Ob Nursing Bullets
Ob Nursing Bullets
Ob Nursing Bullets
When preparing a single injection for a patient whoϖ 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 lungϖ auscultation. They are
more
pronounced during expiration than during inspiration.
Gavage is forced feeding, usually through a gastric tubeϖ (a tube
passed into
the stomach through the mouth).
According toϖ Maslow’s hierarchy of needs, physiologic needs (air,
water, food,
shelter, sex, activity, and comfort) have the highest priority.
The safest and surestϖ 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 theϖ primary
concern.
Fluid oscillation in the tubing of a chest drainageϖ system indicates
that the
system is working properly.
The nurse shouldϖ place a patient who has a Sengstaken-Blakemore
tube in
semi-Fowler position.
The nurse can elicit Trousseau’s sign by occluding theϖ brachial or
radial
artery. Hand and finger spasms that occur during occlusion indicate
Trousseau’s sign and suggest hypocalcemia.
For bloodϖ transfusion in an adult, the appropriate needle size is 16 to
20G.
ϖ 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,ϖ telephone, or
other telegraphic means.
Decibel is the unit of measurementϖ of sound.
Informed consent is required for any invasiveϖ procedure.
A patient who can’t write his name to give consent forϖ 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 theϖ drug deep into the
muscle,
thereby minimizing skin irritation and staining. It requires a needle that’s
1" (2.5cm) or longer.
In the event of fire,ϖ 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 aϖ licensed vocational nurse or licensed
practical nurse to perform bedside care, such as suctioning and drug
administration.
If a patient can’t void,ϖ the first nursing action should be bladder
palpation to
assess for bladder distention.
The patient who uses a cane should carry it on the unaffectedϖ side and
advance
it at the same time as the affected extremity.
To fitϖ 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 theϖ 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 needleϖ size for insulin injection is 25G and 5/8"
long.
Residual urine isϖ 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 areϖ assessment, nursing
diagnosis,
planning, implementation, and evaluation.
Assessment is the stage of the nursing process in which theϖ nurse
continuously collects data to identify a patient’s actual and potential
health needs.
Nursing diagnosis is the stage of the nursing process inϖ which the
nurse
makes a clinical judgment about individual, family, or community
responses to
actual or potential health problems or life processes.
ϖ 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.
ϖ 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 whichϖ the nurse
compares
objective and subjective data with the outcome criteria and, if needed,
modifies
the nursing care plan.
Before administering any “asϖ needed” pain medication, the nurse
should ask
the patient to indicate the location of the pain.
Jehovah’s Witnesses believe that they shouldn’tϖ receive blood
components
donated by other people.
To test visualϖ acuity, the nurse should ask the patient to cover each
eye
separately and to read the eye chart with glasses and without, as
appropriate.
Whenϖ providing oral care for an unconscious patient, to minimize the
risk of
aspiration, the nurse should position the patient on the side.
Duringϖ 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
roomϖ temperature is
66° to 76° F (18.8° to 24.4° C).
Normal room humidity isϖ 30% to 60%.
Hand washing is the single best method of limiting theϖ spread of
microorganisms. Once gloves are removed after routine contact with a
patient,
hands should be washed for 10 to 15 seconds.
To performϖ catheterization, the nurse should place a woman in the
dorsal
recumbent position.
A positive Homans’ sign may indicateϖ thrombophlebitis.
Electrolytes in a solution are measured inϖ milliequivalents per liter
(mEq/L). A
milliequivalent is the number of milligrams per 100 milliliters of a
solution.
Metabolism occurs in twoϖ phases: anabolism (the constructive phase)
and
catabolism (the destructive phase).
The basal metabolic rate is the amount of energy needed toϖ 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 consumedϖ per hour
per
kilogram of body weight.
Dietary fiber (roughage), whichϖ is derived from cellulose, supplies bulk,
maintains intestinal motility, and helps to establish regular bowel habits.
Alcohol is metabolizedϖ primarily in the liver. Smaller amounts are
metabolized
by the kidneys and lungs.
Petechiae are tiny, round, purplish red spots that appear on theϖ skin
and
mucous membranes as a result of intradermal or submucosal
hemorrhage.
Purpura is a purple discoloration of the skin that’sϖ caused by blood
extravasation.
According to the standard precautionsϖ 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 needleϖ 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 nurseϖ should leave
the old
ties in place until the new ones are applied.
