fundamentals of nursing bullets222

8/19/2019 Fundamentals of Nursing Bullets222

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!!. Behovah’s Witnesses believe that they shouldn’treceive blood coponents donated by other people.

!%. #o test visual acuity, the nurse should ask the patient to cover each eye separately and to readthe eye chart with glasses and without, asappropriate.

!). When providing oral care for an unconscious patient, to inii5e the risk of aspiration, the

nurse should position the patient on the side.

!+. 6uring assessent of distance vision, the patientshould stand 24C '+.1 ( fro the chart.

!. /or a geriatric patient or one who is e$treelyill, the ideal roo teperature is ++D to +D /'1.D to 2%.%D ;(.

!. >oral roo huidity is !4E to +4E.

!0. Hand washing is the single best ethod ofliiting the spread of icroorganiss. Fncegloves are reoved after routine contact with a patient, hands should be washed for 14 to 1)

seconds.%4. #o perfor catheteri5ation, the nurse should

place a woan in the dorsal recubent position.

%1. A positive Hoan’s sign ay indicatethrobophlebitis.

%2.


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thready or weak pulse 'difficult to detect(M and 4,absent pulse 'not detectable(.

+. #he intraoperative period begins when a patientis transferred to the operating roo bed and endswhen the patient is aditted to the postanesthesia care unit.

+0. Fn the orning of surgery, the nurse shouldensure that the infored consent for has beensignedM that the patient hasn’t taken anything by

outh since idnight, has taken a shower withantiicrobial soap, has had outh care 'withoutswallowing the water(, has reoved coon jewelry, and has received preoperativeedication as prescribedM and that vital signshave been taken and recorded. Artificial libsand other prostheses are usually reoved.

4. ;ofort easures, such as positioning the patient, rubbing the patient’s back, and providing a restful environent, ay decreasethe patient’s need for analgesics or ay enhancetheir effectiveness.

1. A drug has three naes generic nae, which is

used in official publicationsM trade, or brand,nae 'such as #ylenol(, which is selected by thedrug copanyM and cheical nae, whichdescribes the drug’s cheical coposition.

2. #o avoid staining the teeth, the patient shouldtake a li7uid iron preparation through a straw.

!. #he nurse should use the 9track ethod toadinister an -.*. injection of iron de$tran'-feron(.

%. An organis ay enter the body through thenose, outh, rectu, urinary or reproductivetract, or skin.

). -n descending order, the levels of consciousnessare alertness, lethargy, stupor, light coa, anddeep coa.

+. #o turn a patient by logrolling, the nurse foldsthe patient’s ars across the chestM e$tends the patient’s legs and inserts a pillow between the,if neededM places a draw sheet under the patientMand turns the patient by slowly and gently pulling on the draw sheet.

. #he diaphrag of the stethoscope is used to hear highpitched sounds, such as breath sounds.

. A slight difference in blood pressure ') to 14

Hg( between the right and the left ars isnoral.

0. #he nurse should place the blood pressure cuff1: '2.) c( above the antecubital fossa.

4. When instilling ophthalic ointents, the nurseshould waste the first bead of ointent and thenapply the ointent fro the inner canthus to theouter canthus.

1. #he nurse should use a leg cuff to easure blood pressure in an obese patient.

2. -f a blood pressure cuff is applied too loosely,the reading will be falsely lowered.

!. ?tosis is drooping of the eyelid.

%. A tilt table is useful for a patient with a spinalcord injury, orthostatic hypotension, or braindaage because it can ove the patientgradually fro a hori5ontal to a vertical'upright( position.

). #o perfor venipuncture with the least injury tothe vessel, the nurse should turn the bevelupward when the vessel’s luen is larger thanthe needle and turn it downward when the luenis only slightly larger than the needle.

+. #o ove a patient to the edge of the bed fortransfer, the nurse should follow these steps*ove the patient’s head and shoulders towardthe edge of the bed. *ove the patient’s feet andlegs to the edge of the bed 'crescent position(.?lace both ars well under the patient’s hips,and straighten the back while oving the patienttoward the edge of the bed.

. When being easured for crutches, a patientshould wear shoes.

. #he nurse should attach a restraint to the part ofthe bed frae that oves with the head, not tothe attress or side rails.

