- A nurse
may clarify a physician’s explanation about an operation or a procedure to a
patient, but must refer questions about informed consent to the physician.
- When
obtaining a health history from an acutely ill or agitated patient, the nurse
should limit questions to those that provide necessary information.
- If a chest
drainage system line is broken or interrupted, the nurse should clamp the tube
immediately.
- Eupnea is
normal respiration.
- During
blood pressure measurement, the patient should rest the arm against a surface.
Using muscle strength to hold up the arm may raise the blood pressure.
- Major,
unalterable risk factors for coronary artery disease include heredity, sex,
race, and age.
- Inspection
is the most frequently used assessment technique.
- Family
members of an elderly person in a long-term care facility should transfer some
personal items (such as photographs, a favorite chair, and knickknacks) to the
person’s room to provide a comfortable atmosphere.
- Pulsus
alternans is a regular pulse rhythm with alternating weak and strong beats. It
occurs in ventricular enlargement because the stroke volume varies with each
heartbeat.
- The upper
respiratory tract warms and humidifies inspired air and plays a role in taste,
smell, and mastication.
- Signs of
accessory muscle use include shoulder elevation, intercostal muscle retraction,
and scalene and sternocleidomastoid muscle use during respiration.
- When
patients use axillary crutches, their palms should bear the brunt of the
weight.
- Activities
of daily living include eating, bathing, dressing, grooming, toileting, and
interacting socially.
- Normal
gait has two phases: the stance phase, in which the patient’s foot rests on the
ground, and the swing phase, in which the patient’s foot moves forward.
- The phases
of mitosis are prophase, metaphase, anaphase, and telophase.
- The nurse
should follow standard precautions in the routine care of all patients.
- The nurse
should use the bell of the stethoscope to listen for venous hums and cardiac
murmurs.
- The nurse
can assess a patient’s general knowledge by asking questions such as “Who is
the president of the United States?”
- Cold packs
are applied for the first 20 to 48 hours after an injury; then heat is applied.
During cold application, the pack is applied for 20 minutes and then removed
for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and
frostbite injury.
- The pons
is located above the medulla and consists of white matter (sensory and motor
tracts) and gray matter (reflex centers).
- The
autonomic nervous system controls the smooth muscles.
- A
correctly written patient goal expresses the desired patient behavior, criteria
for measurement, time frame for achievement, and conditions under which the
behavior will occur. It’s developed in collaboration with the patient.
- Percussion
causes five basic notes: tympany (loud intensity, as heard over a gastric air
bubble or puffed out cheek), hyperresonance (very loud, as heard over an
emphysematous lung), resonance (loud, as heard over a normal lung), dullness
(medium intensity, as heard over the liver or other solid organ), and flatness
(soft, as heard over the thigh).
- The optic
disk is yellowish pink and circular, with a distinct border.
- A primary
disability is caused by a pathologic process. A secondary disability is caused
by inactivity.
- Nurses are
commonly held liable for failing to keep an accurate count of sponges and other
devices during surgery.
- The best
dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and
whole-grain cereals.
- Iron-rich
foods, such as organ meats, nuts, legumes, dried fruit, green leafy vegetables,
eggs, and whole grains, commonly have a low water content.
-
Collaboration is joint communication and decision making between nurses and
physicians. It’s designed to meet patients’ needs by integrating the care
regimens of both professions into one comprehensive approach.
-
Bradycardia is a heart rate of fewer than 60 beats/minute.
- A nursing
diagnosis is a statement of a patient’s actual or potential health problem that
can be resolved, diminished, or otherwise changed by nursing interventions.
- During the
assessment phase of the nursing process, the nurse collects and analyzes three
types of data: health history, physical examination, and laboratory and
diagnostic test data.
- The
patient’s health history consists primarily of subjective data, information
that’s supplied by the patient.
- The
physical examination includes objective data obtained by inspection, palpation,
percussion, and auscultation.
- When
documenting patient care, the nurse should write legibly, use only standard
abbreviations, and sign each entry. The nurse should never destroy or attempt
to obliterate documentation or leave vacant lines.
- Factors
that affect body temperature include time of day, age, physical activity, phase
of menstrual cycle, and pregnancy.
- The most
accessible and commonly used artery for measuring a patient’s pulse rate is the
radial artery. To take the pulse rate, the artery is compressed against the
radius.
- In a
resting adult, the normal pulse rate is 60 to 100 beats/minute. The rate is
slightly faster in women than in men and much faster in children than in
adults.
- Laboratory
test results are an objective form of assessment data.
- The
measurement systems most commonly used in clinical practice are the metric
system, apothecaries’ system, and household system.
- Before
signing an informed consent form, the patient should know whether other
treatment options are available and should understand what will occur during
the preoperative, intraoperative, and postoperative phases; the risks involved;
and the possible complications. The patient should also have a general idea of
the time required from surgery to recovery. In addition, he should have an opportunity
to ask questions.
- A patient
must sign a separate informed consent form for each procedure.
- During
percussion, the nurse uses quick, sharp tapping of the fingers or hands against
body surfaces to produce sounds. This procedure is done to determine the size,
shape, position, and density of underlying organs and tissues; elicit
tenderness; or assess reflexes.
-
Ballottement is a form of light palpation involving gentle, repetitive bouncing
of tissues against the hand and feeling their rebound.
- A foot
cradle keeps bed linen off the patient’s feet to prevent skin irritation and
breakdown, especially in a patient who has peripheral vascular disease or
neuropathy.
- Gastric
lavage is flushing of the stomach and removal of ingested substances through a
nasogastric tube. It’s used to treat poisoning or drug overdose.
- During the
evaluation step of the nursing process, the nurse assesses the patient’s
response to therapy.
- Bruits
commonly indicate life- or limb-threatening vascular disease.
- O.U. means
each eye. O.D. is the right eye, and O.S. is the left eye.
- To remove
a patient’s artificial eye, the nurse depresses the lower lid.
- The nurse
should use a warm saline solution to clean an artificial eye.
- A thready
pulse is very fine and scarcely perceptible.
- Axillary
temperature is usually 1° F lower than oral temperature.
- After
suctioning a tracheostomy tube, the nurse must document the color, amount,
consistency, and odor of secretions.
- On a drug
prescription, the abbreviation p.c. means that the drug should be administered
after meals.
- After
bladder irrigation, the nurse should document the amount, color, and clarity of
the urine and the presence of clots or sediment.
