Topics

Topics included are:

Vital Signs
Some Anatomy and Physiology
Nursing Procedures
Various concepts about Fundamentals of Nursing
Bullets
1. A blood pressure cuff thats too narro can cause a
falsely ele!ated blood pressure reading.
". #hen preparing a single in$ection for a patient ho ta%es
regular and neutral protein &agedorn insulin' the nurse
should dra the regular insulin into the syringe first so
that it does not contaminate the regular insulin.
(. )honchi are the rumbling sounds heard on lung
auscultation. They are more pronounced during
e*piration than during inspiration.
+. ,a!age is forced feeding' usually through a gastric tube
-a tube passed into the stomach through the mouth..
/. According to 0aslos hierarchy of needs' physiologic
needs -air' ater' food' shelter' se*' acti!ity' and
comfort. ha!e the highest priority.
1. The safest and surest ay to !erify a patients identity is
to chec% the identification band on his rist.
2. 3n the therapeutic en!ironment' the patients safety is the
primary concern.
4. Fluid oscillation in the tubing of a chest drainage system
indicates that the system is or%ing properly.
5. The nurse should place a patient ho has a Sengsta%en6
7la%emore tube in semi6Foler position.
18. The nurse can elicit Trousseaus sign by occluding the
brachial or radial artery. &and and finger spasms that
occur during occlusion indicate Trousseaus sign and
suggest hypocalcemia.
11. For blood transfusion in an adult' the appropriate needle
si9e is 11 to "8,.
1". 3ntractable pain is pain that incapacitates a patient and
cant be relie!ed by drugs.
1(. 3n an emergency' consent for treatment can be obtained
by fa*' telephone' or other telegraphic means.
1+. :ecibel is the unit of measurement of sound.
1/. 3nformed consent is re;uired for any in!asi!e procedure.
11. A patient ho cant rite his name to gi!e consent for
treatment must ma%e an < in the presence of to
itnesses' such as a nurse' priest' or physician.
12. The =6trac% 3.0. in$ection techni;ue seals the drug deep
into the muscle' thereby minimi9ing s%in irritation and
staining. 3t re;uires a needle thats 1> -"./ cm. or longer.
14. 3n the e!ent of fire' the acronym most often used is
)A?@. -). )emo!e the patient. -A. Acti!ate the alarm.
-?. Attempt to contain the fire by closing the door. -@.
@*tinguish the fire if it can be done safely.
15. A registered nurse should assign a licensed !ocational
nurse or licensed practical nurse to perform bedside care'
such as suctioning and drug administration.
"8. 3f a patient cant !oid' the first nursing action should be
bladder palpation to assess for bladder distention.
"1. The patient ho uses a cane should carry it on the
unaffected side and ad!ance it at the same time as the
affected e*tremity.
"". To fit a supine patient for crutches' the nurse should
measure from the a*illa to the sole and add "> -/ cm. to
that measurement.
"(. Assessment begins ith the nurses first encounter ith
the patient and continues throughout the patients stay.
The nurse obtains assessment data through the health
history' physical e*amination' and re!ie of diagnostic
studies.
"+. The appropriate needle si9e for insulin in$ection is "/,
and /A4> long.
"/. )esidual urine is urine that remains in the bladder after
!oiding. The amount of residual urine is normally /8 to
188 ml.
"1. The fi!e stages of the nursing process are assessment'
nursing diagnosis' planning' implementation' and
e!aluation.
"2. Assessment is the stage of the nursing process in hich
the nurse continuously collects data to identify a
patients actual and potential health needs.
"4. Nursing diagnosis is the stage of the nursing process in
hich the nurse ma%es a clinical $udgment about
indi!idual' family' or community responses to actual or
potential health problems or life processes.
"5. Planning is the stage of the nursing process in hich the
nurse assigns priorities to nursing diagnoses' defines
short6term and long6term goals and e*pected outcomes'
and establishes the nursing care plan.
(8. 3mplementation is the stage of the nursing process in
hich the nurse puts the nursing care plan into action'
delegates specific nursing inter!entions to members of
the nursing team' and charts patient responses to nursing
inter!entions.
(1. @!aluation is the stage of the nursing process in hich
the nurse compares ob$ecti!e and sub$ecti!e data ith
the outcome criteria and' if needed' modifies the nursing
care plan.
(". 7efore administering any Bas neededC pain medication'
the nurse should as% the patient to indicate the location
of the pain.
((. Deho!ahs #itnesses belie!e that they shouldnt recei!e
blood components donated by other people.