0. #he ist in a ist tent should never becoe sodense that it obscures clear visuali5ation of the patient’s respiratory pattern.

04. #o adinister heparin subcutaneously, the nurseshould follow these steps ;lean, but don’t rub,the site with alcohol. tretch the skin taut or pickup a welldefined skin fold. Hold the shaft of theneedle in a dart position. -nsert the needle intothe skin at a right '04degree( angle. /irlydepress the plunger, but don’t aspirate. Geave theneedle in place for 14 seconds. Withdraw theneedle gently at the angle of insertion. Apply pressure to the injection site with an alcohol pad

01. /or a sigoidoscopy, the nurse should place the patient in the kneechest position or is’ position, depending on the physician’s preference.

02. *aslow’s hierarchy of needs ust be et in thefollowing order physiologic 'o$ygen, food,water, se$, rest, and cofort(, safety andsecurity, love and belonging, selfestee and

recognition, and selfactuali5ation.

0!. When caring for a patient who has a nasogastrictube, the nurse should apply a watersolublelubricant to the nostril to prevent soreness.

0%. 6uring gastric lavage, a nasogastric tube isinserted, the stoach is flushed, and ingestedsubstances are reoved through the tube.

0). -n docuenting drainage on a surgical dressing,the nurse should include the si5e, color, andconsistency of the drainage 'for e$aple, @14 of brown ucoid drainage noted ondressing(.


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0+. #o elicit 3abinski’s refle$, the nurse strokes thesole of the patient’s foot with a oderately sharpobject, such as a thubnail.

0. A positive 3abinski’s refle$ is shown bydorsifle$ion of the great toe and fanning out ofthe other toes.

0. When assessing a patient for bladder distention,the nurse should check the contour of the lower

abdoen for a rounded ass above thesyphysis pubis.

00. #he best way to prevent pressure ulcers is toreposition the bedridden patient at least every 2hours.

144. Antiebolis stockings decopress thesuperficial blood vessels, reducing the risk ofthrobus foration.

141. -n adults, the ost convenient veins forvenipuncture are the basilic and edian cubitalveins in the antecubital space.

142. #wo to three hours before beginning atube feeding, the nurse should aspirate the patient’s stoach contents to verify that gastriceptying is ade7uate.

14!. ?eople with type F blood are considereduniversal donors.

14%. ?eople with type A3 blood areconsidered universal recipients.

14). Hert5 'H5( is the unit of easureent of sound fre7uency.

14+. Hearing protection is re7uired when thesound intensity e$ceeds % d3. 6ouble hearing protection is re7uired if it e$ceeds 14% d3.

14. ?rothrobin, a clotting factor, is produced in the liver.

14. -f a patient is enstruating when a urinesaple is collected, the nurse should note this onthe laboratory re7uest.

140. 6uring lubar puncture, the nurse ustnote the initial intracranial pressure and thecolor of the cerebrospinal fluid.

114. -f a patient can’t cough to provide asputu saple for culture, a heated aerosol

treatent can be used to help to obtain a saple.

111. -f eye ointent and eyedrops ust beinstilled in the sae eye, the eyedrops should beinstilled first.

112. When leaving an isolation roo, thenurse should reove her gloves before her ask because fewer pathogens are on the ask.

11!. keletal traction, which is applied to a bone with wire pins or tongs, is the osteffective eans of traction.

11%. #he total parenteral nutrition solutionshould be stored in a refrigerator and reoved!4 to +4 inutes before use. 6elivery of achilled solution can cause pain, hypotheria,venous spas, and venous constriction.

11). 6rugs aren’t routinely injectedintrauscularly into edeatous tissue becausethey ay not be absorbed.

11+. When caring for a coatose patient, the

nurse should e$plain each action to the patient ina noral voice.

11. 6entures should be cleaned in a sinkthat’s lined with a washcloth.

11. A patient should void within hoursafter surgery.

110. An


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1!1. When preparing for a skull 8ray, the patient should reove all jewelry and dentures.

1!2. #he fightorflight response is asypathetic nervous syste response.

1!!. 3ronchovesicular breath sounds in peripheral lung fields are abnoral and suggest pneuonia.

1!%. Whee5ing is an abnoral, highpitched

breath sound that’s accentuated on e$piration.

1!). Wa$ or a foreign body in the ear should be flushed out gently by irrigation with warsaline solution.