Aϖ nurse should have assistance when changing the ties on a
tracheostomy
tube.
A filter is always used for blood transfusions.ϖ
Aϖ 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 toϖ ask, “What made you
seek
medical help?”
When caring for any patient,ϖ the nurse should follow standard
precautions for
handling blood and body fluids.
Potassium (K+) is the most abundant cation in intracellularϖ fluid.
In the four-point, or alternating, gait, the patient first movesϖ 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 crutchesϖ and the
affected leg
simultaneously and then moves the unaffected leg.
ϖ 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 thatϖ are essential
for
metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine
(B6),
and cyanocobalamin (B12).
When being weighed, anϖ adult patient should be lightly dressed and
shoeless.
Before taking anϖ 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.
ϖ 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,ϖ measuring temperature rectally
may
stimulate a vagal response and lead to vasodilation and decreased cardiac
output.
When recording pulseϖ 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 isϖ transferred to the
operating
room bed and ends when the patient is admitted to the postanesthesia
care unit.
On the morning of surgery, the nurseϖ 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 positioningϖ 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 usedϖ 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 shouldϖ take a liquid iron
preparation
through a straw.
The nurse should useϖ the Z-track method to administer an I.M.
injection of iron
dextran (Imferon).
An organism may enter the body through the nose, mouth,ϖ rectum,
urinary or
reproductive tract, or skin.
In descendingϖ order, the levels of consciousness are alertness,
lethargy, stupor,
light coma, and deep coma.
To turn a patient by logrolling, the nurse folds theϖ 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 diaphragmϖ 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) betweenϖ the right
and the
left arms is normal.
The nurse should place the bloodϖ pressure cuff 1" (2.5 cm) above the
antecubital fossa.
When instillingϖ ophthalmic ointments, the nurse should waste the first
bead of
ointment and then apply the ointment from the inner canthus to the outer
canthus.
Theϖ nurse should use a leg cuff to measure blood pressure in an obese
patient.
If a blood pressure cuff is applied too loosely, the readingϖ will be falsely
elevated.
Ptosis is drooping of the eyelid.ϖ
A tiltϖ 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 venipunctureϖ 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 edgeϖ 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 wearϖ shoes.
The nurse should attach a restraint to the part of the bed frameϖ that
moves
with the head, not to the mattress or side rails.
The mistϖ in a mist tent should never become so dense that it obscures
clear
visualization of the patient’s respiratory pattern.
To administer heparinϖ subcutaneously, the nurse should follow these
steps:
Clean, but don’t rub, the site with alcohol. Stretch the skin taut or pick up
a welldefined
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 theϖ knee-
chest
position or Sims’ position, depending on the physician’s preference.
Maslow’s hierarchy of needs must be met in theϖ 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 nasogastricϖ tube, the nurse should
apply a
water-soluble lubricant to the nostril to prevent soreness.
During gastric lavage, a nasogastriϖ c tube is inserted, the stomach is
flushed,
and ingested substances are removed through the tube.
In documenting drainage on a surgical dressing, the nurse
shouldϖ 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,ϖ 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 byϖ dorsiflexion of the great toe and
fanning
out of the other toes.
Whenϖ assessing a patient for bladder distention, the nurse should check
the
contour of the lower abdomen for a rounded mass above the symphysis
pubis.
Theϖ best way to prevent pressure ulcers is to reposition the bedridden
patient
at least every 2 hours.
Antiembolism stockings decompress the superficialϖ blood vessels,
reducing the
risk of thrombus formation.
In adults, theϖ most convenient veins for venipuncture are the basilic
and
median cubital veins in the antecubital space.
Two to three hours before beginning a tubeϖ feeding, the nurse should
aspirate
the patient’s stomach contents to verify that gastric emptying is
adequate.
People with type O blood are consideredϖ universal donors.
People with type AB blood are considered universalϖ recipients.
Hertz (Hz) is the unit of measurement of soundϖ frequency.
Hearing protection is required when the sound intensityϖ exceeds 84 dB.
Double
hearing protection is required if it exceeds 104 dB.
Prothrombin, a clotting factor, is produced in the liver.ϖ
ϖ If a patient is menstruating when a urine sample is collected, the nurse
should
note this on the laboratory request.
During lumbar puncture, the nurseϖ 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,ϖ a
heated
aerosol treatment can be used to help to obtain a sample.