(+. To test !isual acuity' the nurse should as% the patient to
co!er each eye separately and to read the eye chart ith
glasses and ithout' as appropriate.
(/. #hen pro!iding oral care for an unconscious patient' to
minimi9e the ris% of aspiration' the nurse should position
the patient on the side.
(1. :uring assessment of distance !ision' the patient should
stand "8E -1.1 m. from the chart.
(2. For a geriatric patient or one ho is e*tremely ill' the
ideal room temperature is 11F to 21F F -14.4F to "+.+F
?..
(4. Normal room humidity is (8G to 18G.
(5. &and ashing is the single best method of limiting the
spread of microorganisms. Hnce glo!es are remo!ed
after routine contact ith a patient' hands should be
ashed for 18 to 1/ seconds.
+8. To perform catheteri9ation' the nurse should place a
oman in the dorsal recumbent position.
+1. A positi!e &omans sign may indicate thrombophlebitis.
+". @lectrolytes in a solution are measured in
millie;ui!alents per liter -m@;AI.. A millie;ui!alent is
the number of milligrams per 188 milliliters of a
solution.
+(. 0etabolism occurs in to phases: anabolism -the
constructi!e phase. and catabolism -the destructi!e
phase..
++. The basal metabolic rate is the amount of energy needed
to maintain essential body functions. 3ts measured hen
the patient is aa%e and resting' hasnt eaten for 1+ to 14
hours' and is in a comfortable' arm en!ironment.
+/. The basal metabolic rate is e*pressed in calories
consumed per hour per %ilogram of body eight.
+1. :ietary fiber -roughage.' hich is deri!ed from
cellulose' supplies bul%' maintains intestinal motility'
and helps to establish regular boel habits.
+2. Alcohol is metaboli9ed primarily in the li!er. Smaller
amounts are metaboli9ed by the %idneys and lungs.
+4. Petechiae are tiny' round' purplish red spots that appear
on the s%in and mucous membranes as a result of
intradermal or submucosal hemorrhage.
+5. Purpura is a purple discoloration of the s%in thats caused
by blood e*tra!asation.
/8. According to the standard precautions recommended by
the ?enters for :isease ?ontrol and Pre!ention' the
nurse shouldnt recap needles after use. 0ost needle
stic%s result from missed needle recapping.
/1. The nurse administers a drug by 3.V. push by using a
needle and syringe to deli!er the dose directly into a
!ein' 3.V. tubing' or a catheter.
/". #hen changing the ties on a tracheostomy tube' the
nurse should lea!e the old ties in place until the ne
ones are applied.
/(. A nurse should ha!e assistance hen changing the ties
on a tracheostomy tube.
/+. A filter is alays used for blood transfusions.
//. A four6point -;uad. cane is indicated hen a patient
needs more stability than a regular cane can pro!ide.
/1. A good ay to begin a patient inter!ie is to as%' B#hat
made you see% medical helpJC
/2. #hen caring for any patient' the nurse should follo
standard precautions for handling blood and body fluids.
/4. Potassium -KL. is the most abundant cation in
intracellular fluid.
/5. 3n the four6point' or alternating' gait' the patient first
mo!es the right crutch folloed by the left foot and then
the left crutch folloed by the right foot.
18. 3n the three6point gait' the patient mo!es to crutches
and the affected leg simultaneously and then mo!es the
unaffected leg.
11. 3n the to6point gait' the patient mo!es the right leg and
the left crutch simultaneously and then mo!es the left leg
and the right crutch simultaneously.
1". The !itamin 7 comple*' the ater6soluble !itamins that
are essential for metabolism' include thiamine -71.'
ribofla!in -7".' niacin -7(.' pyrido*ine -71.' and
cyanocobalamin -71"..
1(. #hen being eighed' an adult patient should be lightly
dressed and shoeless.
1+. 7efore ta%ing an adults temperature orally' the nurse
should ensure that the patient hasnt smo%ed or
consumed hot or cold substances in the pre!ious 1/
minutes.
1/. The nurse shouldnt ta%e an adults temperature rectally
if the patient has a cardiac disorder' anal lesions' or
bleeding hemorrhoids or has recently undergone rectal
surgery.
11. 3n a patient ho has a cardiac disorder' measuring
temperature rectally may stimulate a !agal response and
lead to !asodilation and decreased cardiac output.
12. #hen recording pulse amplitude and rhythm' the nurse
should use these descripti!e measures: L(' bounding
pulse -readily palpable and forceful.M L"' normal pulse
-easily palpable.M L1' thready or ea% pulse -difficult to
detect.M and 8' absent pulse -not detectable..
