredwhen the patient is awake and resting,hasnt eaten for 14 to 18 hours, and isin a comfortable, warm environment.

The basal metabolic rate isexpressed in calories consumed per

hour per kilogram of body weight.

Dietary fiber (roughage), which isderived from cellulose, supplies bulk,maintains intestinal motility, and helpsto establish regular bowel habits.

Alcohol is metabolized primarily inthe liver. Smaller amounts aremetabolized by the kidneys and lungs.

Petechiae are tiny, round, purplishred spots that appear on the skin andmucous membranes as a result ofintradermal or submucosal hemorrhage.

Purpura is a purple discoloration ofthe skin thats caused by bloodextravasation.

According to the standardprecautions recommended by theCenters for Disease Control andPrevention, the nurse shouldnt recap

needles after use. Most needle sticksresult from missed needle recapping.

The nurse administers a drug by I.V.push by using a needle and syringe todeliver the dose directly into a vein, I.V.

tubing, or a catheter.

When changing the ties on atracheostomy tube, the nurse shouldleave the old ties in place until the newones are applied.

A nurse should have assistancewhen changing the ties on atracheostomy tube.

A filter is always used for bloodtransfusions.

A four-point (quad) cane is indicatedwhen a patient needs more stabilitythan a regular cane can provide.

A good way to begin a patient

interview is to ask, What made youseek medical help?

When caring for any patient, thenurse should follow standardprecautions for handling blood andbody fluids.

Potassium (K+) is the most abundantcation in intracellular fluid.

When being measured for crutches,a patient should wear shoes.

In the four-point, or alternating, gait,the patient first moves the right crutchfollowed by the left foot and then the leftcrutch followed by the right foot.

In the three-point gait, the patientmoves two crutches and the affected

leg simultaneously and then moves theunaffected leg.

In the two-point gait, the patient

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Fundamentals of Nursingmoves the right leg and the left crutchsimultaneously and then moves the leftleg and the right crutch simultaneously.

The vitamin B complex, the water-soluble vitamins that are essential for

metabolism, include thiamine (B1),riboflavin (B2), niacin (B3), pyridoxine(B6), and cyanocobalamin (B12).

When being weighed, an adultpatient should be lightly dressed andshoeless.

Before taking an adults temperatureorally, the nurse should ensure that thepatient hasnt smoked or consumed hotor cold substances in the previous 15minutes.

The nurse shouldnt take an adultstemperature rectally if the patient has acardiac disorder, anal lesions, orbleeding hemorrhoids or has recentlyundergone rectal surgery.

In a patient who has a cardiacdisorder, measuring temperaturerectally may stimulate a vagal responseand lead to vasodilation and decreasedcardiac output.

When recording pulse amplitude andrhythm, the nurse should use thesedescriptive measures: +3, bounding

pulse (readily palpable and forceful);+2, normal pulse (easily palpable); +1,thready or weak pulse (difficult todetect); and 0, absent pulse (notdetectable).

Ptosis is drooping of the eyelid.

The intraoperative period beginswhen a patient is transferred to the

operating room bed and ends when thepatient is admitted to thepostanesthesia care unit.

On the morning of surgery, the nurseshould ensure that the informedconsent form has been signed; that thepatient hasnt taken anything by mouthsince midnight, has taken a shower withantimicrobial soap, has had mouth care

(without swallowing the water), hasremoved common jewelry, and hasreceived preoperative medication asprescribed; and that vital signs havebeen taken and recorded. Artificiallimbs and other prostheses are usuallyremoved.

Comfort measures, such aspositioning the patient, rubbing thepatients back, and providing a restfulenvironment, may decrease thepatients need for analgesics or mayenhance their effectiveness.

A drug has three names: genericname, which is used in officialpublications; trade, or brand, name(such as Tylenol), which is selected by

the drug company; and chemical name,which describes the drugs chemicalcomposition.

To avoid staining the teeth, thepatient should take a liquid ironpreparation through a straw.

The nurse should use the Z-trackmethod to administer an I.M. injection of

iron dextran (Imferon).

The mist in a mist tent should neverbecome so dense that it obscures clearvisualization of the patients respiratorypattern.

An organism may enter the bodythrough the nose, mouth, rectum,urinary or reproductive tract, or skin.

In descending order, the levels ofconsciousness are alertness, lethargy,stupor, light coma, and deep coma.

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Fundamentals of Nursing To turn a patient by logrolling, thenurse folds the patients arms acrossthe chest; extends the patients legsand inserts a pillow between them, ifneeded; places a draw sheet under thepatient; and turns the patient by slowly

and gently pulling on the draw sheet.

The diaphragm of the stethoscope isused to hear high-pitched sounds, suchas breath sounds.

A slight difference in blood pressure(5 to 10 mm Hg) between the right andthe left arms is normal.

The nurse should place the bloodpressure cuff 1" (2.5 cm) above theantecubital fossa.

When instilling ophthalmic ointments,the nurse should waste the first bead ofointment and then apply the ointmentfrom the inner canthus to the outercanthus.

The nurse should use a leg cuff tomeasure blood pressure in an obesepatient.

If a blood pressure cuff is applied tooloosely, the reading will be falselyelevated.

A tilt table is useful for a patient with

a spinal cord injury, orthostatichypotension, or brain damage becauseit can move the patient gradually from ahorizontal to a vertical (upright) position.

To perform venipuncture with theleast injury to the vessel, the nurseshould turn the bevel upward when thevessels lumen is larger than the needleand turn it downward when the lumen is

only slightly larger than the needle.