Ifϖ eye ointment and eyedrops must be instilled in the same eye, the
eyedrops
should be instilled first.
When leaving an isolation room, the nurse shouldϖ remove her gloves
before her
mask because fewer pathogens are on the mask.
Skeletal traction, which is applied to a bone with wire pins orϖ tongs, is
the most
effective means of traction.
The total parenteralϖ 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 injectedϖ intramuscularly into edematous tissue
because
they may not be absorbed.
ϖ 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’sϖ lined with a washcloth.
A patient should void within 8 hours afterϖ surgery.
An EEG identifies normal and abnormal brain waves.ϖ
ϖ Samples of feces for ova and parasite tests should be delivered to the
laboratory without delay and without refrigeration.
The autonomicϖ nervous system regulates the cardiovascular and
respiratory
systems.
ϖ 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,ϖ rice, and
pasta.
A rectal tube shouldn’t be inserted for longer than 20ϖ 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,ϖ arms,
hands,
chest, abdomen, back, legs, perineum.
To prevent injuryϖ when lifting and moving a patient, the nurse should
primarily
use the upper leg muscles.
Patient preparation for cholecystography includes ingestion ofϖ a
contrast
medium and a low-fat evening meal.
While an occupied bed isϖ being changed, the patient should be covered
with a
bath blanket to promote warmth and prevent exposure.
Anticipatory grief is mourning that occursϖ for an extended time when
the
patient realizes that death is inevitable.
ϖ 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 allϖ jewelry
and
dentures.
The fight-or-flight response is a sympatheticϖ nervous system response.
Bronchovesicular breath sounds in peripheralϖ lung fields are abnormal
and
suggest pneumonia.
Wheezing is anϖ abnormal, high-pitched breath sound that’s accentuated
on
expiration.
ϖ 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 isϖ “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 bicepsϖ and triceps reflexes as +4.
If two eye medications are prescribed forϖ twice-daily instillation, they
should be
administered 5 minutes apart.
ϖ In a postoperative patient, forcing fluids helps prevent constipation.
ϖ 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 thatϖ 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,ϖ digestion,
absorption, transport, cell metabolism, and excretion.
Theϖ body metabolizes alcohol at a fixed rate, regardless of serum
concentration.
In an alcoholic beverage, proof reflects the percentageϖ 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’sϖ 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 aϖ 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.
ϖ Quality assurance is a method of determining whether nursing actions
and
practices meet established standards.
The five rights of medicationϖ administration are the right patient, right
drug,
right dose, right route of administration, and right time.
The evaluation phase of the nursingϖ process is to determine whether
nursing
interventions have enabled the patient to meet the desired goals.
Outside of the hospital setting, onlyϖ the sublingual and translingual
forms of
nitroglycerin should be used to relieve acute anginal attacks.
The implementation phase of the nursing processϖ 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 Rightsϖ 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, theϖ nurse should record
information as soon as it’s gathered.
Whenϖ 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 nurseϖ should record the
current
illness chronologically, beginning with the onset of the problem and
continuing to
the present.
A nurse shouldn’t give falseϖ assurance to a patient.
After receiving preoperative medication, aϖ patient isn’t competent to
sign an
informed consent form.
When liftingϖ a patient, a nurse uses the weight of her body instead of
the
strength in her arms.
A nurse may clarify a physician’s explanation about an operationϖ 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 orϖ agitated patient,
the
nurse should limit questions to those that provide necessary information.
If a chest drainage system line is broken orϖ interrupted, the nurse
should clamp
the tube immediately.
The nurseϖ 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 andϖ an expiration count as one respiration.
Eupnea is normalϖ respiration.
During blood pressure measurement, the patient should restϖ the arm
against a
surface. Using muscle strength to hold up the arm may raise the blood
pressure.
Major, unalterable risk factors for coronary arteryϖ disease include
heredity, sex,
race, and age.
Inspection is the mostϖ frequently used assessment technique.
Family members of an elderly personϖ 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 rhythmϖ with alternating weak and
strong
beats. It occurs in ventricular enlargement because the stroke volume
varies with
each heartbeat.
The upperϖ respiratory tract warms and humidifies inspired air and plays
a role
in taste, smell, and mastication.
Signs of accessory muscle use include shoulderϖ elevation, intercostal
muscle
retraction, and scalene and sternocleidomastoid muscle use during
respiration.