1!+. -f a patient coplains that his hearingaid is @not working, the nurse should check theswitch first to see if it’s turned on and thencheck the batteries.

1!. #he nurse should grade hyperactive biceps and triceps refle$es as L%.

1!. -f two eye edications are prescribed

for twicedaily instillation, they should beadinistered ) inutes apart.

1!0. -n a postoperative patient, forcing fluidshelps prevent constipation.

1%4. A nurse ust provide care in accordancewith standards of care established by theAerican >urses Association, state regulations,and facility policy.

1%1. #he kilocalorie 'kcal( is a unit of energyeasureent that represents the aount of heatneeded to raise the teperature of 1 kilogra ofwater 1D ;.

1%2. As nutrients ove through the body,they undergo ingestion, digestion, absorption,transport, cell etabolis, and e$cretion.

1%!. #he body etaboli5es alcohol at a fi$edrate, regardless of seru concentration.

1%%. -n an alcoholic beverage, proof reflectsthe percentage of alcohol ultiplied by 2. /ore$aple, a 144proof beverage contains )4Ealcohol.

1%). A living will is a witnessed docuentthat states a patient’s desire for certain types ofcare and treatent. #hese decisions are based on

the patient’s wishes and views on 7uality of life.

1%+. #he nurse should flush a peripheralheparin lock every hours 'if it wasn’t usedduring the previous hours( and as needed withnoral saline solution to aintain patency.

1%. Nuality assurance is a ethod ofdeterining whether nursing actions and practices eet established standards.

1%. #he five rights of edicationadinistration are the right patient, right drug,right dose, right route of adinistration, andright tie.

1%0. #he evaluation phase of the nursing process is to deterine whether nursinginterventions have enabled the patient to eetthe desired goals.

1)4. Futside of the hospital setting, only thesublingual and translingual fors ofnitroglycerin should be used to relieve acuteanginal attacks.

1)1. #he ipleentation phase of thenursing process involves recording the patient’sresponse to the nursing plan, putting the nursing plan into action, delegating specific nursinginterventions, and coordinating the patient’sactivities.

1)2. #he ?atient’s 3ill of "ights offers patients guidance and protection by stating theresponsibilities of the hospital and its stafftoward patients and their failies duringhospitali5ation.

1)!. #o inii5e oission and distortion offacts, the nurse should record inforation as

soon as it’s gathered.1)%. When assessing a patient’s health

history, the nurse should record the currentillness chronologically, beginning with the onsetof the proble and continuing to the present.

1)). When assessing a patient’s healthhistory, the nurse should record the currentillness chronologically, beginning with the onsetof the proble and continuing to the present.

1)+. A nurse shouldn’t give false assuranceto a patient.

1). After receiving preoperative edication,a patient isn’t copetent to sign an inforedconsent for.

1). When lifting a patient, a nurse uses theweight of her body instead of the strength in herars.

1)0. A nurse ay clarify a physician’se$planation about an operation or a procedure toa patient, but ust refer 7uestions aboutinfored consent to the physician.

1+4. When obtaining a health history fro anacutely ill or agitated patient, the nurse shouldliit 7uestions to those that provide necessary

inforation.

1+1. -f a chest drainage syste line is brokenor interrupted, the nurse should clap the tubeiediately.

1+2. #he nurse shouldn’t use her thub totake a patient’s pulse rate because the thub hasa pulse that ay be confused with the patient’s pulse.

1+!. An inspiration and an e$piration countas one respiration.

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1+). 6uring blood pressure easureent, the patient should rest the ar against a surface.Osing uscle strength to hold up the ar ayraise the blood pressure.

1++. *ajor, unalterable risk factors forcoronary artery disease include heredity, se$,race, and age.

1+. -nspection is the ost fre7uently used

assessent techni7ue.

1+. /aily ebers of an elderly person ina longter care facility should transfer soe personal ites 'such as photographs, a favoritechair, and knickknacks( to the person’s roo to provide a cofortable atosphere.

1+0. ?ulsus alternans is a regular pulserhyth with alternating weak and strong beats.-t occurs in ventricular enlargeent because thestroke volue varies with each heartbeat.

14. #he upper respiratory tract wars andhuidifies inspired air and plays a role in taste,

sell, and astication.11. igns of accessory uscle use include

shoulder elevation, intercostal uscle retraction,and scalene and sternocleidoastoid uscle useduring respiration.