To move a patient to the edge of thebed for transfer, the nurse should follow

these steps: Move the patients headand shoulders toward the edge of thebed. Move the patients feet and legs tothe edge of the bed (crescent position).Place both arms well under the patientships, and straighten the back while

moving the patient toward the edge ofthe bed.

The nurse should attach a restraintto the part of the bed frame that moveswith the head, not to the mattress orside rails.

To administer heparinsubcutaneously, the nurse should followthese steps: Clean, but dont rub, thesite with alcohol. Stretch the skin taut orpick up a well-defined skin fold. Holdthe shaft of the needle in a dartposition. Insert the needle into the skinat a right (90-degree) angle. Firmlydepress the plunger, but dont aspirate.Leave the needle in place for 10seconds. Withdraw the needle gently atthe angle of insertion. Apply pressure tothe injection site with an alcohol pad.

For a sigmoidoscopy, the nurseshould place the patient in the knee-chest position or Sims position,depending on the physicianspreference.

In adults, the most convenient veins

for venipuncture are the basilic andmedian cubital veins in the antecubitalspace.

Maslows hierarchy of needs must bemet in the following order: physiologic(oxygen, food, water, sex, rest, andcomfort), safety and security, love andbelonging, self-esteem and recognition,and self-actualization.

When caring for a patient who has anasogastric tube, the nurse shouldapply a water-soluble lubricant to the

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Fundamentals of Nursingnostril to prevent soreness.

During gastric lavage, a nasogastrictube is inserted, the stomach is flushed,and ingested substances are removedthrough the tube.

In documenting drainage on asurgical dressing, the nurse shouldinclude the size, color, and consistencyof the drainage (for example, 10 mm ofbrown mucoid drainage noted ondressing).

To elicit Babinskis reflex, the nursestrokes the sole of the patients footwith a moderately sharp object, such asa thumbnail.

A positive Babinskis reflex is shownby dorsiflexion of the great toe andfanning out of the other toes.

When assessing a patient forbladder distention, the nurse should

check the contour of the lowerabdomen for a rounded mass above thesymphysis pubis.

The best way to prevent pressureulcers is to reposition the bedriddenpatient at least every 2 hours.

Antiembolism stockings decompressthe superficial blood vessels, reducing

the risk of thrombus formation.

Two to three hours before beginninga tube feeding, the nurse shouldaspirate the patients stomach contentsto verify that gastric emptying isadequate.

People with type O blood are

considered universal donors.

People with type AB blood areconsidered universal recipients.

Hertz (Hz) is the unit ofmeasurement of sound frequency.

Hearing protection is required whenthe sound intensity exceeds 84 dB.Double hearing protection is required ifit exceeds 104 dB.

Prothrombin, a clotting factor, isproduced in the liver.

If a patient is menstruating when aurine sample is collected, the nurseshould note this on the laboratory

request.

During lumbar puncture, the nursemust note the initial intracranialpressure and the color of thecerebrospinal fluid.

If a patient cant cough to provide asputum sample for culture, a heatedaerosol treatment can be used to help

to obtain a sample.

If eye ointment and eyedrops mustbe instilled in the same eye, theeyedrops should be instilled first.

When leaving an isolation room, thenurse should remove her gloves beforeher mask because fewer pathogens areon the mask.

Skeletal traction, which is applied toa bone with wire pins or tongs, is themost effective means of traction.

The total parenteral nutrition solutionshould be stored in a refrigerator andremoved 30 to 60 minutes before use.Delivery of a chilled solution can causepain, hypothermia, venous spasm, and

venous constriction.

Drugs arent routinely injectedintramuscularly into edematous tissue

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Fundamentals of Nursingbecause they may not be absorbed.

When caring for a comatose patient,the nurse should explain each action tothe patient in a normal voice.

Dentures should be cleaned in a sinkthats lined with a washcloth.

A patient should void within 8 hoursafter surgery.

An EEG identifies normal andabnormal brain waves.

Samples of feces for ova andparasite tests should be delivered to thelaboratory without delay and withoutrefrigeration.

The autonomic nervous systemregulates the cardiovascular andrespiratory systems.

When providing tracheostomy care,

the nurse should insert the cathetergently into the tracheostomy tube.When withdrawing the catheter, thenurse should apply intermittent suctionfor no more than 15 seconds and use aslight twisting motion.

The fight-or-flight response is asympathetic nervous system response.

A low-residue diet includes such

foods as roasted chicken, rice, andpasta.

A rectal tube shouldnt be insertedfor longer than 20 minutes because itcan irritate the rectal mucosa and causeloss of sphincter control.

A patients bed bath should proceedin this order: face, neck, arms, hands,

chest, abdomen, back, legs, perineum.

To prevent injury when lifting andmoving a patient, the nurse should

primarily use the upper leg muscles.

Patient preparation forcholecystography includes ingestion ofa contrast medium and a low-fatevening meal.

While an occupied bed is beingchanged, the patient should be coveredwith a bath blanket to promote warmthand prevent exposure.

Anticipatory grief is mourning thatoccurs for an extended time when thepatient realizes that death is inevitable.

The following foods can alter thecolor of the feces: beets (red), cocoa(dark red or brown), licorice (black),spinach (green), and meat protein (darkbrown).

When preparing for a skull X-ray, thepatient should remove all jewelry anddentures.

Bronchovesicular breath sounds inperipheral lung fields are abnormal andsuggest pneumonia.

The nurse should grade hyperactivebiceps and triceps reflexes as +4.

The implementation phase of thenursing process involves recording thepatients response to the nursing plan,

putting the nursing plan into action,delegating specific nursinginterventions, and coordinating thepatients activities.

The evaluation phase of the nursingprocess is to determine whether nursinginterventions have enabled the patientto meet the desired goals.