When patients use axillary crutches,ϖ their palms should bear the brunt
of the
weight.
Activities of dailyϖ living include eating, bathing, dressing, grooming,
toileting,
and interacting socially.
Normal gait has two phases: the stance phase, in which theϖ 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,ϖ anaphase, and
telophase.
The nurse should follow standard precautionsϖ in the routine care of all
patients.
The nurse should use the bell ofϖ the stethoscope to listen for venous
hums and
cardiac murmurs.
Theϖ 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 theϖ 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
matterϖ (sensory
and motor tracts) and gray matter (reflex centers).
Theϖ autonomic nervous system controls the smooth muscles.
A correctlyϖ 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.
ϖ 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 yellowishϖ pink and circular, with a distinct border.
A primary disability isϖ caused by a pathologic process. A secondary
disability is
caused by inactivity.
Nurses are commonly held liable for failing to keep anϖ accurate count of
sponges and other devices during surgery.
The bestϖ dietary sources of vitamin B6 are liver, kidney, pork,
soybeans, corn,
and whole-grain cereals.
Iron-rich foods, such as organ meats, nuts,ϖ legumes, dried fruit, green
leafy
vegetables, eggs, and whole grains, commonly have a low water content.
Collaboration is joint communication andϖ 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 60ϖ beats/minute.
A nursing diagnosis is a statement of a patient’s actualϖ or potential
health
problem that can be resolved, diminished, or otherwise changed by
nursing
interventions.
During the assessment phase of theϖ nursing process, the nurse collects
and
analyzes three types of data: health history, physical examination, and
laboratory
and diagnostic test data.
ϖ The patient’s health history consists primarily of subjective data,
information
that’s supplied by the patient.
The physical examination includesϖ objective data obtained by
inspection,
palpation, percussion, and auscultation.
When documenting patient care, the nurse should writeϖ 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,ϖ physical
activity,
phase of menstrual cycle, and pregnancy.
The mostϖ 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 100ϖ 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 objectiveϖ form of assessment data.
The measurement systems most commonly used inϖ clinical practice are
the
metric system, apothecaries’ system, and household system.
Before signing an informed consent form, the patient shouldϖ 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 aϖ separate informed consent form for each
procedure.
During percussion,ϖ 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 involvingϖ gentle, repetitive
bouncing of
tissues against the hand and feeling their rebound.
A foot cradle keeps bed linen off the patient’s feet toϖ prevent skin
irritation and
breakdown, especially in a patient who has peripheral vascular disease or
neuropathy.
Gastric lavage is flushingϖ of the stomach and removal of ingested
substances
through a nasogastric tube. It’s used to treat poisoning or drug overdose.
During the evaluationϖ step of the nursing process, the nurse assesses
the
patient’s response to therapy.
Bruits commonly indicate life- or limb-threatening vascularϖ disease.
O.U. means each eye. O.D. is the right eye, and O.S. is theϖ left eye.
To remove a patient’s artificial eye, the nurse depresses theϖ lower lid.
The nurse should use a warm saline solution to clean anϖ artificial eye.
A thready pulse is very fine and scarcelyϖ perceptible.
Axillary temperature is usually 1° F lower than oralϖ temperature.
After suctioning a tracheostomy tube, the nurse mustϖ document the
color,
amount, consistency, and odor of secretions.
On aϖ drug prescription, the abbreviation p.c. means that the drug
should be
administered after meals.
After bladder irrigation, the nurse shouldϖ document the amount, color,
and
clarity of the urine and the presence of clots or sediment.
After bladder irrigation, the nurse should document theϖ amount, color,
and
clarity of the urine and the presence of clots or sediment.
Laws regarding patient self-determination vary from state toϖ 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 theϖ gauge, the
larger the
diameter.
An adult normally has 32 permanentϖ teeth.
After turning a patient, the nurse should document the positionϖ used,
the time
that the patient was turned, and the findings of skin assessment.
PERRLA is an abbreviation for normal pupil assessmentϖ findings: pupils
equal,
round, and reactive to light with accommodation.
When percussing a patient’s chest for postural drainage,ϖ the nurse’s
hands
should be cupped.
When measuring a patient’s pulse,ϖ the nurse should assess its rate,
rhythm,
quality, and strength.
Beforeϖ 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 assessingϖ respirations, the nurse should document their rate,
rhythm,
depth, and quality.