- After
bladder irrigation, the nurse should document the amount, color, and clarity of
the urine and the presence of clots or sediment.
- Laws
regarding patient self-determination vary from state to state. Therefore, the
nurse must be familiar with the laws of the state in which she works.
- Gauge is
the inside diameter of a needle: the smaller the gauge, the larger the
diameter.
- An adult
normally has 32 permanent teeth.
- After
turning a patient, the nurse should document the position used, the time that
the patient was turned, and the findings of skin assessment.
- PERRLA is
an abbreviation for normal pupil assessment findings: pupils equal, round, and
reactive to light with accommodation.
- When
percussing a patient’s chest for postural drainage, the nurse’s hands should be
cupped.
- When
measuring a patient’s pulse, the nurse should assess its rate, rhythm, quality,
and strength.
- Before
transferring a patient from a bed to a wheelchair, the nurse should push the
wheelchair’s footrests to the sides and lock its wheels.
- When assessing
respirations, the nurse should document their rate, rhythm, depth, and quality.
- For a
subcutaneous injection, the nurse should use a 5/8" 25G needle.
- The
notation “AA & O × 3” indicates that the patient is awake, alert, and
oriented to person (knows who he is), place (knows where he is), and time
(knows the date and time).
- Fluid
intake includes all fluids taken by mouth, including foods that are liquid at
room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and
fluids administered in feeding tubes. Fluid output includes urine, vomitus, and
drainage (such as from a nasogastric tube or from a wound) as well as blood
loss, diarrhea or feces, and perspiration.
- After
administering an intradermal injection, the nurse shouldn’t massage the area
because massage can irritate the site and interfere with results.
- When
administering an intradermal injection, the nurse should hold the syringe
almost flat against the patient’s skin (at about a 15-degree angle), with the
bevel up.
- To obtain
an accurate blood pressure, the nurse should inflate the manometer to 20 to 30
mm Hg above the disappearance of the radial pulse before releasing the cuff
pressure.
- The nurse
should count an irregular pulse for 1 full minute.
- A patient
who is vomiting while lying down should be placed in a lateral position to
prevent aspiration of vomitus.
-
Prophylaxis is disease prevention.
- Body
alignment is achieved when body parts are in proper relation to their natural
position.
- Trust is
the foundation of a nurse-patient relationship.
- Blood
pressure is the force exerted by the circulating volume of blood on the
arterial walls.
-
Malpractice is a professional’s wrongful conduct, improper discharge of duties,
or failure to meet standards of care that causes harm to another.
- As a
general rule, nurses can’t refuse a patient care assignment; however, in most
states, they may refuse to participate in abortions.
- A nurse
can be found negligent if a patient is injured because the nurse failed to
perform a duty that a reasonable and prudent person would perform or because
the nurse performed an act that a reasonable and prudent person wouldn’t
perform.
- States
have enacted Good Samaritan laws to encourage professionals to provide medical
assistance at the scene of an accident without fear of a lawsuit arising from
the assistance. These laws don’t apply to care provided in a health care
facility.
- A
physician should sign verbal and telephone orders within the time established
by facility policy, usually 24 hours.
- A
competent adult has the right to refuse lifesaving medical treatment; however,
the individual should be fully informed of the consequences of his refusal.
- Although a
patient’s health record, or chart, is the health care facility’s physical
property, its contents belong to the patient.
- Before a
patient’s health record can be released to a third party, the patient or the
patient’s legal guardian must give written consent.
- Under the
Controlled Substances Act, every dose of a controlled drug that’s dispensed by
the pharmacy must be accounted for, whether the dose was administered to a
patient or discarded accidentally.
- A nurse
can’t perform duties that violate a rule or regulation established by a state
licensing board, even if they are authorized by a health care facility or
physician.
- To
minimize interruptions during a patient interview, the nurse should select a
private room, preferably one with a door that can be closed.
- In
categorizing nursing diagnoses, the nurse addresses life-threatening problems
first, followed by potentially life-threatening concerns.
- The major
components of a nursing care plan are outcome criteria (patient goals) and
nursing interventions.
- Standing
orders, or protocols, establish guidelines for treating a specific disease or
set of symptoms.
- In
assessing a patient’s heart, the nurse normally finds the point of maximal
impulse at the fifth intercostal space, near the apex.
- The S1
heard on auscultation is caused by closure of the mitral and tricuspid valves.
- To
maintain package sterility, the nurse should open a wrapper’s top flap away
from the body, open each side flap by touching only the outer part of the
wrapper, and open the final flap by grasping the turned-down corner and pulling
it toward the body.
- The nurse
shouldn’t dry a patient’s ear canal or remove wax with a cotton-tipped
applicator because it may force cerumen against the tympanic membrane.
- A
patient’s identification bracelet should remain in place until the patient has
been discharged from the health care facility and has left the premises.
- The
Controlled Substances Act designated five categories, or schedules, that
classify controlled drugs according to their abuse potential.
- Schedule I
drugs, such as heroin, have a high abuse potential and have no currently accepted
medical use in the United States.
- Schedule
II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse
potential, but currently have accepted medical uses. Their use may lead to
physical or psychological dependence.
- Schedule III
drugs, such as paregoric and butabarbital (Butisol), have a lower abuse
potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to
moderate or low physical or psychological dependence, or both.
- Schedule
IV drugs, such as chloral hydrate, have a low abuse potential compared with
Schedule III drugs.
- Schedule V
drugs, such as cough syrups that contain codeine, have the lowest abuse
potential of the controlled substances.
- Activities
of daily living are actions that the patient must perform every day to provide
self-care and to interact with society.
- Testing of
the six cardinal fields of gaze evaluates the function of all extraocular
muscles and cranial nerves III, IV, and VI.
- The six
types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be
heard with the stethoscope slightly raised from the chest.
- The most
important goal to include in a care plan is the patient’s goal.
- Fruits are
high in fiber and low in protein, and should be omitted from a low-residue
diet.
- The nurse
should use an objective scale to assess and quantify pain. Postoperative pain
varies greatly among individuals.
- Postmortem
care includes cleaning and preparing the deceased patient for family viewing,
arranging transportation to the morgue or funeral home, and determining the
disposition of belongings.
- The nurse
should provide honest answers to the patient’s questions.
- Milk
shouldn’t be included in a clear liquid diet.