Wheezing is an abnormal, high-pitched breath sound thats accentuatedon expiration.

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Fundamentals of Nursing Wax or a foreign body in the earshould be flushed out gently byirrigation with warm saline solution.

If a patient complains that hishearing aid is not working, the nurseshould check the switch first to see if itsturned on and then check the batteries.

If two eye medications areprescribed for twice-daily instillation,they should be administered 5 minutesapart.

In a postoperative patient, forcing

fluids helps prevent constipation.

A nurse must provide care inaccordance with standards of careestablished by the American NursesAssociation, state regulations, andfacility policy.

The kilocalorie (kcal) is a unit ofenergy measurement that represents

the amount of heat needed to raise thetemperature of 1 kilogram of water 1 C.

As nutrients move through the body,they undergo ingestion, digestion,absorption, transport, cell metabolism,and excretion.

The body metabolizes alcohol at afixed rate, regardless of serumconcentration.

In an alcoholic beverage, proofreflects the percentage of alcoholmultiplied by 2. For example, a 100-proof beverage contains 50% alcohol.

The nurse should flush a peripheralheparin lock every 8 hours (if it wasntused during the previous 8 hours) andas needed with normal saline solution

to maintain patency.

The five rights of medicationadministration are the right patient, right

drug, right dose, right route ofadministration, and right time.

Outside of the hospital setting, onlythe sublingual and translingual forms ofnitroglycerin should be used to relieve

acute anginal attacks.

Quality assurance is a method ofdetermining whether nursing actionsand practices meet establishedstandards.

The Patients Bill of Rights offerspatients guidance and protection bystating the responsibilities of thehospital and its staff toward patientsand their families during hospitalization.

To minimize omission and distortionof facts, the nurse should recordinformation as soon as its gathered.

A living will is a witnessed documentthat states a patients desire for certaintypes of care and treatment. Thesedecisions are based on the patientswishes and views on quality of life.

A nurse shouldnt give falseassurance to a patient.

When assessing a patients healthhistory, the nurse should record thecurrent illness chronologically,beginning with the onset of the problem

and continuing to the present.

After receiving preoperativemedication, a patient isnt competent tosign an informed consent form.

When lifting a patient, a nurse usesthe weight of her body instead of thestrength in her arms.

A nurse may clarify a physiciansexplanation about an operation or aprocedure to a patient, but must referquestions about informed consent to

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Fundamentals of Nursingthe physician.

When obtaining a health history froman acutely ill or agitated patient, thenurse should limit questions to thosethat provide necessary information.

If a chest drainage system line isbroken or interrupted, the nurse shouldclamp the tube immediately.

The nurse shouldnt use her thumbto take a patients pulse rate becausethe thumb has a pulse that may beconfused with the patients pulse.

An inspiration and an expirationcount as one respiration.

Eupnea is normal respiration.

During blood pressuremeasurement, the patient should restthe arm against a surface. Usingmuscle strength to hold up the arm may

raise the blood pressure.

Inspection is the most frequentlyused assessment technique.

Major, unalterable risk factors forcoronary artery disease includeheredity, sex, race, and age.

Family members of an elderly personin a long-term care facility should

transfer some personal items (such asphotographs, a favorite chair, andknickknacks) to the persons room toprovide a comfortable atmosphere.

Pulsus alternans is a regular pulserhythm with alternating weak and strongbeats. It occurs in ventricularenlargement because the strokevolume varies with each heartbeat.

The upper respiratory tract warmsand humidifies inspired air and plays a

role in taste, smell, and mastication.

Signs of accessory muscle useinclude shoulder elevation, intercostalmuscle retraction, and scalene andsternocleidomastoid muscle use during

respiration.

When patients use axillary crutches,their palms should bear the brunt of theweight.

Activities of daily living includeeating, bathing, dressing, grooming,toileting, and interacting socially.

Normal gait has two phases: thestance phase, in which the patients footrests on the ground, and the swingphase, in which the patients foot movesforward.

The phases of mitosis are prophase,metaphase, anaphase, and telophase.

The nurse should follow standardprecautions in the routine care of all

patients.

The nurse should use the bell of thestethoscope to listen for venous humsand cardiac murmurs.

The nurse can assess a patientsgeneral knowledge by asking questions

such as Who is the president of theUnited States?

Cold packs are applied for the first20 to 48 hours after an injury; then heatis applied. During cold application, thepack is applied for 20 minutes and thenremoved for 10 to 15 minutes to preventreflex dilation (rebound phenomenon)and frostbite injury.

The pons is located above themedulla and consists of white matter(sensory and motor tracts) and gray

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Fundamentals of Nursingmatter (reflex centers).

The autonomic nervous systemcontrols the smooth muscles.

A correctly written patient goalexpresses the desired patient behavior,criteria for measurement, time frame forachievement, and conditions underwhich the behavior will occur. Itsdeveloped in collaboration with thepatient.

Percussion causes five basic notes:tympany (loud intensity, as heard over agastric air bubble or puffed out cheek),hyperresonance (very loud, as heardover an emphysematous lung),resonance (loud, as heard over anormal lung), dullness (mediumintensity, as heard over the liver orother solid organ), and flatness (soft, asheard over the thigh).

The optic disk is yellowish pink and

circular, with a distinct border.

A primary disability is caused by apathologic process. A secondarydisability is caused by inactivity.

Nurses are commonly held liable forfailing to keep an accurate count ofsponges and other devices duringsurgery.

The best dietary sources of vitaminB6 are liver, kidney, pork, soybeans,corn, and whole-grain cereals.

Iron-rich foods, such as organmeats, nuts, legumes, dried fruit, greenleafy vegetables, eggs, and wholegrains, commonly have a low watercontent.