For a subcutaneous injection, the nurse should use a 5/8" 25Gϖ needle.
The notation “AAϖ & 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 allϖ 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, theϖ nurse shouldn’t
massage the
area because massage can irritate the site and interfere with results.
When administering an intradermal injection,ϖ 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 accurateϖ 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 fullϖ minute.
A patient who is vomiting while lying down should be placed inϖ a lateral
position
to prevent aspiration of vomitus.
Prophylaxis isϖ disease prevention.
Body alignment is achieved when body parts are inϖ proper relation to
their
natural position.
Trust is the foundation of aϖ nurse-patient relationship.
Blood pressure is the force exerted by theϖ circulating volume of blood
on the
arterial walls.
Malpractice is aϖ professional’s wrongful conduct, improper discharge of
duties,
or failure to meet standards of care that causes harm to another.
As a general rule,ϖ 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 aϖ 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 enactedϖ 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.
Aϖ physician should sign verbal and telephone orders within the time
established
by facility policy, usually 24 hours.
A competent adult has the right toϖ refuse lifesaving medical treatment;
however, the individual should be fully informed of the consequences of
his
refusal.
Although a patient’sϖ 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 beϖ 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 aϖ controlled drug
that’s
dispensed by the pharmacy must be accounted for, whether the dose was
administered to a patient or discarded accidentally.
Aϖ 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, theϖ nurse should
select a
private room, preferably one with a door that can be closed.
In categorizing nursing diagnoses, the nurse addressesϖ life-threatening
problems first, followed by potentially life-threatening concerns.
The major components of a nursing care plan are outcomeϖ criteria
(patient
goals) and nursing interventions.
Standing orders, orϖ protocols, establish guidelines for treating a specific
disease
or set of symptoms.
In assessing a patient’s heart, the nurse normally finds theϖ point of
maximal
impulse at the fifth intercostal space, near the apex.
ϖ The S1 heard on auscultation is caused by closure of the mitral and
tricuspid
valves.
To maintain package sterility, the nurse should open aϖ 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 aϖ patient’s ear canal or remove wax with a
cottontipped
applicator because it may force cerumen against the tympanic
membrane.
A patient’s identificationϖ bracelet should remain in place until the
patient has
been discharged from the health care facility and has left the premises.
The Controlledϖ Substances Act designated five categories, or schedules,
that
classify controlled drugs according to their abuse potential.
Schedule I drugs, suchϖ 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,ϖ 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 butabarbitalϖ (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 aϖ low abuse potential
compared with Schedule III drugs.
Schedule V drugs,ϖ such as cough syrups that contain codeine, have the
lowest
abuse potential of the controlled substances.
Activities of daily living are actions thatϖ the patient must perform every
day to
provide self-care and to interact with society.
Testing of the six cardinal fields of gaze evaluates theϖ function of all
extraocular
muscles and cranial nerves III, IV, and VI.
ϖ 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.
Theϖ most important goal to include in a care plan is the patient’s goal.
ϖ Fruits are high in fiber and low in protein, and should be omitted from
a lowresidue
diet.
The nurse should use an objective scale to assess andϖ quantify pain.
Postoperative pain varies greatly among individuals.
ϖ 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 answersϖ to the patient’s questions.
Milk shouldn’t be included in a clearϖ liquid diet.
When caring for an infant, a child, or a confused patient,ϖ consistency in
nursing
personnel is paramount.
The hypothalamusϖ secretes vasopressin and oxytocin, which are stored
in the
pituitary gland.
The three membranes that enclose the brain and spinal cord areϖ the
dura
mater, pia mater, and arachnoid.
A nasogastric tube is used toϖ remove fluid and gas from the small
intestine
preoperatively or postoperatively.
Psychologists, physical therapists, and chiropractorsϖ aren’t authorized
to write
prescriptions for drugs.
The area around aϖ stoma is cleaned with mild soap and water.
Vegetables have a high fiberϖ content.
The nurse should use a tuberculin syringe to administer aϖ subcutaneous
injection of less than 1 ml.
For adults, subcutaneousϖ injections require a 25G 1" needle; for
infants,
children, elderly, or very thin patients, they require a 25G to 27G ½"
needle.
Before administering aϖ 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 anϖ 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 deepϖ into subcutaneous tissue at a 90-
degree
angle (perpendicular to the skin) to prevent skin irritation.