- When
caring for an infant, a child, or a confused patient, consistency in nursing
personnel is paramount.
- The
hypothalamus secretes vasopressin and oxytocin, which are stored in the
pituitary gland.
- The three
membranes that enclose the brain and spinal cord are the dura mater, pia mater,
and arachnoid.
- A
nasogastric tube is used to remove fluid and gas from the small intestine
preoperatively or postoperatively.
-
Psychologists, physical therapists, and chiropractors aren’t authorized to
write prescriptions for drugs.
- The area
around a stoma is cleaned with mild soap and water.
- Vegetables
have a high fiber content.
- The nurse
should use a tuberculin syringe to administer a subcutaneous injection of less
than 1 ml.
- For
adults, subcutaneous injections require a 25G 1" needle; for infants,
children, elderly, or very thin patients, they require a 25G to 27G ½"
needle.
- Before
administering a drug, the nurse should identify the patient by checking the
identification band and asking the patient to state his name.
- To clean
the skin before an injection, the nurse uses a sterile alcohol swab to wipe
from the center of the site outward in a circular motion.
- The nurse
should inject heparin deep into subcutaneous tissue at a 90-degree angle
(perpendicular to the skin) to prevent skin irritation.
- If blood
is aspirated into the syringe before an I.M. injection, the nurse should
withdraw the needle, prepare another syringe, and repeat the procedure.
- The nurse
shouldn’t cut the patient’s hair without written consent from the patient or an
appropriate relative.
- If
bleeding occurs after an injection, the nurse should apply pressure until the
bleeding stops. If bruising occurs, the nurse should monitor the site for an
enlarging hematoma.
- When
providing hair and scalp care, the nurse should begin combing at the end of the
hair and work toward the head.
- The
frequency of patient hair care depends on the length and texture of the hair,
the duration of hospitalization, and the patient’s condition.
- Proper
function of a hearing aid requires careful handling during insertion and
removal, regular cleaning of the ear piece to prevent wax buildup, and prompt
replacement of dead batteries.
- The
hearing aid that’s marked with a blue dot is for the left ear; the one with a
red dot is for the right ear.
- A hearing
aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in
water.
- The nurse
should instruct the patient to avoid using hair spray while wearing a hearing
aid.
- The five
branches of pharmacology are pharmacokinetics, pharmacodynamics,
pharmacotherapeutics, toxicology, and pharmacognosy.
- The nurse
should remove heel protectors every 8 hours to inspect the foot for signs of
skin breakdown.
- Heat is
applied to promote vasodilation, which reduces pain caused by inflammation.
- A sutured
surgical incision is an example of healing by first intention (healing
directly, without granulation).
- Healing by
secondary intention (healing by granulation) is closure of the wound when
granulation tissue fills the defect and allows reepithelialization to occur,
beginning at the wound edges and continuing to the center, until the entire
wound is covered.
- Keloid
formation is an abnormality in healing that’s characterized by overgrowth of
scar tissue at the wound site.
- The nurse
should administer procaine penicillin by deep I.M. injection in the upper outer
portion of the buttocks in the adult or in the midlateral thigh in the child.
The nurse shouldn’t massage the injection site.
- An
ascending colostomy drains fluid feces. A descending colostomy drains solid
fecal matter.
- A folded
towel (scrotal bridge) can provide scrotal support for the patient with scrotal
edema caused by vasectomy, epididymitis, or orchitis.
- When
giving an injection to a patient who has a bleeding disorder, the nurse should
use a small-gauge needle and apply pressure to the site for 5 minutes after the
injection.
- Platelets
are the smallest and most fragile formed element of the blood and are essential
for coagulation.
- To insert
a nasogastric tube, the nurse instructs the patient to tilt the head back
slightly and then inserts the tube. When the nurse feels the tube curving at
the pharynx, the nurse should tell the patient to tilt the head forward to
close the trachea and open the esophagus by swallowing. (Sips of water can
facilitate this action.)
- Families
with loved ones in intensive care units report that their four most important
needs are to have their questions answered honestly, to be assured that the
best possible care is being provided, to know the patient’s prognosis, and to
feel that there is hope of recovery.
-
Double-bind communication occurs when the verbal message contradicts the
nonverbal message and the receiver is unsure of which message to respond to.
- A
nonjudgmental attitude displayed by a nurse shows that she neither approves nor
disapproves of the patient.
- Target
symptoms are those that the patient finds most distressing.
- A patient
should be advised to take aspirin on an empty stomach, with a full glass of
water, and should avoid acidic foods such as coffee, citrus fruits, and cola.
- For every
patient problem, there is a nursing diagnosis; for every nursing diagnosis, there
is a goal; and for every goal, there are interventions designed to make the
goal a reality. The keys to answering examination questions correctly are
identifying the problem presented, formulating a goal for the problem, and
selecting the intervention from the choices provided that will enable the
patient to reach that goal.
- Fidelity
means loyalty and can be shown as a commitment to the profession of nursing and
to the patient.
-
Administering an I.M. injection against the patient’s will and without legal
authority is battery.
- An example
of a third-party payer is an insurance company.
- The
formula for calculating the drops per minute for an I.V. infusion is as
follows: (volume to be infused × drip factor) ÷ time in minutes = drops/minute
- On-call
medication should be given within 5 minutes of the call.
- Usually,
the best method to determine a patient’s cultural or spiritual needs is to ask
him.
- An
incident report or unusual occurrence report isn’t part of a patient’s record,
but is an in-house document that’s used for the purpose of correcting the
problem.
- Critical
pathways are a multidisciplinary guideline for patient care.
- When
prioritizing nursing diagnoses, the following hierarchy should be used:
Problems associated with the airway, those concerning breathing, and those
related to circulation.
- The two
nursing diagnoses that have the highest priority that the nurse can assign are
Ineffective airway clearance and Ineffective breathing pattern.
- A
subjective sign that a sitz bath has been effective is the patient’s expression
of decreased pain or discomfort.
- For the
nursing diagnosis Deficient diversional activity to be valid, the patient must
state that he’s “bored,” that he has “nothing to do,” or words to that effect.
- The most
appropriate nursing diagnosis for an individual who doesn’t speak English is
Impaired verbal communication related to inability to speak dominant language
(English).
- The family
of a patient who has been diagnosed as hearing impaired should be instructed to
face the individual when they speak to him.