12. When patients use a$illary crutches,their pals should bear the brunt of the weight.

1!. Activities of daily living include eating, bathing, dressing, grooing, toileting, andinteracting socially.

1%. >oral gait has two phases the stance phase, in which the patient’s foot rests on theground, and the swing phase, in which the patient’s foot oves forward.

1). #he phases of itosis are prophase,etaphase, anaphase, and telophase.

1+. #he nurse should follow standard precautions in the routine care of all patients.

1. #he nurse should use the bell of thestethoscope to listen for venous hus andcardiac ururs.

1. #he nurse can assess a patient’s generalknowledge by asking 7uestions such as @Who is

the president of the Onited tatesJ

10. ;old packs are applied for the first 24 to% hours after an injuryM then heat is applied.6uring cold application, the pack is applied for24 inutes and then reoved for 14 to 1)inutes to prevent refle$ dilation 'rebound phenoenon( and frostbite injury.

14. #he pons is located above the edullaand consists of white atter 'sensory and otortracts( and gray atter 'refle$ centers(.

11. #he autonoic nervous syste controlsthe sooth uscles.

12. A correctly written patient goale$presses the desired patient behavior, criteriafor easureent, tie frae for achieveent,and conditions under which the behavior willoccur. -t’s developed in collaboration with the patient.

1!. ?ercussion causes five basic notestypany 'loud intensity, as heard over a gastricair bubble or puffed out cheek(, hyperresonance

'very loud, as heard over an ephyseatouslung(, resonance 'loud, as heard over a norallung(, dullness 'ediu intensity, as heard overthe liver or other solid organ(, and flatness 'soft,as heard over the thigh(.

1%. #he optic disk is yellowish pink andcircular, with a distinct border.

1). A priary disability is caused by a pathologic process. A secondary disability iscaused by inactivity.

1+. >urses are coonly held liable forfailing to keep an accurate count of sponges and

other devices during surgery.1. #he best dietary sources of vitain 3+

are liver, kidney, pork, soybeans, corn, andwholegrain cereals.

1. -ronrich foods, such as organ eats,nuts, legues, dried fruit, green leafyvegetables, eggs, and whole grains, coonlyhave a low water content.

10. ;ollaboration is joint counicationand decision aking between nurses and physicians. -t’s designed to eet patients’ needs by integrating the care regiens of both professions into one coprehensive approach.

104. 3radycardia is a heart rate of fewer than+4 beats=inute.

101. A nursing diagnosis is a stateent of a patient’s actual or potential health proble thatcan be resolved, diinished, or otherwisechanged by nursing interventions.

102. 6uring the assessent phase of thenursing process, the nurse collects and analy5esthree types of data health history, physicale$aination, and laboratory and diagnostic testdata.

10!. #he patient’s health history consists priarily of subjective data, inforation that’ssupplied by the patient.

10%. #he physical e$aination includesobjective data obtained by inspection, palpation, percussion, and auscultation.

10). When docuenting patient care, thenurse should write legibly, use only standardabbreviations, and sign each entry. #he nurseshould never destroy or attept to obliteratedocuentation or leave vacant lines.


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10+. /actors that affect body teperatureinclude tie of day, age, physical activity, phaseof enstrual cycle, and pregnancy.

10. #he ost accessible and coonly usedartery for easuring a patient’s pulse rate is theradial artery. #o take the pulse rate, the artery iscopressed against the radius.

10. -n a resting adult, the noral pulse rateis +4 to 144 beats=inute. #he rate is slightly

faster in woen than in en and uch faster inchildren than in adults.

100. Gaboratory test results are an objectivefor of assessent data.

244. #he easureent systes ostcoonly used in clinical practice are theetric syste, apothecaries’ syste, andhousehold syste.

241. 3efore signing an infored consentfor, the patient should know whether othertreatent options are available and shouldunderstand what will occur during the

preoperative, intraoperative, and postoperative phasesM the risks involvedM and the possiblecoplications. #he patient should also have ageneral idea of the tie re7uired fro surgery torecovery. -n addition, he should have anopportunity to ask 7uestions.