Collaboration is joint communicationand decision making between nursesand physicians. Its designed to meet

patients needs by integrating the careregimens of both professions into onecomprehensive approach.

Bradycardia is a heart rate of fewerthan 60 beats/minute.

A nursing diagnosis is a statement ofa patients actual or potential healthproblem that can be resolved,diminished, or otherwise changed bynursing interventions.

During the assessment phase of thenursing process, the nurse collects andanalyzes three types of data: healthhistory, physical examination, andlaboratory and diagnostic test data.

The patients health history consistsprimarily of subjective data, informationthats supplied by the patient.

The physical examination includesobjective data obtained by inspection,

palpation, percussion, and auscultation.

When documenting patient care, thenurse should write legibly, use onlystandard abbreviations, and sign eachentry. The nurse should never destroyor attempt to obliterate documentationor leave vacant lines.

Factors that affect body temperature

include time of day, age, physicalactivity, phase of menstrual cycle, andpregnancy.

The most accessible and commonlyused artery for measuring a patientspulse rate is the radial artery. To takethe pulse rate, the artery is compressedagainst the radius.

In a resting adult, the normal pulserate is 60 to 100 beats/minute. The rateis slightly faster in women than in menand much faster in children than in

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Fundamentals of Nursingadults.

Laboratory test results are anobjective form of assessment data.

The measurement systems mostcommonly used in clinical practice arethe metric system, apothecariessystem, and household system.

Before signing an informed consentform, the patient should know whetherother treatment options are availableand should understand what will occurduring the preoperative, intraoperative,and postoperative phases; the risksinvolved; and the possiblecomplications. The patient should alsohave a general idea of the time requiredfrom surgery to recovery. In addition, heshould have an opportunity to askquestions.

A patient must sign a separateinformed consent form for each

procedure. During percussion, the nurse usesquick, sharp tapping of the fingers orhands against body surfaces to producesounds. This procedure is done todetermine the size, shape, position, anddensity of underlying organs andtissues; elicit tenderness; or assessreflexes.

Ballottement is a form of lightpalpation involving gentle, repetitivebouncing of tissues against the handand feeling their rebound.

A foot cradle keeps bed linen off thepatients feet to prevent skin irritationand breakdown, especially in a patientwho has peripheral vascular disease orneuropathy.

Gastric lavage is flushing of thestomach and removal of ingestedsubstances through a nasogastric tube.

Its used to treat poisoning or drugoverdose.

During the evaluation step of thenursing process, the nurse assessesthe patients response to therapy.

Bruits commonly indicate life- orlimb-threatening vascular disease.

O.U. means each eye. O.D. is theright eye, and O.S. is the left eye.

To remove a patients artificial eye,the nurse depresses the lower lid.

The nurse should use a warm salinesolution to clean an artificial eye.

A thready pulse is very fine andscarcely perceptible.

Axillary temperature is usually 1 Flower than oral temperature.

After suctioning a tracheostomy

tube, the nurse must document thecolor, amount, consistency, and odor ofsecretions.

For a subcutaneous injection, thenurse should use a 5/8" 25G needle.

On a drug prescription, theabbreviation p.c. means that the drugshould be administered after meals.

After bladder irrigation, the nurseshould document the amount, color,and clarity of the urine and thepresence of clots or sediment.

Laws regarding patient self-determination vary from state to state.Therefore, the nurse must be familiarwith the laws of the state in which sheworks.

Gauge is the inside diameter of aneedle: the smaller the gauge, the

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Fundamentals of Nursinglarger the diameter.

An adult normally has 32 permanentteeth.

After turning a patient, the nurseshould document the position used, thetime that the patient was turned, andthe findings of skin assessment.

PERRLA is an abbreviation fornormal pupil assessment findings:pupils equal, round, and reactive to lightwith accommodation.

When percussing a patients chestfor postural drainage, the nurses handsshould be cupped.

When measuring a patients pulse,the nurse should assess its rate,rhythm, quality, and strength.

Before transferring a patient from abed to a wheelchair, the nurse shouldpush the wheelchairs footrests to the

sides and lock its wheels.

When assessing respirations, thenurse should document their rate,rhythm, depth, and quality.

The notation AA & O 3 indicatesthat the patient is awake, alert, andoriented to person (knows who he is),place (knows where he is), and time

(knows the date and time).

Fluid intake includes all fluids takenby mouth, including foods that are liquidat room temperature, such as gelatin,custard, and ice cream; I.V. fluids; andfluids administered in feeding tubes.

Fluid output includes urine, vomitus,and drainage (such as from a

nasogastric tube or from a wound) aswell as blood loss, diarrhea or feces,and perspiration.

After administering an intradermalinjection, the nurse shouldnt massagethe area because massage can irritatethe site and interfere with results.

When administering an intradermalinjection, the nurse should hold thesyringe almost flat against the patientsskin (at about a 15-degree angle), withthe bevel up.

To obtain an accurate bloodpressure, the nurse should inflate themanometer to 20 to 30 mm Hg abovethe disappearance of the radial pulsebefore releasing the cuff pressure.

The nurse should count an irregularpulse for 1 full minute.

Prophylaxis is disease prevention.

A patient who is vomiting while lyingdown should be placed in a lateralposition to prevent aspiration ofvomitus.

Body alignment is achieved whenbody parts are in proper relation to theirnatural position.

Trust is the foundation of a nurse-patient relationship.

Blood pressure is the force exertedby the circulating volume of blood on

the arterial walls.

Malpractice is a professionalswrongful conduct, improper dischargeof duties, or failure to meet standards ofcare that causes harm to another.