14. The intraoperati!e period begins hen a patient is
transferred to the operating room bed and ends hen the
patient is admitted to the postanesthesia care unit.
15. Hn the morning of surgery' the nurse should ensure that
the informed consent form has been signedM that the
patient hasnt ta%en anything by mouth since midnight'
has ta%en a shoer ith antimicrobial soap' has had
mouth care -ithout salloing the ater.' has remo!ed
common $eelry' and has recei!ed preoperati!e
medication as prescribedM and that !ital signs ha!e been
ta%en and recorded. Artificial limbs and other prostheses
are usually remo!ed.
28. ?omfort measures' such as positioning the patient'
rubbing the patients bac%' and pro!iding a restful
en!ironment' may decrease the patients need for
analgesics or may enhance their effecti!eness.
21. A drug has three names: generic name' hich is used in
official publicationsM trade' or brand' name -such as
Tylenol.' hich is selected by the drug companyM and
chemical name' hich describes the drugs chemical
composition.
2". To a!oid staining the teeth' the patient should ta%e a
li;uid iron preparation through a stra.
2(. The nurse should use the =6trac% method to administer
an 3.0. in$ection of iron de*tran -3mferon..
2+. An organism may enter the body through the nose'
mouth' rectum' urinary or reproducti!e tract' or s%in.
2/. 3n descending order' the le!els of consciousness are
alertness' lethargy' stupor' light coma' and deep coma.
21. To turn a patient by logrolling' the nurse folds the
patients arms across the chestM e*tends the patients legs
and inserts a pillo beteen them' if neededM places a
dra sheet under the patientM and turns the patient by
sloly and gently pulling on the dra sheet.
22. The diaphragm of the stethoscope is used to hear high6
pitched sounds' such as breath sounds.
24. A slight difference in blood pressure -/ to 18 mm &g.
beteen the right and the left arms is normal.
25. The nurse should place the blood pressure cuff 1> -"./
cm. abo!e the antecubital fossa.
48. #hen instilling ophthalmic ointments' the nurse should
aste the first bead of ointment and then apply the
ointment from the inner canthus to the outer canthus.
41. The nurse should use a leg cuff to measure blood
pressure in an obese patient.
4". 3f a blood pressure cuff is applied too loosely' the
reading ill be falsely loered.
4(. Ptosis is drooping of the eyelid.
4+. A tilt table is useful for a patient ith a spinal cord
in$ury' orthostatic hypotension' or brain damage because
it can mo!e the patient gradually from a hori9ontal to a
!ertical -upright. position.
4/. To perform !enipuncture ith the least in$ury to the
!essel' the nurse should turn the be!el upard hen the
!essels lumen is larger than the needle and turn it
donard hen the lumen is only slightly larger than
the needle.
41. To mo!e a patient to the edge of the bed for transfer' the
nurse should follo these steps: 0o!e the patients head
and shoulders toard the edge of the bed. 0o!e the
patients feet and legs to the edge of the bed -crescent
position.. Place both arms ell under the patients hips'
and straighten the bac% hile mo!ing the patient toard
the edge of the bed.
42. #hen being measured for crutches' a patient should ear
shoes.
44. The nurse should attach a restraint to the part of the bed
frame that mo!es ith the head' not to the mattress or
side rails.
45. The mist in a mist tent should ne!er become so dense
that it obscures clear !isuali9ation of the patients
respiratory pattern.
58. To administer heparin subcutaneously' the nurse should
follo these steps: ?lean' but dont rub' the site ith
alcohol. Stretch the s%in taut or pic% up a ell6defined
s%in fold. &old the shaft of the needle in a dart position.
3nsert the needle into the s%in at a right -586degree.
angle. Firmly depress the plunger' but dont aspirate.
Iea!e the needle in place for 18 seconds. #ithdra the
needle gently at the angle of insertion. Apply pressure to
the in$ection site ith an alcohol pad.
51. For a sigmoidoscopy' the nurse should place the patient
in the %nee6chest position or Sims position' depending
on the physicians preference.
5". 0aslos hierarchy of needs must be met in the
folloing order: physiologic -o*ygen' food' ater' se*'
rest' and comfort.' safety and security' lo!e and
belonging' self6esteem and recognition' and self6
actuali9ation.
5(. #hen caring for a patient ho has a nasogastric tube' the
nurse should apply a ater6soluble lubricant to the
nostril to pre!ent soreness.