If blood is aspirated into the syringe beforeϖ an I.M. injection, the nurse
should
withdraw the needle, prepare another syringe, and repeat the procedure.
The nurse shouldn’t cut theϖ patient’s hair without written consent from
the
patient or an appropriate relative.
If bleeding occurs after an injection, the nurse should applyϖ pressure
until the
bleeding stops. If bruising occurs, the nurse should monitor the site for an
enlarging hematoma.
When providing hair and scalp care,ϖ 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 andϖ texture of
the
hair, the duration of hospitalization, and the patient’s condition.
Proper function of a hearing aid requires careful handlingϖ during
insertion and
removal, regular cleaning of the ear piece to prevent wax buildup, and
prompt
replacement of dead batteries.
The hearing aidϖ 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 humidityϖ and shouldn’t
be
immersed in water.
The nurse should instruct theϖ patient to avoid using hair spray while
wearing a
hearing aid.
The fiveϖ branches of pharmacology are pharmacokinetics,
pharmacodynamics,
pharmacotherapeutics, toxicology, and pharmacognosy.
The nurse shouldϖ remove heel protectors every 8 hours to inspect the
foot for
signs of skin breakdown.
Heat is applied to promote vasodilation, which reduces painϖ caused by
inflammation.
A sutured surgical incision is an example ofϖ healing by first intention
(healing
directly, without granulation).
ϖ 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 healingϖ that’s characterized by
overgrowth
of scar tissue at the wound site.
ϖ 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 ascendingϖ colostomy drains fluid feces. A descending colostomy
drains solid
fecal matter.
A folded towel (scrotal bridge) can provide scrotal support forϖ the
patient with
scrotal edema caused by vasectomy, epididymitis, or orchitis.
When giving an injection to a patient who has a bleedingϖ 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 andϖ most fragile formed element of the blood
and are
essential for coagulation.
To insert a nasogastric tube, the nurse instructs theϖ 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 inϖ 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
messageϖ contradicts the
nonverbal message and the receiver is unsure of which message to
respond to.
A nonjudgmental attitude displayed by a nurse shows thatϖ she neither
approves
nor disapproves of the patient.
Target symptomsϖ are those that the patient finds most distressing.
A patient should beϖ 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.
Forϖ 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 canϖ be shown as a commitment to the
profession of
nursing and to the patient.
Administering an I.M. injection against the patient’s will andϖ without
legal
authority is battery.
An example of a third-party payerϖ is an insurance company.
The formula for calculating the drops perϖ 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 givenϖ within 5 minutes of the call.
Usually, the best method to determine aϖ patient’s cultural or spiritual
needs is
to ask him.
An incident reportϖ 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 forϖ patient care.
When prioritizing nursing diagnoses, the followingϖ hierarchy should be
used:
Problems associated with the airway, those concerning breathing, and
those
related to circulation.
The two nursing diagnoses thatϖ have the highest priority that the nurse
can
assign are Ineffective airway clearance and Ineffective breathing pattern.
A subjective sign that aϖ sitz bath has been effective is the patient’s
expression
of decreased pain or discomfort.
For the nursing diagnosis Deficient diversional activity toϖ 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 anϖ individual who doesn’t
speak
English is Impaired verbal communication related to inability to speak
dominant
language (English).
The family of a patientϖ who has been diagnosed as hearing impaired
should be
instructed to face the individual when they speak to him.
Before instilling medication intoϖ 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 theϖ cornea when administering eyedrops, the nurse
should
waste the first drop and instill the drug in the lower conjunctival sac.
After administering eyeϖ ointment, the nurse should twist the medication
tube to
detach the ointment.
When the nurse removes gloves and a mask, she should removeϖ the
gloves
first. They are soiled and are likely to contain pathogens.
ϖ 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 effectiveϖ communication technique.
Before teaching any procedure to a patient,ϖ the nurse must assess the
patient’s
current knowledge and willingness to learn.
Process recording is a method of evaluating one’s
communicationϖ effectiveness.
When feeding an elderly patient, the nurse should limitϖ high-
carbohydrate foods
because of the risk of glucose intolerance.
ϖ When feeding an elderly patient, essential foods should be given first.
ϖ Passive range of motion maintains joint mobility. Resistive exercises
increase
muscle mass.
Isometric exercises are performed on an extremity that’sϖ in a cast.