- Before
instilling medication into the ear of a patient who is up to age 3, the nurse
should pull the pinna down and back to straighten the eustachian tube.
- To prevent
injury to the cornea when administering eyedrops, the nurse should waste the
first drop and instill the drug in the lower conjunctival sac.
- After
administering eye ointment, the nurse should twist the medication tube to
detach the ointment.
- When the
nurse removes gloves and a mask, she should remove the gloves first. They are
soiled and are likely to contain pathogens.
- Crutches
should be placed 6" (15.2 cm) in front of the patient and 6" to the side
to form a tripod arrangement.
- Listening
is the most effective communication technique.
- Before
teaching any procedure to a patient, the nurse must assess the patient’s
current knowledge and willingness to learn.
- Process
recording is a method of evaluating one’s communication effectiveness.
- When
feeding an elderly patient, the nurse should limit high-carbohydrate foods
because of the risk of glucose intolerance.
- When
feeding an elderly patient, essential foods should be given first.
- Passive
range of motion maintains joint mobility. Resistive exercises increase muscle
mass.
- Isometric
exercises are performed on an extremity that’s in a cast.
- A back rub
is an example of the gate-control theory of pain.
- Anything
that’s located below the waist is considered unsterile; a sterile field becomes
unsterile when it comes in contact with any unsterile item; a sterile field
must be monitored continuously; and a border of 1" (2.5 cm) around a
sterile field is considered unsterile.
- A “shift
to the left” is evident when the number of immature cells (bands) in the blood
increases to fight an infection.
- A “shift
to the right” is evident when the number of mature cells in the blood
increases, as seen in advanced liver disease and pernicious anemia.
- Before
administering preoperative medication, the nurse should ensure that an informed
consent form has been signed and attached to the patient’s record.
- A nurse
should spend no more than 30 minutes per 8-hour shift providing care to a
patient who has a radiation implant.
- A nurse
shouldn’t be assigned to care for more than one patient who has a radiation
implant.
-
Long-handled forceps and a lead-lined container should be available in the room
of a patient who has a radiation implant.
- Usually,
patients who have the same infection and are in strict isolation can share a
room.
- Diseases
that require strict isolation include chickenpox, diphtheria, and viral
hemorrhagic fevers such as Marburg disease.
- For the
patient who abides by Jewish custom, milk and meat shouldn’t be served at the
same meal.
- Whether
the patient can perform a procedure (psychomotor domain of learning) is a
better indicator of the effectiveness of patient teaching than whether the patient
can simply state the steps involved in the procedure (cognitive domain of
learning).
- According
to Erik Erikson, developmental stages are trust versus mistrust (birth to 18
months), autonomy versus shame and doubt (18 months to age 3), initiative versus
guilt (ages 3 to 5), industry versus inferiority (ages 5 to 12), identity
versus identity diffusion (ages 12 to 18), intimacy versus isolation (ages 18
to 25), generativity versus stagnation (ages 25 to 60), and ego integrity
versus despair (older than age 60).
- When
communicating with a hearing impaired patient, the nurse should face him.
- An
appropriate nursing intervention for the spouse of a patient who has a serious
incapacitating disease is to help him to mobilize a support system.
- Hyperpyrexia
is extreme elevation in temperature above 106° F (41.1° C).
- Milk is
high in sodium and low in iron.
- When a
patient expresses concern about a health-related issue, before addressing the
concern, the nurse should assess the patient’s level of knowledge.
- The most
effective way to reduce a fever is to administer an antipyretic, which lowers
the temperature set point.
- When a
patient is ill, it’s essential for the members of his family to maintain
communication about his health needs.
-
Ethnocentrism is the universal belief that one’s way of life is superior to
others’.
- When a
nurse is communicating with a patient through an interpreter, the nurse should
speak to the patient and the interpreter.
- In
accordance with the “hot-cold” system used by some Mexicans, Puerto Ricans, and
other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are
described as “cold.”
- Prejudice
is a hostile attitude toward individuals of a particular group.
-
Discrimination is preferential treatment of individuals of a particular group.
It’s usually discussed in a negative sense.
- Increased
gastric motility interferes with the absorption of oral drugs.
- The three
phases of the therapeutic relationship are orientation, working, and
termination.
- Patients
often exhibit resistive and challenging behaviors in the orientation phase of
the therapeutic relationship.
- Abdominal
assessment is performed in the following order: inspection, auscultation,
palpation, and percussion.
- When
measuring blood pressure in a neonate, the nurse should select a cuff that’s no
less than one-half and no more than two-thirds the length of the extremity
that’s used.
- When
administering a drug by Z-track, the nurse shouldn’t use the same needle that
was used to draw the drug into the syringe because doing so could stain the
skin.
- Sites for
intradermal injection include the inner arm, the upper chest, and on the back,
under the scapula.
- When
evaluating whether an answer on an examination is correct, the nurse should
consider whether the action that’s described promotes autonomy (independence),
safety, self-esteem, and a sense of belonging.
- When
answering a question on the NCLEX examination, the student should consider the
cue (the stimulus for a thought) and the inference (the thought) to determine
whether the inference is correct. When in doubt, the nurse should select an
answer that indicates the need for further information to eliminate ambiguity.
For example, the patient complains of chest pain (the stimulus for the thought)
and the nurse infers that the patient is having cardiac pain (the thought). In
this case, the nurse hasn’t confirmed whether the pain is cardiac. It would be
more appropriate to make further assessments.
- Veracity
is truth and is an essential component of a therapeutic relationship between a
health care provider and his patient.
-
Beneficence is the duty to do no harm and the duty to do good. There’s an
obligation in patient care to do no harm and an equal obligation to assist the
patient.
-
Nonmaleficence is the duty to do no harm.
- Frye’s
ABCDE cascade provides a framework for prioritizing care by identifying the
most important treatment concerns.
- A =
Airway. This category includes everything that affects a patent airway,
including a foreign object, fluid from an upper respiratory infection, and
edema from trauma or an allergic reaction.
- B =
Breathing. This category includes everything that affects the breathing
pattern, including hyperventilation or hypoventilation and abnormal breathing
patterns, such as Korsakoff’s, Biot’s, or Cheyne-Stokes respiration.
- C =
Circulation. This category includes everything that affects the circulation,
including fluid and electrolyte disturbances and disease processes that affect
cardiac output.