As a general rule, nurses cantrefuse a patient care assignment;however, in most states, they may

refuse to participate in abortions.

A nurse can be found negligent if apatient is injured because the nurse

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Fundamentals of Nursingfailed to perform a duty that areasonable and prudent person wouldperform or because the nurseperformed an act that a reasonable andprudent person wouldnt perform.

A physician should sign verbal andtelephone orders within the timeestablished by facility policy, usually 24hours.

States have enacted GoodSamaritan laws to encourageprofessionals to provide medicalassistance at the scene of an accidentwithout fear of a lawsuit arising from the

assistance. These laws dont apply tocare provided in a health care facility.

A competent adult has the right torefuse lifesaving medical treatment;however, the individual should be fullyinformed of the consequences of hisrefusal.

Although a patients health record, orchart, is the health care facilitysphysical property, its contents belong tothe patient.

Before a patients health record canbe released to a third party, the patientor the patients legal guardian must givewritten consent.

Under the Controlled SubstancesAct, every dose of a controlled drugthats dispensed by the pharmacy mustbe accounted for, whether the dose wasadministered to a patient or discardedaccidentally.

A nurse cant perform duties thatviolate a rule or regulation establishedby a state licensing board, even if they

are authorized by a health care facilityor physician.

To minimize interruptions during a

patient interview, the nurse shouldselect a private room, preferably onewith a door that can be closed.

In categorizing nursing diagnoses,the nurse addresses life-threatening

problems first, followed by potentiallylife-threatening concerns.

The major components of a nursingcare plan are outcome criteria (patientgoals) and nursing interventions.

Standing orders, or protocols,establish guidelines for treating aspecific disease or set of symptoms.

In assessing a patients heart, thenurse normally finds the point ofmaximal impulse at the fifth intercostalspace, near the apex.

The S1 heard on auscultation iscaused by closure of the mitral andtricuspid valves.

To maintain package sterility, thenurse should open a wrappers top flapaway from the body, open each sideflap by touching only the outer part ofthe wrapper, and open the final flap bygrasping the turned-down corner andpulling it toward the body.

The nurse shouldnt dry a patients

ear canal or remove wax with a cotton-tipped applicator because it may forcecerumen against the tympanicmembrane.

Fruits are high in fiber and low inprotein, and should be omitted from alow-residue diet.

A patients identification bracelet

should remain in place until the patienthas been discharged from the healthcare facility and has left the premises.

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Fundamentals of Nursing The Controlled Substances Actdesignated five categories, orschedules, that classify controlled drugsaccording to their abuse potential.

Schedule I drugs, such as heroin,

have a high abuse potential and haveno currently accepted medical use inthe United States.

Schedule II drugs, such asmorphine, opium, and meperidine(Demerol), have a high abuse potential,but currently have accepted medicaluses. Their use may lead to physical orpsychological dependence.

Schedule III drugs, such asparegoric and butabarbital (Butisol),have a lower abuse potential thanSchedule I or II drugs. Abuse ofSchedule III drugs may lead tomoderate or low physical orpsychological dependence, or both.

Schedule IV drugs, such as chloralhydrate, have a low abuse potentialcompared with Schedule III drugs.

Schedule V drugs, such as coughsyrups that contain codeine, have thelowest abuse potential of the controlledsubstances.

Activities of daily living are actionsthat the patient must perform every day

to provide self-care and to interact withsociety.

Testing of the six cardinal fields ofgaze evaluates the function of allextraocular muscles and cranial nervesIII, IV, and VI.

The six types of heart murmurs aregraded from 1 to 6. A grade 6 heart

murmur can be heard with thestethoscope slightly raised from thechest.

The most important goal to include ina care plan is the patients goal.

The nurse should use an objectivescale to assess and quantify pain.Postoperative pain varies greatlyamong individuals.

Postmortem care includes cleaningand preparing the deceased patient forfamily viewing, arranging transportationto the morgue or funeral home, anddetermining the disposition ofbelongings.

When caring for an infant, a child, ora confused patient, consistency innursing personnel is paramount.

The hypothalamus secretesvasopressin and oxytocin, which arestored in the pituitary gland.

The three membranes that enclosethe brain and spinal cord are the dura

mater, pia mater, and arachnoid.

A nasogastric tube is used to removefluid and gas from the small intestinepreoperatively or postoperatively.

Psychologists, physical therapists,and chiropractors arent authorized towrite prescriptions for drugs.

The area around a stoma is cleanedwith mild soap and water.

The nurse should use a tuberculinsyringe to administer a subcutaneousinjection of less than 1 ml.

For adults, subcutaneous injectionsrequire a 25G 1" needle; for infants,children, elderly, or very thin patients,

they require a 25G to 27G " needle.

Before administering a drug, thenurse should identify the patient by

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Fundamentals of Nursingchecking the identification band andasking the patient to state his name.

To clean the skin before an injection,the nurse uses a sterile alcohol swab towipe from the center of the site outward

in a circular motion.

The nurse should inject heparin deepinto subcutaneous tissue at a 90-degree angle (perpendicular to the skin)to prevent skin irritation.

If blood is aspirated into the syringebefore an I.M. injection, the nurseshould withdraw the needle, prepareanother syringe, and repeat theprocedure.

If bleeding occurs after an injection,the nurse should apply pressure untilthe bleeding stops. If bruising occurs,the nurse should monitor the site for anenlarging hematoma.

The nurse shouldnt cut the patientshair without written consent from thepatient or an appropriate relative.

When providing hair and scalp care,the nurse should begin combing at theend of the hair and work toward thehead.

The frequency of patient hair care

depends on the length and texture ofthe hair, the duration of hospitalization,and the patients condition.