A back rub is an example of the gate-control theory ofϖ pain.
Anything that’s located below the waist is considered unsterile;ϖ 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 theϖ 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 whenϖ the number of mature cells in the
blood
increases, as seen in advanced liver disease and pernicious anemia.
Before administering preoperativeϖ medication, the nurse should ensure
that an
informed consent form has been signed and attached to the patient’s
record.
A nurse should spend noϖ 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 thanϖ one patient who
has a
radiation implant.
Long-handled forceps and aϖ lead-lined container should be available in
the
room of a patient who has a radiation implant.
Usually, patients who have the same infection andϖ are in strict isolation
can
share a room.
Diseases that require strictϖ isolation include chickenpox, diphtheria, and
viral
hemorrhagic fevers such as Marburg disease.
For the patient who abides by Jewish custom, milk andϖ meat shouldn’t
be
served at the same meal.
Whether the patient canϖ 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).
ϖ 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 impairedϖ patient, the nurse should
face
him.
An appropriate nursing interventionϖ 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 inϖ temperature above 106° F (41.1°
C).
Milk is high in sodium and low inϖ iron.
When a patient expresses concern about a health-related issue,ϖ 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
anϖ antipyretic, which
lowers the temperature set point.
When a patient isϖ ill, it’s essential for the members of his family to
maintain
communication about his health needs.
Ethnocentrism is the universal belief thatϖ one’s way of life is superior to
others’.
When a nurse is communicatingϖ 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 someϖ Mexicans,
Puerto
Ricans, and other Hispanic and Latino groups, most foods, beverages,
herbs, and
drugs are described as “cold.”
Prejudice is aϖ hostile attitude toward individuals of a particular group.
ϖ Discrimination is preferential treatment of individuals of a particular
group. It’s
usually discussed in a negative sense.
Increased gastric motilityϖ interferes with the absorption of oral drugs.
The three phases of theϖ therapeutic relationship are orientation,
working, and
termination.
ϖ Patients often exhibit resistive and challenging behaviors in the
orientation
phase of the therapeutic relationship.
Abdominal assessment isϖ performed in the following order: inspection,
auscultation, palpation, and percussion.
When measuring blood pressure in a neonate, the nurseϖ 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 byϖ 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 forϖ intradermal injection include the inner arm, the upper chest,
and on
the back, under the scapula.
When evaluating whether an answer on an examinationϖ 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, theϖ 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 aϖ therapeutic
relationship
between a health care provider and his patient.
Beneficence is the duty to do no harm and the duty to do good.ϖ 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.ϖ
ϖ Frye’s ABCDE cascade provides a framework for prioritizing care by
identifying
the most important treatment concerns.
A = Airway. This categoryϖ 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 affectsϖ 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 includesϖ everything that affects the
circulation,
including fluid and electrolyte disturbances and disease processes that
affect
cardiac output.
D =ϖ 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 includesϖ such issues as writing an
incident
report and completing the patient chart. When evaluating needs, this
category is
never the highest priority.
Whenϖ 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.
Ruleϖ utilitarianism is known as the “greatest good for the greatest
number of
people” theory.
Egalitarian theory emphasizes that equal access to goods andϖ services
must be
provided to the less fortunate by an affluent society.
ϖ Active euthanasia is actively helping a person to die.
Brain death isϖ irreversible cessation of all brain function.
Passive euthanasia isϖ stopping the therapy that’s sustaining life.
A third-party payer is anϖ insurance company.
Utilization review is performed to determine whetherϖ the care provided
to a
patient was appropriate and cost-effective.
A valueϖ cohort is a group of people who experienced an out-of-the-
ordinary
event that shaped their values.
Voluntary euthanasia is actively helping a patientϖ to die at the patient’s
request.
Bananas, citrus fruits, and potatoes areϖ good sources of potassium.
Good sources of magnesium include fish,ϖ nuts, and grains.
Beef, oysters, shrimp, scallops, spinach, beets, andϖ greens are good
sources of
iron.
Intrathecal injection is administeringϖ a drug through the spine.
When a patient asks a question or makes aϖ 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:ϖ
– 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 requestϖ a vegetarian diet.
Pain threshold, or pain sensation, is the initialϖ point at which a patient
feels
pain.
The difference between acute painϖ and chronic pain is its duration.
Referred pain is pain that’s felt atϖ a site other than its origin.