- D =
Disease processes. If the patient has no problem with the airway, breathing, or
circulation, then the nurse should evaluate the disease processes, giving
priority to the disease process that poses the greatest immediate risk. For
example, if a patient has terminal cancer and hypoglycemia, hypoglycemia is a more
immediate concern.
- E =
Everything else. This category includes such issues as writing an incident
report and completing the patient chart. When evaluating needs, this category
is never the highest priority.
- When
answering a question on an NCLEX examination, the basic rule is “assess before
action.” The student should evaluate each possible answer carefully. Usually,
several answers reflect the implementation phase of nursing and one or two
reflect the assessment phase. In this case, the best choice is an assessment
response unless a specific course of action is clearly indicated.
- Rule
utilitarianism is known as the “greatest good for the greatest number of
people” theory.
-
Egalitarian theory emphasizes that equal access to goods and services must be
provided to the less fortunate by an affluent society.
- Active
euthanasia is actively helping a person to die.
- Brain
death is irreversible cessation of all brain function.
- Passive
euthanasia is stopping the therapy that’s sustaining life.
- A
third-party payer is an insurance company.
-
Utilization review is performed to determine whether the care provided to a
patient was appropriate and cost-effective.
- A value
cohort is a group of people who experienced an out-of-the-ordinary event that
shaped their values.
- Voluntary
euthanasia is actively helping a patient to die at the patient’s request.
- Bananas,
citrus fruits, and potatoes are good sources of potassium.
- Good
sources of magnesium include fish, nuts, and grains.
- Beef,
oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron.
-
Intrathecal injection is administering a drug through the spine.
- When a
patient asks a question or makes a statement that’s emotionally charged, the
nurse should respond to the emotion behind the statement or question rather
than to what’s being said or asked.
- The steps
of the trajectory-nursing model are as follows:
Step 1:
Identifying the trajectory phase
Step 2:
Identifying the problems and establishing goals
Step 3:
Establishing a plan to meet the goals
Step 4:
Identifying factors that facilitate or hinder attainment of the goals
Step 5:
Implementing interventions
Step 6:
Evaluating the effectiveness of the interventions
- A Hindu
patient is likely to request a vegetarian diet.
- Pain
threshold, or pain sensation, is the initial point at which a patient feels
pain.
- The
difference between acute pain and chronic pain is its duration.
- Referred
pain is pain that’s felt at a site other than its origin.
-
Alleviating pain by performing a back massage is consistent with the gate
control theory.
- Romberg’s
test is a test for balance or gait.
- Pain seems
more intense at night because the patient isn’t distracted by daily activities.
- Older
patients commonly don’t report pain because of fear of treatment, lifestyle
changes, or dependency.
- No pork or
pork products are allowed in a Muslim diet.
- Two goals
of Healthy People 2010 are:
Help
individuals of all ages to increase the quality of life and the number of years
of optimal health
Eliminate
health disparities among different segments of the population.
- A
community nurse is serving as a patient’s advocate if she tells a malnourished
patient to go to a meal program at a local park.
- If a
patient isn’t following his treatment plan, the nurse should first ask why.
- Falls are
the leading cause of injury in elderly people.
- Primary
prevention is true prevention. Examples are immunizations, weight control, and
smoking cessation.
- Secondary
prevention is early detection. Examples include purified protein derivative
(PPD), breast self-examination, testicular self-examination, and chest X-ray.
- Tertiary
prevention is treatment to prevent long-term complications.
- A patient
indicates that he’s coming to terms with having a chronic disease when he says,
“I’m never going to get any better.”
- On
noticing religious artifacts and literature on a patient’s night stand, a
culturally aware nurse would ask the patient the meaning of the items.
- A Mexican
patient may request the intervention of a curandero, or faith healer, who
involves the family in healing the patient.
- In an
infant, the normal hemoglobin value is 12 g/dl.
- The
nitrogen balance estimates the difference between the intake and use of
protein.
- Most of
the absorption of water occurs in the large intestine.
- Most
nutrients are absorbed in the small intestine.
- When
assessing a patient’s eating habits, the nurse should ask, “What have you eaten
in the last 24 hours?”
- A vegan
diet should include an abundant supply of fiber.
- A
hypotonic enema softens the feces, distends the colon, and stimulates
peristalsis.
-
First-morning urine provides the best sample to measure glucose, ketone, pH,
and specific gravity values.
- To induce
sleep, the first step is to minimize environmental stimuli.
- Before
moving a patient, the nurse should assess the patient’s physical abilities and
ability to understand instructions as well as the amount of strength required
to move the patient.
- To lose 1
lb (0.5 kg) in 1 week, the patient must decrease his weekly intake by 3,500
calories (approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the
patient must decrease his weekly caloric intake by 7,000 calories
(approximately 1,000 calories daily).
- To avoid
shearing force injury, a patient who is completely immobile is lifted on a
sheet.
- To insert
a catheter from the nose through the trachea for suction, the nurse should ask
the patient to swallow.
- Vitamin C
is needed for collagen production.
- Only the
patient can describe his pain accurately.
- Cutaneous
stimulation creates the release of endorphins that block the transmission of
pain stimuli.
-
Patient-controlled analgesia is a safe method to relieve acute pain caused by
surgical incision, traumatic injury, labor and delivery, or cancer.
- An Asian
American or European American typically places distance between himself and
others when communicating.
- The
patient who believes in a scientific, or biomedical, approach to health is
likely to expect a drug, treatment, or surgery to cure illness.
- Chronic
illnesses occur in very young as well as middle-aged and very old people.
- The
trajectory framework for chronic illness states that preferences about daily
life activities affect treatment decisions.
-
Exacerbations of chronic disease usually cause the patient to seek treatment
and may lead to hospitalization.
- School
health programs provide cost-effective health care for low-income families and
those who have no health insurance.
-
Collegiality is the promotion of collaboration, development, and
interdependence among members of a profession.
- A change
agent is an individual who recognizes a need for change or is selected to make
a change within an established entity, such as a hospital.
- The
patients’ bill of rights was introduced by the American Hospital Association.
-
Abandonment is premature termination of treatment without the patient’s
permission and without appropriate relief of symptoms.
- Values
clarification is a process that individuals use to prioritize their personal values.
-
Distributive justice is a principle that promotes equal treatment for all.
- Milk and
milk products, poultry, grains, and fish are good sources of phosphate.
- The best
way to prevent falls at night in an oriented, but restless, elderly patient 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 be caused by poor vision.