Proper function of a hearing aidrequires careful handling duringinsertion and removal, regular cleaningof the ear piece to prevent wax buildup,and prompt replacement of deadbatteries.

The hearing aid thats marked with ablue dot is for the left ear; the one witha red dot is for the right ear.

A hearing aid shouldnt be exposedto heat or humidity and shouldnt beimmersed in water.

The nurse should instruct the patientto avoid using hair spray while wearinga hearing aid.

The nurse should remove heelprotectors every 8 hours to inspect thefoot for signs of skin breakdown.

The five branches of pharmacologyare pharmacokinetics,pharmacodynamics,pharmacotherapeutics, toxicology, andpharmacognosy.

Heat is applied to promotevasodilation, which reduces paincaused by inflammation.

A sutured surgical incision is anexample of healing by first intention(healing directly, without granulation).

Healing by secondary intention(healing by granulation) is closure of thewound when granulation tissue fills thedefect and allows reepithelialization tooccur, beginning at the wound edgesand continuing to the center, until theentire wound is covered.

Keloid formation is an abnormality in

healing thats characterized byovergrowth of scar tissue at the woundsite.

The nurse should administerprocaine penicillin by deep I.M. injectionin the upper outer portion of thebuttocks in the adult or in the midlateralthigh in the child. The nurse shouldntmassage the injection site.

An ascending colostomy drains fluidfeces. A descending colostomy drainssolid fecal matter.

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Fundamentals of Nursing

A folded towel (scrotal bridge) canprovide scrotal support for the patientwith scrotal edema caused byvasectomy, epididymitis, or orchitis.

When giving an injection to a patientwho has a bleeding disorder, the nurseshould use a small-gauge needle andapply pressure to the site for 5 minutesafter the injection.

Platelets are the smallest and mostfragile formed element of the blood andare essential for coagulation.

To insert a nasogastric tube, thenurse instructs the patient to tilt thehead back slightly and then inserts thetube. When the nurse feels the tubecurving at the pharynx, the nurseshould tell the patient to tilt the headforward to close the trachea and openthe esophagus by swallowing. (Sips ofwater can facilitate this action.)

Families with loved ones in intensivecare units report that their four mostimportant needs are to have theirquestions answered honestly, to beassured that the best possible care isbeing provided, to know the patientsprognosis, and to feel that there is hopeof recovery.

Double-bind communication occurs

when the verbal message contradictsthe nonverbal message and thereceiver is unsure of which message torespond to.

A nonjudgmental attitude displayedby a nurse shows that she neitherapproves nor disapproves of thepatient.

Target symptoms are those that thepatient finds most distressing.

A patient should be advised to take

aspirin on an empty stomach, with a fullglass of water, and should avoid acidicfoods such as coffee, citrus fruits, andcola.

When the nurse removes gloves and

a mask, she should remove the glovesfirst. They are soiled and are likely tocontain pathogens.

For every patient problem, there is anursing diagnosis; for every nursingdiagnosis, there is a goal; and for everygoal, there are interventions designedto make the goal a reality. The keys toanswering examination questions

correctly are identifying the problempresented, formulating a goal for theproblem, and selecting the interventionfrom the choices provided that willenable the patient to reach that goal.

Fidelity means loyalty and can beshown as a commitment to theprofession of nursing and to the patient.

Administering an I.M. injectionagainst the patients will and withoutlegal authority is battery.

An example of a third-party payer isan insurance company.

On-call medication should be givenwithin 5 minutes of the call.

Usually, the best method todetermine a patients cultural or spiritualneeds is to ask him.

An incident report or unusualoccurrence report isnt part of apatients record, but is an in-housedocument thats used for the purpose ofcorrecting the problem.

Critical pathways are amultidisciplinary guideline for patientcare.

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When prioritizing nursing diagnoses,the following hierarchy should be used:Problems associated with the airway,those concerning breathing, and thoserelated to circulation.

Listening is the most effectivecommunication technique.

A subjective sign that a sitz bath hasbeen effective is the patientsexpression of decreased pain ordiscomfort.

For the nursing diagnosis Deficientdiversional activity to be valid, thepatient must state that hes bored, thathe has nothing to do, or words to thateffect.

The most appropriate nursingdiagnosis for an individual who doesntspeak English is Impaired verbalcommunication related to inability tospeak dominant language (English).

The family of a patient who has beendiagnosed as hearing impaired shouldbe instructed to face the individualwhen they speak to him.

Before instilling medication into theear of a patient who is up to age 3, thenurse should pull the pinna down andback to straighten the eustachian tube.

To prevent injury to the cornea whenadministering eyedrops, the nurseshould waste the first drop and instillthe drug in the lower conjunctival sac.

After administering eye ointment, thenurse should twist the medication tubeto detach the ointment.

Crutches should be placed 6" (15.2cm) in front of the patient and 6" to theside to form a tripod arrangement.

Before teaching any procedure to apatient, the nurse must assess thepatients current knowledge andwillingness to learn.

Process recording is a method ofevaluating ones communicationeffectiveness.

When feeding an elderly patient, thenurse should limit high-carbohydratefoods because of the risk of glucoseintolerance.

When feeding an elderly patient,essential foods should be given first.

Passive range of motion maintainsjoint mobility. Resistive exercisesincrease muscle mass.

Isometric exercises are performedon an extremity thats in a cast.

A back rub is an example of thegate-control theory of pain.

Anything thats located below thewaist is considered unsterile; a sterilefield becomes unsterile when it comesin contact with any unsterile item; asterile field must be monitoredcontinuously; and a border of 1" (2.5cm) around a sterile field is consideredunsterile.

A shift to the left is evident whenthe number of immature cells (bands) inthe blood increases to fight an infection.