Alleviating pain by performing a backϖ massage is consistent with the
gate
control theory.
Romberg’s test is aϖ test for balance or gait.
Pain seems more intense at night because theϖ patient isn’t distracted
by daily
activities.
Older patients commonlyϖ don’t report pain because of fear of
treatment,
lifestyle changes, or dependency.
No pork or pork products are allowed in a Muslim diet.ϖ
ϖ 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 sheϖ tells a
malnourished
patient to go to a meal program at a local park.
ϖ 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.ϖ
ϖ Primary prevention is true prevention. Examples are immunizations,
weight
control, and smoking cessation.
Secondary prevention is earlyϖ detection. Examples include purified
protein
derivative (PPD), breast self-examination, testicular self-examination, and
chest
X-ray.
ϖ Tertiary prevention is treatment to prevent long-term complications.
Aϖ 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 religiousϖ 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 mayϖ request the intervention of a curandero, or faith
healer,
who involves the family in healing the patient.
In an infant, the normal hemoglobinϖ value is 12 g/dl.
The nitrogen balance estimates the difference betweenϖ the intake and
use of
protein.
Most of the absorption of water occursϖ in the large intestine.
Most nutrients are absorbed in the smallϖ intestine.
When assessing a patient’s eating habits, the nurse shouldϖ ask, “What
have you
eaten in the last 24 hours?”
A vegan diet shouldϖ include an abundant supply of fiber.
A hypotonic enema softens theϖ feces, distends the colon, and
stimulates
peristalsis.
First-morningϖ urine provides the best sample to measure glucose,
ketone, pH,
and specific gravity values.
To induce sleep, the first step is to minimizeϖ environmental stimuli.
Before moving a patient, the nurse should assessϖ 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 lbϖ (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 isϖ completely immobile is
lifted on
a sheet.
To insert a catheter from theϖ nose through the trachea for suction, the
nurse
should ask the patient to swallow.
Vitamin C is needed for collagen production.ϖ
Only theϖ patient can describe his pain accurately.
Cutaneous stimulation createsϖ the release of endorphins that block the
transmission of pain stimuli.
ϖ Patient-controlled analgesia is a safe method to relieve acute pain
caused by
surgical incision, traumatic injury, labor and delivery, or cancer.
Anϖ Asian American or European American typically places distance
between
himself and others when communicating.
The patient who believes in aϖ scientific, or biomedical, approach to
health is
likely to expect a drug, treatment, or surgery to cure illness.
Chronic illnesses occur in veryϖ young as well as middle-aged and very
old
people.
The trajectoryϖ framework for chronic illness states that preferences
about daily
life activities affect treatment decisions.
Exacerbations of chronic diseaseϖ usually cause the patient to seek
treatment
and may lead to hospitalization.
School health programs provide cost-effective healthϖ care for low-
income
families and those who have no health insurance.
ϖ Collegiality is the promotion of collaboration, development, and
interdependence among members of a profession.
A change agent is an individual whoϖ recognizes a need for change or is
selected
to make a change within an established entity, such as a hospital.
The patients’ bill of rightsϖ was introduced by the American Hospital
Association.
Abandonment isϖ premature termination of treatment without the
patient’s
permission and without appropriate relief of symptoms.
Values clarification is a process thatϖ individuals use to prioritize their
personal
values.
Distributiveϖ justice is a principle that promotes equal treatment for all.
Milk andϖ milk products, poultry, grains, and fish are good sources of
phosphate.
ϖ 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 orientationϖ phase, the patient should begin to trust
the nurse.
Falls in theϖ elderly are likely to be caused by poor vision.
Barriers toϖ communication include language deficits, sensory deficits,
cognitive
impairments, structural deficits, and paralysis.
The three elementsϖ that are necessary for a fire are heat, oxygen, and
combustible material.
Sebaceous glands lubricate the skin.ϖ
To check forϖ 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 firstϖ glove at the
folded
border and adjust the fingers when both gloves are on.
To increase patient comfort, the nurse should let the alcohol dryϖ before
giving
an intramuscular injection.
Treatment for a stage 1 ulcerϖ on the heels includes heel protectors.
Seventh-Day Adventists areϖ usually vegetarians.
Endorphins are morphinelike substances thatϖ produce a feeling of well-
being.
Pain tolerance is the maximum amountϖ and duration of pain that an
individual
is willing to endure.