- Barriers
to communication include language deficits, sensory deficits, cognitive
impairments, structural deficits, and paralysis.
- The three
elements that are necessary 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 should assess the oral
mucosa.
- To put on
a sterile glove, the nurse should pick up the first glove at the folded border
and adjust the fingers when both gloves are on.
- To increase
patient comfort, the nurse should let the alcohol dry before giving an
intramuscular injection.
- Treatment
for a stage 1 ulcer on the heels includes heel protectors.
-
Seventh-Day Adventists are usually vegetarians.
- Endorphins
are morphinelike substances that produce a feeling of well-being.
- Pain
tolerance is the maximum amount and duration of pain that an individual is
willing to endure.
- A blood
pressure cuff that’s too narrow can cause a falsely elevated blood pressure
reading.
- When preparing
a single injection for a patient who takes regular and neutral protein Hagedorn
insulin, the nurse should draw the regular insulin into the syringe first so
that it does not contaminate the regular insulin.
- Rhonchi
are the rumbling sounds heard on lung auscultation. They are more pronounced
during expiration than during inspiration.
- Gavage is
forced feeding, usually through a gastric tube (a tube passed into the stomach
through the mouth).
- According
to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter,
sex, activity, and comfort) have the highest priority.
- The safest
and surest way to verify a patient’s identity is to check the identification
band on his wrist.
- In the
therapeutic environment, the patient’s safety is the primary concern.
- Fluid
oscillation in the tubing of a chest drainage system indicates that the system
is working properly.
- The nurse
should place a patient who has a Sengstaken-Blakemore tube in semi-Fowler
position.
- The nurse
can elicit Trousseau’s sign by occluding the brachial or radial artery. Hand
and finger spasms that occur during occlusion indicate Trousseau’s sign and
suggest hypocalcemia.
- For blood
transfusion in an adult, the appropriate needle size is 16 to 20G.
-
Intractable pain is pain that incapacitates a patient and can’t be relieved by
drugs.
- In an
emergency, consent for treatment can be obtained by fax, telephone, or other
telegraphic means.
- Decibel is
the unit of measurement of sound.
- Informed
consent is required for any invasive procedure.
- A patient
who can’t write his name to give consent for treatment must make an X in the
presence of two witnesses, such as a nurse, priest, or physician.
- The Z-track
I.M. injection technique seals the drug deep into the muscle, thereby
minimizing skin irritation and staining. It requires a needle that’s 1"
(2.5 cm) or longer.
- In the
event of fire, the acronym most often used is RACE. (R) Remove the patient. (A)
Activate the alarm. (C) Attempt to contain the fire by closing the door. (E)
Extinguish the fire if it can be done safely.
- A
registered nurse should assign a licensed vocational nurse or licensed
practical nurse to perform bedside care, such as suctioning and drug
administration.
- If a
patient can’t void, the first nursing action should be bladder palpation to
assess for bladder distention.
- The
patient who uses a cane should carry it on the unaffected side and advance it
at the same time as the affected extremity.
- To fit a
supine patient for crutches, the nurse should measure from the axilla to the
sole and add 2" (5 cm) to that measurement.
- Assessment
begins with the nurse’s first encounter with the patient and continues
throughout the patient’s stay. The nurse obtains assessment data through the
health history, physical examination, and review of diagnostic studies.
- The
appropriate needle size for insulin injection is 25G and 5/8" long.
- Residual
urine is urine that remains in the bladder after voiding. The amount of
residual urine is normally 50 to 100 ml.
- The five
stages of the nursing process are assessment, nursing diagnosis, planning,
implementation, and evaluation.
- Assessment
is the stage of the nursing process in which the nurse continuously collects
data to identify a patient’s actual and potential health needs.
- Nursing
diagnosis is the stage of the nursing process in which the nurse makes a
clinical judgment about individual, family, or community responses to actual or
potential health problems or life processes.
- Planning
is the stage of the nursing process in which the nurse assigns priorities to
nursing diagnoses, defines short-term and long-term goals and expected
outcomes, and establishes the nursing care plan.
-
Implementation is the stage of the nursing process in which the nurse puts the
nursing care plan into action, delegates specific nursing interventions to
members of the nursing team, and charts patient responses to nursing
interventions.
- Evaluation
is the stage of the nursing process in which the nurse compares objective and
subjective data with the outcome criteria and, if needed, modifies the nursing
care plan.
- Before
administering any “as needed” pain medication, the nurse should ask the patient
to indicate the location of the pain.
- Jehovah’s
Witnesses believe that they shouldn’t receive blood components donated by other
people.
- To test
visual acuity, the nurse should ask the patient to cover each eye separately
and to read the eye chart with glasses and without, as appropriate.
- When
providing oral care for an unconscious patient, to minimize the risk of
aspiration, the nurse should position the patient on the side.
- During
assessment of distance vision, the patient should stand 20' (6.1 m) from the
chart.
- For a
geriatric patient or one who is extremely ill, the ideal room temperature is
66° to 76° F (18.8° to 24.4° C).
- Normal
room humidity is 30% to 60%.
- Hand
washing is the single best method of limiting the spread of microorganisms.
Once gloves are removed after routine contact with a patient, hands should be
washed for 10 to 15 seconds.
- To perform
catheterization, the nurse should place a woman in the dorsal recumbent
position.
- A positive
Homans’ sign may indicate thrombophlebitis.
-
Electrolytes in a solution are measured in milliequivalents per liter (mEq/L).
A milliequivalent is the number of milligrams per 100 milliliters of a
solution.
- Metabolism
occurs in two phases: anabolism (the constructive phase) and catabolism (the
destructive phase).
- The basal
metabolic rate is the amount of energy needed to maintain essential body
functions. It’s measured when the patient is awake and resting, hasn’t eaten
for 14 to 18 hours, and is in a comfortable, warm environment.
- The basal
metabolic rate is expressed in calories consumed per hour per kilogram of body
weight.
- Dietary
fiber (roughage), which is derived from cellulose, supplies bulk, maintains
intestinal motility, and helps to establish regular bowel habits.
- Alcohol is
metabolized primarily in the liver. Smaller amounts are metabolized by the
kidneys and lungs.
- Petechiae
are tiny, round, purplish red spots that appear on the skin and mucous
membranes as a result of intradermal or submucosal hemorrhage.
- Purpura is
a purple discoloration of the skin that’s caused by blood extravasation.