A shift to the right is evident whenthe number of mature cells in the bloodincreases, as seen in advanced liverdisease and pernicious anemia.

Before administering preoperative

medication, the nurse should ensurethat an informed consent form has beensigned and attached to the patientsrecord.

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A nurse should spend no more than30 minutes per 8-hour shift providingcare to a patient who has a radiationimplant.

A nurse shouldnt be assigned tocare for more than one patient who hasa radiation implant.

Long-handled forceps and a lead-lined container should be available inthe room of a patient who has aradiation implant.

Usually, patients who have the sameinfection and are in strict isolation canshare a room.

Diseases that require strict isolationinclude chickenpox, diphtheria, and viralhemorrhagic fevers such as Marburgdisease.

For the patient who abides by Jewish

custom, milk and meat shouldnt beserved at the same meal.

Whether the patient can perform aprocedure (psychomotor domain oflearning) is a better indicator of theeffectiveness of patient teaching thanwhether the patient can simply state thesteps involved in the procedure(cognitive domain of learning).

According to Erik Erikson,developmental stages are trust versusmistrust (birth to 18 months), autonomyversus shame and doubt (18 months toage 3), initiative versus guilt (ages 3 to5), industry versus inferiority (ages 5 to12), identity versus identity diffusion(ages 12 to 18), intimacy versusisolation (ages 18 to 25), generativity

versus stagnation (ages 25 to 60), andego integrity versus despair (older thanage 60).

When communicating with a hearingimpaired patient, the nurse should facehim.

An appropriate nursing interventionfor the spouse of a patient who has a

serious incapacitating disease is to helphim to mobilize a support system.

Hyperpyrexia is extreme elevation intemperature above 106 F (41.1 C).

Milk is high in sodium and low iniron.

When a patient expresses concernabout a health-related issue, beforeaddressing the concern, the nurseshould assess the patients level ofknowledge.

The most effective way to reduce afever is to administer an antipyretic,which lowers the temperature set point.

When a patient is ill, its essential forthe members of his family to maintaincommunication about his health needs.

Ethnocentrism is the universal beliefthat ones way of life is superior toothers.

When a nurse is communicating witha patient through an interpreter, the

nurse should speak to the patient andthe interpreter.

In accordance with the hot-coldsystem used by some Mexicans, PuertoRicans, and other Hispanic and Latinogroups, most foods, beverages, herbs,and drugs are described as cold.

Prejudice is a hostile attitude toward

individuals of a particular group.

Discrimination is preferentialtreatment of individuals of a particular

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Fundamentals of Nursinggroup. Its usually discussed in anegative sense.

Increased gastric motility interfereswith the absorption of oral drugs.

The three phases of the therapeuticrelationship are orientation, working,and termination.

Patients often exhibit resistive andchallenging behaviors in the orientationphase of the therapeutic relationship.

Abdominal assessment is performed

in the following order: inspection,auscultation, palpation, and percussion.

When measuring blood pressure in aneonate, the nurse should select a cuffthats no less than one-half and nomore than two-thirds the length of theextremity thats used.

When administering a drug by Z-

track, the nurse shouldnt use the sameneedle that was used to draw the druginto the syringe because doing so couldstain the skin.

Sites for intradermal injection includethe inner arm, the upper chest, and onthe back, under the scapula.

When evaluating whether an answer

on an examination is correct, the nurseshould consider whether the actionthats described promotes autonomy(independence), safety, self-esteem,and a sense of belonging.

Veracity is truth and is an essentialcomponent of a therapeutic relationshipbetween a health care provider and hispatient.

Beneficence is the duty to do noharm and the duty to do good. Theresan obligation in patient care to do no

harm and an equal obligation to assistthe patient.

Nonmaleficence is the duty to do noharm.

Fryes ABCDE cascade provides aframework for prioritizing care byidentifying the most important treatmentconcerns.

A = Airway. This category includeseverything that affects a patent airway,including a foreign object, fluid from anupper respiratory infection, and edemafrom trauma or an allergic reaction.

B = Breathing. This categoryincludes everything that affects thebreathing pattern, includinghyperventilation or hypoventilation andabnormal breathing patterns, such asKorsakoffs, Biots, or Cheyne-Stokesrespiration.

C = Circulation. This category

includes everything that affects thecirculation, including fluid andelectrolyte disturbances and diseaseprocesses that affect cardiac output.

D = Disease processes. If the patienthas no problem with the airway,breathing, or circulation, then the nurseshould evaluate the disease processes,giving priority to the disease process

that poses the greatest immediate risk.For example, if a patient has terminalcancer and hypoglycemia,hypoglycemia is a more immediateconcern.

E = Everything else. This categoryincludes such issues as writing anincident report and completing thepatient chart. When evaluating needs,

this category is never the highestpriority.

Rule utilitarianism is known as the

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Fundamentals of Nursinggreatest good for the greatest numberof people theory.

Egalitarian theory emphasizes thatequal access to goods and servicesmust be provided to the less fortunateby an affluent society.

Active euthanasia is actively helpinga person to die.

Brain death is irreversible cessationof all brain function.

Passive euthanasia is stopping thetherapy thats sustaining life.

Utilization review is performed todetermine whether the care provided toa patient was appropriate and cost-effective.

A value cohort is a group of peoplewho experienced an out-of-the-ordinaryevent that shaped their values.

Voluntary euthanasia is activelyhelping a patient to die at the patientsrequest.

Bananas, citrus fruits, and potatoesare good sources of potassium.

Good sources of magnesium includefish, nuts, and grains.

Beef, oysters, shrimp, scallops,spinach, beets, and greens are goodsources of iron.