5+. :uring gastric la!age' a nasogastric tube is inserted' the
stomach is flushed' and ingested substances are remo!ed
through the tube.
5/. 3n documenting drainage on a surgical dressing' the
nurse should include the si9e' color' and consistency of
the drainage -for e*ample' B18 mm of bron mucoid
drainage noted on dressingC..
51. To elicit 7abins%is refle*' the nurse stro%es the sole of
the patients foot ith a moderately sharp ob$ect' such as
a thumbnail.
52. A positi!e 7abins%is refle* is shon by dorsifle*ion of
the great toe and fanning out of the other toes.
54. #hen assessing a patient for bladder distention' the
nurse should chec% the contour of the loer abdomen for
a rounded mass abo!e the symphysis pubis.
55. The best ay to pre!ent pressure ulcers is to reposition
the bedridden patient at least e!ery " hours.
188. Antiembolism stoc%ings decompress the superficial
blood !essels' reducing the ris% of thrombus formation.
181. 3n adults' the most con!enient !eins for !enipuncture are
the basilic and median cubital !eins in the antecubital
space.
18". To to three hours before beginning a tube feeding' the
nurse should aspirate the patients stomach contents to
!erify that gastric emptying is ade;uate.
18(. People ith type H blood are considered uni!ersal
donors.
18+. People ith type A7 blood are considered uni!ersal
recipients.
18/. &ert9 -&9. is the unit of measurement of sound
fre;uency.
181. &earing protection is re;uired hen the sound intensity
e*ceeds 4+ d7. :ouble hearing protection is re;uired if it
e*ceeds 18+ d7.
182. Prothrombin' a clotting factor' is produced in the li!er.
184. 3f a patient is menstruating hen a urine sample is
collected' the nurse should note this on the laboratory
re;uest.
185. :uring lumbar puncture' the nurse must note the initial
intracranial pressure and the color of the cerebrospinal
fluid.
118. 3f a patient cant cough to pro!ide a sputum sample for
culture' a heated aerosol treatment can be used to help to
obtain a sample.
111. 3f eye ointment and eyedrops must be instilled in the
same eye' the eyedrops should be instilled first.
11". #hen lea!ing an isolation room' the nurse should
remo!e her glo!es before her mas% because feer
pathogens are on the mas%.
11(. S%eletal traction' hich is applied to a bone ith ire
pins or tongs' is the most effecti!e means of traction.
11+. The total parenteral nutrition solution should be stored in
a refrigerator and remo!ed (8 to 18 minutes before use.
:eli!ery of a chilled solution can cause pain'
hypothermia' !enous spasm' and !enous constriction.
11/. :rugs arent routinely in$ected intramuscularly into
edematous tissue because they may not be absorbed.
111. #hen caring for a comatose patient' the nurse should
e*plain each action to the patient in a normal !oice.
112. :entures should be cleaned in a sin% thats lined ith a
ashcloth.
114. A patient should !oid ithin 4 hours after surgery.
115. An @@, identifies normal and abnormal brain a!es.
1"8. Samples of feces for o!a and parasite tests should be
deli!ered to the laboratory ithout delay and ithout
refrigeration.
1"1. The autonomic ner!ous system regulates the
cardio!ascular and respiratory systems.
1"". #hen pro!iding tracheostomy care' the nurse should
insert the catheter gently into the tracheostomy tube.
#hen ithdraing the catheter' the nurse should apply
intermittent suction for no more than 1/ seconds and use
a slight tisting motion.
1"(. A lo6residue diet includes such foods as roasted
chic%en' rice' and pasta.
1"+. A rectal tube shouldnt be inserted for longer than "8
minutes because it can irritate the rectal mucosa and
cause loss of sphincter control.
1"/. A patients bed bath should proceed in this order: face'
nec%' arms' hands' chest' abdomen' bac%' legs' perineum.
1"1. To pre!ent in$ury hen lifting and mo!ing a patient' the
nurse should primarily use the upper leg muscles.
1"2. Patient preparation for cholecystography includes
ingestion of a contrast medium and a lo6fat e!ening
meal.
1"4. #hile an occupied bed is being changed' the patient
should be co!ered ith a bath blan%et to promote
armth and pre!ent e*posure.
1"5. Anticipatory grief is mourning that occurs for an
e*tended time hen the patient reali9es that death is
ine!itable.
1(8. The folloing foods can alter the color of the feces:
beets -red.' cocoa -dar% red or bron.' licorice -blac%.'
spinach -green.' and meat protein -dar% bron..