- According
to the standard precautions recommended by the Centers for Disease Control and
Prevention, the nurse shouldn’t recap needles after use. Most needle sticks
result from missed needle recapping.
- The nurse
administers a drug by I.V. push by using a needle and syringe to deliver the
dose directly into a vein, I.V. tubing, or a catheter.
- When
changing the ties on a tracheostomy tube, the nurse should leave the old ties
in place until the new ones are applied.
- A nurse
should have assistance when changing the ties on a tracheostomy tube.
- A filter
is always used for blood transfusions.
- A
four-point (quad) cane is indicated when a patient needs more stability than a
regular cane can provide.
- A good way
to begin a patient interview is to ask, “What made you seek medical help?”
- When
caring for any patient, the nurse should follow standard precautions for
handling blood and body fluids.
- Potassium
(K+) is the most abundant cation in intracellular fluid.
- In the
four-point, or alternating, gait, the patient first moves the right crutch
followed by the left foot and then the left crutch followed by the right foot.
- In the
three-point gait, the patient moves two crutches and the affected leg
simultaneously and then moves the unaffected leg.
- In the
two-point gait, the patient moves the right leg and the left crutch
simultaneously and then moves the left leg 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 adult patient should be lightly dressed and shoeless.
- Before
taking an adult’s temperature orally, the nurse should ensure that the patient
hasn’t smoked or consumed hot or cold substances in the previous 15 minutes.
- The nurse
shouldn’t take an adult’s temperature rectally if the patient has a cardiac
disorder, anal lesions, or bleeding hemorrhoids or has recently undergone
rectal surgery.
- In a
patient who has a cardiac disorder, measuring temperature rectally may
stimulate a vagal response and lead to vasodilation and decreased cardiac
output.
- When
recording pulse amplitude and rhythm, the nurse should use these descriptive
measures: +3, bounding pulse (readily palpable and forceful); +2, normal pulse
(easily palpable); +1, thready or weak pulse (difficult to detect); and 0,
absent pulse (not detectable).
- The
intraoperative period begins when a patient is transferred to the operating
room bed and ends when the patient is admitted to the postanesthesia care unit.
- On the
morning of surgery, the nurse should ensure that the informed consent form has
been signed; that the patient hasn’t taken anything by mouth since midnight,
has taken a shower with antimicrobial soap, has had mouth care (without
swallowing the water), has removed common jewelry, and has received
preoperative medication as prescribed; and that vital signs have been taken and
recorded. Artificial limbs and other prostheses are usually removed.
- Comfort
measures, such as positioning the patient, rubbing the patient’s back, and
providing a restful environment, may decrease the patient’s need for analgesics
or may enhance their effectiveness.
- A drug has
three names: generic name, which is used in official publications; trade, or
brand, name (such as Tylenol), which is selected by the drug company; and
chemical name, which describes the drug’s chemical composition.
- To avoid
staining the teeth, the patient should take a liquid iron preparation through a
straw.
- The nurse
should use the Z-track method to administer an I.M. injection of iron dextran
(Imferon).
- An
organism may enter the body through the nose, mouth, rectum, urinary or
reproductive tract, or skin.
- In
descending order, the levels of consciousness are alertness, lethargy, stupor,
light coma, and deep coma.
- To turn a
patient by logrolling, the nurse folds the patient’s arms across the chest;
extends the patient’s legs and inserts a pillow between them, if needed; places
a draw sheet under the patient; and turns the patient by slowly and gently
pulling on the draw sheet.
- The
diaphragm of the stethoscope is used to hear high-pitched sounds, such as
breath sounds.
- A slight
difference in blood pressure (5 to 10 mm Hg) between the right and the left
arms is normal.
- The nurse
should place the blood pressure cuff 1" (2.5 cm) above the antecubital
fossa.
- When
instilling ophthalmic ointments, the nurse should waste the first bead of
ointment and then apply the ointment from the inner canthus to the outer
canthus.
- The nurse
should use a leg cuff to measure blood pressure in an obese patient.
- If a blood
pressure cuff is applied too loosely, the reading will be falsely elevated.
- Ptosis is
drooping of the eyelid.
- A tilt
table is useful for a patient with a spinal cord injury, orthostatic
hypotension, or brain damage because it can move the patient gradually from a
horizontal to a vertical (upright) position.
- To perform
venipuncture with the least injury to the vessel, the nurse should turn the
bevel upward when the vessel’s lumen is larger than the needle and turn it
downward when the lumen is only slightly larger than the needle.
- To move a
patient to the edge of the bed for transfer, the nurse should follow these
steps: Move the patient’s head and shoulders toward the edge of the bed. Move
the patient’s feet and legs to the edge of the bed (crescent position). Place
both arms well under the patient’s hips, and straighten the back while moving
the patient toward the edge of the bed.
- When being
measured for crutches, a patient should wear shoes.
- The nurse
should attach a restraint to the part of the bed frame that moves with the
head, not to the mattress or side rails.
- The mist
in a mist tent should never become so dense that it obscures clear
visualization of the patient’s respiratory pattern.
- To
administer heparin subcutaneously, the nurse should follow these steps: Clean,
but don’t rub, the site with alcohol. Stretch the skin taut or pick up a
well-defined skin fold. Hold the shaft of the needle in a dart position. Insert
the needle into the skin at a right (90-degree) angle. Firmly depress the
plunger, but don’t aspirate. Leave the needle in place for 10 seconds. Withdraw
the needle gently at the angle of insertion. Apply pressure to the injection
site with an alcohol pad.
- For a
sigmoidoscopy, the nurse should place the patient in the knee-chest position or
Sims’ position, depending on the physician’s preference.
- Maslow’s
hierarchy of needs must be met in the following order: physiologic (oxygen,
food, water, sex, rest, and comfort), safety and security, love and belonging,
self-esteem and recognition, and self-actualization.
- When
caring for a patient who has a nasogastric tube, the nurse should apply a
water-soluble lubricant to the nostril to prevent soreness.
- During
gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and
ingested substances are removed through the tube.
- In
documenting drainage on a surgical dressing, the nurse should include the size,
color, and consistency of the drainage (for example, “10 mm of brown mucoid
drainage noted on dressing”).
- To elicit
Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a
moderately sharp object, such as a thumbnail.
- A positive
Babinski’s reflex is shown by dorsiflexion of the great toe and fanning out of
the other toes.