Intrathecal injection is administeringa drug through the spine.

When a patient asks a question ormakes a statement thats emotionallycharged, the nurse should respond to

the emotion behind the statement orquestion rather than to whats beingsaid or asked.

The steps of the trajectory-nursingmodel are as follows:

Step 1: Identifying the trajectoryphase

Step 2: Identifying the problems andestablishing goals

Step 3: Establishing a plan to meetthe goals

Step 4: Identifying factors thatfacilitate or hinder attainment of thegoals

Step 5: Implementing interventions Step 6: Evaluating the effectivenessof the interventions

A Hindu patient is likely to request avegetarian diet.

Pain threshold, or pain sensation, isthe initial point at which a patient feelspain.

The difference between acute painand chronic pain is its duration.

Referred pain is pain thats felt at asite other than its origin.

Alleviating pain by performing a backmassage is consistent with the gatecontrol theory.

Rombergs test is a test for balanceor gait.

Pain seems more intense at nightbecause the patient isnt distracted bydaily activities.

Older patients commonly dont reportpain because of fear of treatment,lifestyle changes, or dependency.

No pork or pork products are allowedin a Muslim diet.

Falls are the leading cause of injuryin elderly people.

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Fundamentals of Nursing Two goals of Healthy People 2010are:

Help individuals of all ages toincrease the quality of life and thenumber of years of optimal health

Eliminate health disparities among

different segments of the population.

A community nurse is serving as apatients advocate if she tells amalnourished patient to go to a mealprogram at a local park.

If a patient isnt following histreatment plan, the nurse should firstask why.

Primary prevention is trueprevention. Examples areimmunizations, weight control, andsmoking cessation.

Secondary prevention is earlydetection. Examples include purifiedprotein derivative (PPD), breast self-

examination, testicular self-examination, and chest X-ray.

Tertiary prevention is treatment toprevent long-term complications.

A patient indicates that hes comingto terms with having a chronic diseasewhen he says, Im never going to getany better.

On noticing religious artifacts andliterature on a patients night stand, aculturally aware nurse would ask thepatient the meaning of the items.

A Mexican patient may request theintervention of a curandero, or faithhealer, who involves the family inhealing the patient.

In an infant, the normal hemoglobinvalue is 12 g/dl.

The nitrogen balance estimates thedifference between the intake and useof protein.

Most of the absorption of wateroccurs in the large intestine.

Most nutrients are absorbed in thesmall intestine.

When assessing a patients eatinghabits, the nurse should ask, Whathave you eaten in the last 24 hours?

A vegan diet should include an

abundant supply of fiber.

A hypotonic enema softens thefeces, distends the colon, andstimulates peristalsis.

First-morning urine provides the bestsample to measure glucose, ketone,pH, and specific gravity values.

To induce sleep, the first step is tominimize environmental stimuli.

Before moving a patient, the nurseshould assess the patients physicalabilities and ability to understandinstructions as well as the amount ofstrength required to move the patient.

To lose 1 lb (0.5 kg) in 1 week, the

patient must decrease his weekly intakeby 3,500 calories (approximately 500calories daily). To lose 2 lb (1 kg) in 1week, the patient must decrease hisweekly caloric intake by 7,000 calories(approximately 1,000 calories daily).

To avoid shearing force injury, apatient who is completely immobile islifted on a sheet.

Only the patient can describe hispain accurately.

To insert a catheter from the nose

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Fundamentals of Nursingthrough the trachea for suction, thenurse should ask the patient to swallow.

Vitamin C is needed for collagenproduction.

Cutaneous stimulation creates therelease of endorphins that block thetransmission of pain stimuli.

Patient-controlled analgesia is a safemethod to relieve acute pain caused bysurgical incision, traumatic injury, laborand delivery, or cancer.

The patient who believes in ascientific, or biomedical, approach tohealth is likely to expect a drug,treatment, or surgery to cure illness.

Chronic illnesses occur in veryyoung as well as middle-aged and veryold people.

The trajectory framework for chronic

illness states that preferences aboutdaily life activities affect treatmentdecisions.

Collegiality is the promotion ofcollaboration, development, andinterdependence among members of aprofession.

A change agent is an individual who

recognizes a need for change or isselected to make a change within anestablished entity, such as a hospital.

The patients bill of rights wasintroduced by the American HospitalAssociation.

Abandonment is prematuretermination of treatment without the

patients permission and withoutappropriate relief of symptoms.

Values clarification is a process thatindividuals use to prioritize their

personal values.

Distributive justice is a principle thatpromotes equal treatment for all.

Milk and milk products, poultry,grains, and fish are good sources ofphosphate.

The best way to prevent falls at nightin an oriented, but restless, elderlypatient is to raise the side rails.

By the end of the orientation phase,the patient should begin to trust the

nurse.

Falls in the elderly are likely to becaused by poor vision.

Barriers to communication includelanguage deficits, sensory deficits,cognitive impairments, structuraldeficits, and paralysis.

The three elements that arenecessary for a fire are heat, oxygen,and combustible material.

Sebaceous glands lubricate the skin.

To check for petechiae in a dark-skinned patient, the nurse shouldassess the oral mucosa.

To put on a sterile glove, the nurseshould pick up the first glove at thefolded border and adjust the fingerswhen both gloves are on.

To increase patient comfort, thenurse should let the alcohol dry beforegiving an intramuscular injection.

Treatment for a stage 1 ulcer on theheels includes heel protectors.

Seventh-Day Adventists are usuallyvegetarians.

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Endorphins are morphinelikesubstances that produce a feeling ofwell-being.

Pain tolerance is the maximumamount and duration of pain that anindividual is willing to endure.

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