242. A patient ust sign a separate inforedconsent for for each procedure.

24!. 6uring percussion, the nurse uses 7uick,sharp tapping of the fingers or hands against body surfaces to produce sounds. #his procedureis done to deterine the si5e, shape, position,and density of underlying organs and tissuesMelicit tendernessM or assess refle$es.

24%. 3allotteent is a for of light palpationinvolving gentle, repetitive bouncing of tissuesagainst the hand and feeling their rebound.

24). 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.

24+. &astric lavage is flushing of the stoachand reoval of ingested substances through anasogastric tube. -t’s used to treat poisoning ordrug overdose.

24. 6uring the evaluation step of thenursing process, the nurse assesses the patient’sresponse to therapy.

24. 3ruits coonly indicate life or libthreatening vascular disease.

240. F.O. eans each eye. F.6. is the righteye, and F.. is the left eye.

214. #o reove a patient’s artificial eye, thenurse depresses the lower lid.

211. #he nurse should use a war salinesolution to clean an artificial eye.

212. A thready pulse is very fine and scarcely perceptible.

21!. A$illary teperature is usually 1D /lower than oral teperature.

21%. After suctioning a tracheostoy tube,the nurse ust docuent the color, aount,consistency, and odor of secretions.

21). Fn a drug prescription, the abbreviation p.c. eans that the drug should be adinisteredafter eals.

21+. After bladder irrigation, the nurseshould docuent the aount, color, and clarityof the urine and the presence of clots orsedient.

21. After bladder irrigation, the nurseshould docuent the aount, color, and clarityof the urine and the presence of clots orsedient.

21. Gaws regarding patient selfdeterination vary fro state to state.

#herefore, the nurse ust be failiar with thelaws of the state in which she works.

210. &auge is the inside diaeter of a needlethe saller the gauge, the larger the diaeter.

224. An adult norally has !2 peranentteeth.


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Fundamentals of Nursing 2

1. After turning a patient, the nurse should docuent the position used, the tie that the patient was turned, andthe findings of skin assessent.

2. ?


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!+. #he nurse shouldn’t dry a patient’s ear canal orreove wa$ with a cottontipped applicator because itay force ceruen against the typanic ebrane.

!. A patient’s identification bracelet should reain in place until the patient has been discharged fro thehealth care facility and has left the preises.

!. #he ;ontrolled ubstances Act designated fivecategories, or schedules, that classify controlled drugs

according to their abuse potential.

!0. chedule - drugs, such as heroin, have a high abuse potential and have no currently accepted edical use inthe Onited tates.

%4. chedule -- drugs, such as orphine, opiu, andeperidine '6eerol(, have a high abuse potential, butcurrently have accepted edical uses. #heir use aylead to physical or psychological dependence.

%1. chedule --- drugs, such as paregoric and butabarbital '3utisol(, have a lower abuse potential thanchedule - or -- drugs. Abuse of chedule --- drugs aylead to oderate or low physical or psychological

dependence, or both.%2. chedule -I drugs, such as chloral hydrate, have alow abuse potential copared with chedule --- drugs.

%!. chedule I drugs, such as cough syrups that containcodeine, have the lowest abuse potential of thecontrolled substances.

%%. Activities of daily living are actions that the patientust perfor every day to provide selfcare and tointeract with society.

%). #esting of the si$ cardinal fields of ga5e evaluatesthe function of all e$traocular uscles and cranial nerves---, -I, and I-.

%+. #he si$ types of heart ururs are graded fro 1 to+. A grade + heart urur can be heard with thestethoscope slightly raised fro the chest.

%. #he ost iportant goal to include in a care plan isthe patient’s goal.

%. /ruits are high in fiber and low in protein, andshould be oitted fro a lowresidue diet.

%0. #he nurse should use an objective scale to assess and7uantify pain. ?ostoperative pain varies greatly aongindividuals.

)4. ?ostorte care includes cleaning and preparing thedeceased patient for faily viewing, arrangingtransportation to the orgue or funeral hoe, anddeterining the disposition of belongings.

)1. #he nurse should provide honest answers to the patient’s 7uestions.

)2. *ilk shouldn’t be included in a clear li7uid diet.

)!. When caring for an infant, a child, or a confused patient, consistency in nursing personnel is paraount.

)%. #he hypothalaus secretes vasopressin ando$ytocin, which are stored in the pituitary gland.

)). #he three ebranes that enclose the brain andspinal cord are the dura ater, pia ater, and arachnoid.