- When
assessing a patient for bladder distention, the nurse should check the contour
of the lower abdomen for a rounded mass above the symphysis pubis.
- The best
way to prevent pressure ulcers is to reposition the bedridden patient at least
every 2 hours.
-
Antiembolism stockings decompress the superficial blood vessels, reducing the
risk of thrombus formation.
- In adults,
the most convenient veins for venipuncture are the basilic and median cubital
veins in the antecubital space.
- Two to
three hours before beginning a tube feeding, the nurse should aspirate the
patient’s stomach contents to verify that gastric emptying is adequate.
- People
with type O blood are considered universal donors.
- People
with type AB blood are considered universal recipients.
- Hertz (Hz)
is the unit of measurement of sound frequency.
- Hearing
protection is required when the sound intensity exceeds 84 dB. Double hearing
protection is required if it exceeds 104 dB.
-
Prothrombin, a clotting factor, is produced in the liver.
- If a
patient is menstruating when a urine sample is collected, the nurse should note
this on the laboratory request.
- During
lumbar puncture, the nurse must note the initial intracranial pressure and the
color of the cerebrospinal fluid.
- If a
patient can’t cough to provide a sputum sample for culture, a heated aerosol
treatment can be used to help to obtain a sample.
- If eye
ointment and eyedrops must be instilled in the same eye, the eyedrops should be
instilled first.
- When
leaving an isolation room, the nurse should remove her gloves before her mask
because fewer pathogens are on the mask.
- Skeletal
traction, which is applied to a bone with wire pins or tongs, is the most
effective means of traction.
- The total
parenteral nutrition solution should be stored in a refrigerator and removed 30
to 60 minutes before use. Delivery of a chilled solution can cause pain,
hypothermia, venous spasm, and venous constriction.
- Drugs
aren’t routinely injected intramuscularly into edematous tissue because they
may not be absorbed.
- When
caring for a comatose patient, the nurse should explain each action to the
patient in a normal voice.
- Dentures
should be cleaned in a sink that’s lined with a washcloth.
- A patient
should void within 8 hours after surgery.
- An EEG
identifies normal and abnormal brain waves.
- Samples of
feces for ova and parasite tests should be delivered to the laboratory without
delay and without refrigeration.
- The
autonomic nervous system regulates the cardiovascular and respiratory systems.
- When
providing tracheostomy care, the nurse should insert the catheter gently into
the tracheostomy tube. When withdrawing the catheter, the nurse should apply
intermittent suction for no more than 15 seconds and use a slight twisting
motion.
- A
low-residue diet includes such foods as roasted chicken, rice, and pasta.
- A rectal
tube shouldn’t be inserted for longer than 20 minutes because it can irritate
the rectal mucosa and cause loss of sphincter control.
- A
patient’s bed bath should proceed in this order: face, neck, arms, hands,
chest, abdomen, back, legs, perineum.
- To prevent
injury when lifting and moving a patient, the nurse should primarily use the
upper leg muscles.
- Patient
preparation for cholecystography includes ingestion of a contrast medium and a
low-fat evening meal.
- While an
occupied bed is being changed, the patient should be covered with a bath
blanket to promote warmth and prevent exposure.
-
Anticipatory grief is mourning that occurs for an extended time when the
patient realizes that death is inevitable.
- The following
foods can alter the color of the feces: beets (red), cocoa (dark red or brown),
licorice (black), spinach (green), and meat protein (dark brown).
- When
preparing for a skull X-ray, the patient should remove all jewelry and
dentures.
- The fight-or-flight
response is a sympathetic nervous system response.
-
Bronchovesicular breath sounds in peripheral lung fields are abnormal and
suggest pneumonia.
- Wheezing
is an abnormal, high-pitched breath sound that’s accentuated on expiration.
- Wax or a
foreign body in the ear should be flushed out gently by irrigation with warm
saline solution.
- If a
patient complains that his hearing aid is “not working,” the nurse should check
the switch first to see if it’s turned on and then check the batteries.
- The nurse
should grade hyperactive biceps and triceps reflexes as +4.
- If two eye
medications are prescribed for twice-daily instillation, they should be
administered 5 minutes apart.
- In a
postoperative patient, forcing fluids helps prevent constipation.
- A nurse
must provide care in accordance with standards of care established by the
American Nurses Association, state regulations, and facility policy.
- The
kilocalorie (kcal) is a unit of energy measurement that represents the amount of
heat needed to raise the temperature 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 a fixed rate, regardless of serum concentration.
- In an
alcoholic beverage, proof reflects the percentage of alcohol multiplied by 2.
For example, a 100-proof beverage contains 50% alcohol.
- A living
will is a witnessed document that states a patient’s desire for certain types
of care and treatment. These decisions are based on the patient’s wishes and
views on quality of life.
- The nurse
should flush a peripheral heparin lock every 8 hours (if it wasn’t used during
the previous 8 hours) and as needed with normal saline solution to maintain
patency.
- Quality
assurance is a method of determining whether nursing actions and practices meet
established standards.
- The five
rights of medication administration are the right patient, right drug, right
dose, right route of administration, and right time.
- The
evaluation phase of the nursing process is to determine whether nursing
interventions have enabled the patient to meet the desired goals.
- Outside of
the hospital setting, only the sublingual and translingual forms of
nitroglycerin should be used to relieve acute anginal attacks.
- The
implementation phase of the nursing process involves recording the patient’s
response to the nursing plan, putting the nursing plan into action, delegating
specific nursing interventions, and coordinating the patient’s activities.
- The
Patient’s Bill of Rights offers patients guidance and protection by stating the
responsibilities of the hospital and its staff toward patients and their
families during hospitalization.
- To
minimize omission and distortion of facts, the nurse should record information
as soon as it’s gathered.
- When
assessing a patient’s health history, the nurse should record the current illness
chronologically, beginning with the onset of the problem and continuing to the
present.
- When
assessing a patient’s health history, the nurse should record the current
illness chronologically, beginning with the onset of the problem and continuing
to the present.
- A nurse
shouldn’t give false assurance to a patient.
- After
receiving preoperative medication, a patient isn’t competent to sign an
informed consent form.
- When
lifting a patient, a nurse uses the weight of her body instead of the strength
in her arms.
- The nurse
shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a
pulse that may be confused with the patient’s pulse.
- An
inspiration and an expiration count as one respiration.
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