)+. A nasogastric tube is used to reove fluid and gasfro the sall intestine preoperatively or postoperatively.

). ?sychologists, physical therapists, and chiropractorsaren’t authori5ed to write prescriptions for drugs.

). #he area around a stoa is cleaned with ild soapand water.

)0. Iegetables have a high fiber content.

+4. #he nurse should use a tuberculin syringe toadinister a subcutaneous injection of less than 1 l.

+1. /or adults, subcutaneous injections re7uire a 2)&)=: to 1: needleM for infants, children, elderly, or verythin patients, they re7uire a 2)& to 2& R needle.

+2. 3efore adinistering a drug, the nurse shouldidentify the patient by checking the identification bandand asking the patient to state his nae.

+!. #o clean the skin before an injection, the nurse uses asterile alcohol swab to wipe fro the center of the siteoutward in a circular otion.

+%. #he nurse should inject heparin deep intosubcutaneous tissue at a 04degree angle 'perpendicularto the skin( to prevent skin irritation.

+). -f blood is aspirated into the syringe before an -.*.injection, the nurse should withdraw the needle, prepareanother syringe, and repeat the procedure.

++. #he nurse shouldn’t cut the patient’s hair withoutwritten consent fro the patient or an appropriaterelative.

+. -f bleeding occurs after an injection, the nurse shouldapply pressure until the bleeding stops. -f bruisingoccurs, the nurse should onitor the site for an enlargingheatoa.

+. When providing hair and scalp care, the nurse should begin cobing at the end of the hair and work towardthe head.

+0. #he fre7uency of patient hair care depends on thelength and te$ture of the hair, the duration ofhospitali5ation, and the patient’s condition.

4. ?roper function of a hearing aid re7uires careful

handling during insertion and reoval, regular cleaningof the ear piece to prevent wa$ buildup, and proptreplaceent of dead batteries.

1. #he hearing aid that’s arked with a blue dot is forthe left earM the one with a red dot is for the right ear.

2. A hearing aid shouldn’t be e$posed to heat orhuidity and shouldn’t be iersed in water.

!. #he nurse should instruct the patient to avoid usinghair spray while wearing a hearing aid.


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%. #he five branches of pharacology are pharacokinetics, pharacodynaics, pharacotherapeutics, to$icology, and pharacognosy.

). #he nurse should reove heel protectors every hours to inspect the foot for signs of skin breakdown.

+. Heat is applied to proote vasodilation, whichreduces pain caused by inflaation.

. A sutured surgical incision is an e$aple of healing

by first intention 'healing directly, without granulation(.

. Healing by secondary intention 'healing bygranulation( is closure of the wound when granulationtissue fills the defect and allows reepitheliali5ation tooccur, beginning at the wound edges and continuing tothe center, until the entire wound is covered.0. Keloid foration is an abnorality in healing that’scharacteri5ed by overgrowth of scar tissue at the woundsite.

4. #he nurse should adinister procaine penicillin bydeep -.*. injection in the upper outer portion of the buttocks in the adult or in the idlateral thigh in thechild. #he nurse shouldn’t assage the injection site.

1. An ascending colostoy drains fluid feces. Adescending colostoy drains solid fecal atter.

2. A folded towel 'scrotal bridge( can provide scrotalsupport for the patient with scrotal edea caused byvasectoy, epididyitis, or orchitis.

!. When giving an injection to a patient who has a bleeding disorder, the nurse should use a sallgaugeneedle and apply pressure to the site for ) inutes afterthe injection.

%. ?latelets are the sallest and ost fragile foredeleent of the blood and are essential for coagulation.

). #o insert a nasogastric tube, the nurse instructs the patient to tilt the head back slightly and then inserts thetube. When the nurse feels the tube curving at the pharyn$, the nurse should tell the patient to tilt the headforward to close the trachea and open the esophagus byswallowing. 'ips of water can facilitate this action.(

+. /ailies with loved ones in intensive care unitsreport that their four ost iportant needs are to havetheir 7uestions 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 ofrecovery.

. 6oublebind counication occurs when the verbal

essage contradicts the nonverbal essage and thereceiver is unsure of which essage to respond to.

. A nonjudgental attitude displayed by a nurse showsthat she neither approves nor disapproves of the patient.

0. #arget syptos are those that the patient finds ostdistressing.

04. A patient should be advised to take aspirin on anepty stoach, with a full glass of water, and shouldavoid acidic foods such as coffee, citrus fruits, and cola.

01. /or every patient proble, there is a nursingdiagnosisM for every nursing diagnosis, there is a goalM

and for every goal, there are interventions designed toake the goal a reality. #he keys to answeringe$aination 7uestions correctly are identifying the proble presented, forulating a goal for the proble,and selecting the intervention fro the choices providedthat will enable the patient to reach that goal.

02. /idelity eans loyalty and can be shown as acoitent to the profession of nursing and to the patient.

0!. Adinistering an -.*. injection against the patient’swill and without legal authority is battery.

0%. An e$aple of a thirdparty payer is an insurancecopany.

0). #he forula for calculating the drops per inute foran -.I. infusion is as follows 'volue to be infused Qdrip factor( S tie in inutes T drops=inute

0+. Fncall edication should be given within ) inutesof the call.

0. Osually, the best ethod to deterine a patient’scultural or spiritual needs is to ask hi.

0. An incident report or unusual occurrence report isn’t part of a patient’s record, but is an inhouse docuentthat’s used for the purpose of correcting the proble.

00. ;ritical pathways are a ultidisciplinary guidelinefor patient care.

144. When prioriti5ing nursing diagnoses, the followinghierarchy should be used ?robles associated with theairway, those concerning breathing, and those related tocirculation.

141. #he two nursing diagnoses that have the highest priority that the nurse can assign are -neffective airwayclearance and -neffective breathing pattern.

142. A subjective sign that a sit5 bath has been effectiveis the patient’s e$pression of decreased pain ordiscofort.

14!. /or the nursing diagnosis 6eficient diversionalactivity to be valid, the patient ust state that he’s@bored, that he has @nothing to do, or words to thateffect.

14%. #he ost appropriate nursing diagnosis for anindividual who doesn’t speak


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140. When the nurse reoves gloves and a ask, sheshould reove the gloves first. #hey are soiled and arelikely to contain pathogens.

114. ;rutches should be placed +: '1).2 c( in front ofthe patient and +: to the side to for a tripodarrangeent.

111. Gistening is the ost effective counicationtechni7ue.

112. 3efore teaching any procedure to a patient, thenurse ust assess the patient’s current knowledge andwillingness to learn.

11!. ?rocess recording is a ethod of evaluating one’scounication effectiveness.

11%. When feeding an elderly patient, the nurse shouldliit highcarbohydrate foods because of the risk ofglucose intolerance.

11). When feeding an elderly patient, essential foodsshould be given first.

11+. ?assive range of otion aintains joint obility.

"esistive e$ercises increase uscle ass.11. -soetric e$ercises are perfored on an e$treitythat’s in a cast.

11. A back rub is an e$aple of the gatecontrol theoryof pain.

110. Anything that’s located below the waist isconsidered unsterileM a sterile field becoes unsterilewhen it coes in contact with any unsterile iteM asterile field ust be onitored continuouslyM and a border of 1: '2.) c( around a sterile field is consideredunsterile.

124. A @shift to the left is evident when the nuber ofiature cells 'bands( in the blood increases to fight aninfection.

121. A @shift to the right is evident when the nuber ofature cells in the blood increases, as seen in advancedliver disease and pernicious aneia.

122. 3efore adinistering preoperative edication, thenurse should ensure that an infored consent for has been signed and attached to the patient’s record.

12!. A nurse should spend no ore than !4 inutes perhour shift providing care to a patient who has aradiation iplant.

12%. A nurse shouldn’t be assigned to care for ore thanone patient who has a radiation iplant.

12). Gonghandled forceps and a leadlined containershould be available in the roo of a patient who has aradiation iplant.

12+. Osually, patients who have the sae infection andare in strict isolation can share a roo.

12. 6iseases that re7uire strict isolation includechickenpo$, diphtheria, and viral heorrhagic feverssuch as *arburg disease.

12. /or the patient who abides by Bewish custo, ilkand eat shouldn’t be served at the sae eal.

120. Whether the patient can perfor a procedure'psychootor doain of learning( is a better indicator ofthe effectiveness of patient teaching than whether the patient can siply state the steps involved in the procedure 'cognitive doain of learning(.

1!4. According to


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1%+. Abdoinal assessent is perfored in thefollowing order inspection, auscultation, percussion P palpation.

1%. When easuring blood pressure in a neonate, thenurse should select a cuff that’s no less than onehalf andno ore than twothirds the length of the e$treitythat’s used.

1%. When adinistering a drug by 9track, the nurseshouldn’t use the sae needle that was used to draw the

drug into the syringe because doing so could stain theskin.

1%0. ites for intraderal injection include the innerar, the upper chest, and on the back, under the scapula.

1)4. When evaluating whether an answer on ane$aination is correct, the nurse should considerwhether the action that’s described prootes autonoy'independence(, safety, selfestee, and a sense of belonging.

1)1. When answering a 7uestion on the >;Gonaleficence is the duty to do no har.

1)). /rye’s A3;6< cascade provides a fraework for prioriti5ing care by identifying the ost iportanttreatent concerns.

1)+. A T Airway. #his category includes everything thataffects a patent airway, including a foreign object, fluidfro an upper respiratory infection, and edea frotraua or an allergic reaction.

1). 3 T 3reathing. #his category includes everythingthat affects the breathing pattern, includinghyperventilation or hypoventilation and abnoral

breathing patterns, such as Korsakoff’s, 3iot’s, or;heynetokes respiration.

1). ; T ;irculation. #his category includes everythingthat affects the circulation, including fluid andelectrolyte disturbances and disease processes that affectcardiac output.

1)0. 6 T 6isease processes. -f the patient has no proble with the airway, breathing, or circulation, thenthe nurse should evaluate the disease processes, giving priority to the disease process that poses the greatestiediate risk. /or e$aple, if a patient has terinalcancer and hypoglyceia, hypoglyceia is a oreiediate concern.

1+4. < T ;G


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1!. A Hindu patient is likely to re7uest a vegetariandiet.

1%. ?ain threshold, or pain sensation, is the initial pointat which a patient feels pain.

1). #he difference between acute pain and chronic painis its duration.

1+. "eferred pain is pain that’s felt at a site other thanits origin.

1. Alleviating pain by perforing a back assage isconsistent with the gate control theory.

1. "oberg’s test is a test for balance or gait.

10. ?ain sees ore intense at night because the patient isn’t distracted by daily activities.

104. Flder patients coonly don’t report pain becauseof fear of treatent, lifestyle changes, or dependency.

101. >o pork or pork products are allowed in a *uslidiet.

102. #wo goals of Healthy ?eople 2414 are10!. Help individuals of all ages to increase the 7ualityof life and the nuber of years of optial health10%.


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22. ;ollegiality is the prootion of collaboration,developent, and interdependence aong ebers of a profession.

22. A change agent is an individual who recogni5es aneed for change or is selected to ake a change withinan established entity, such as a hospital.

220. #he patients’ bill of rights was introduced by theAerican Hospital Association.

2!4. Abandonent is preature terination of treatentwithout the patient’s perission and without appropriaterelief of syptos.

2!1. Ialues clarification is a process that individuals useto prioriti5e their personal values.

2!2. 6istributive justice is a principle that prootese7ual treatent for all.

2!!. *ilk and ilk products, poultry, grains, and fish aregood sources of phosphate.

2!%. #he best way to prevent falls at night in an oriented,

but restless, elderly patient is to raise the side rails.2!). 3y the end of the orientation phase, the patientshould begin to trust the nurse.

2!+. /alls in the elderly are likely to be caused by poorvision.

2!. 3arriers to counication include languagedeficits, sensory deficits, cognitive ipairents,structural deficits, and paralysis.

2!. #he three eleents that are necessary for a fire areheat, o$ygen, and cobustible aterial.

2!0. ebaceous glands lubricate the skin.

2%4. #o check for petechiae in a darkskinned patient,the nurse should assess the oral ucosa.

2%1. #o put on a sterile glove, the nurse should pick upthe first glove at the folded border and adjust the fingerswhen both gloves are on.

2%2. #o increase patient cofort, the nurse should let thealcohol dry before giving an intrauscular injection.

2%!. #reatent for a stage 1 ulcer on the heels includesheel protectors.

2%%. eventh6ay Adventists are usually vegetarians.

2%).

fundamentals of nursing bullets222

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