1(1. #hen preparing for a s%ull <6ray' the patient should
remo!e all $eelry and dentures.
1(". The fight6or6flight response is a sympathetic ner!ous
system response.
1((. 7roncho!esicular breath sounds in peripheral lung fields
are abnormal and suggest pneumonia.
1(+. #hee9ing is an abnormal' high6pitched breath sound
thats accentuated on e*piration.
1(/. #a* or a foreign body in the ear should be flushed out
gently by irrigation ith arm saline solution.
1(1. 3f a patient complains that his hearing aid is Bnot
or%ing'C the nurse should chec% the sitch first to see
if its turned on and then chec% the batteries.
1(2. The nurse should grade hyperacti!e biceps and triceps
refle*es as L+.
1(4. 3f to eye medications are prescribed for tice6daily
instillation' they should be administered / minutes apart.
1(5. 3n a postoperati!e patient' forcing fluids helps pre!ent
constipation.
1+8. A nurse must pro!ide care in accordance ith standards
of care established by the American Nurses Association'
state regulations' and facility policy.
1+1. The %ilocalorie -%cal. is a unit of energy measurement
that represents the amount of heat needed to raise the
temperature of 1 %ilogram of ater 1F ?.
1+". As nutrients mo!e through the body' they undergo
ingestion' digestion' absorption' transport' cell
metabolism' and e*cretion.
1+(. The body metaboli9es alcohol at a fi*ed rate' regardless
of serum concentration.
1++. 3n an alcoholic be!erage' proof reflects the percentage of
alcohol multiplied by ". For e*ample' a 1886proof
be!erage contains /8G alcohol.
1+/. A li!ing ill is a itnessed document that states a
patients desire for certain types of care and treatment.
These decisions are based on the patients ishes and
!ies on ;uality of life.
1+1. The nurse should flush a peripheral heparin loc% e!ery 4
hours -if it asnt used during the pre!ious 4 hours. and
as needed ith normal saline solution to maintain
patency.
1+2. Nuality assurance is a method of determining hether
nursing actions and practices meet established standards.
1+4. The fi!e rights of medication administration are the right
patient' right drug' right dose' right route of
administration' and right time.
1+5. The e!aluation phase of the nursing process is to
determine hether nursing inter!entions ha!e enabled
the patient to meet the desired goals.
1/8. Hutside of the hospital setting' only the sublingual and
translingual forms of nitroglycerin should be used to
relie!e acute anginal attac%s.
1/1. The implementation phase of the nursing process
in!ol!es recording the patients response to the nursing
plan' putting the nursing plan into action' delegating
specific nursing inter!entions' and coordinating the
patients acti!ities.
1/". The Patients 7ill of )ights offers patients guidance and
protection by stating the responsibilities of the hospital
and its staff toard patients and their families during
hospitali9ation.
1/(. To minimi9e omission and distortion of facts' the nurse
should record information as soon as its gathered.
1/+. #hen assessing a patients health history' the nurse
should record the current illness chronologically'
beginning ith the onset of the problem and continuing
to the present.
1//. #hen assessing a patients health history' the nurse
should record the current illness chronologically'
beginning ith the onset of the problem and continuing
to the present.
1/1. A nurse shouldnt gi!e false assurance to a patient.
1/2. After recei!ing preoperati!e medication' a patient isnt
competent to sign an informed consent form.
1/4. #hen lifting a patient' a nurse uses the eight of her
body instead of the strength in her arms.
1/5. A nurse may clarify a physicians e*planation about an
operation or a procedure to a patient' but must refer
;uestions about informed consent to the physician.
118. #hen obtaining a health history from an acutely ill or
agitated patient' the nurse should limit ;uestions to those
that pro!ide necessary information.
111. 3f a chest drainage system line is bro%en or interrupted'
the nurse should clamp the tube immediately.
11". The nurse shouldnt use her thumb to ta%e a patients
pulse rate because the thumb has a pulse that may be
confused ith the patients pulse.
11(. An inspiration and an e*piration count as one respiration.
11+. @upnea is normal respiration.
11/. :uring blood pressure measurement' the patient should
rest the arm against a surface. Osing muscle strength to
hold up the arm may raise the blood pressure.
111. 0a$or' unalterable ris% factors for coronary artery
disease include heredity' se*' race' and age.
112. 3nspection is the most fre;uently used assessment
techni;ue.
114. Family members of an elderly person in a long6term care
facility should transfer some personal items -such as
photographs' a fa!orite chair' and %nic%%nac%s. to the
persons room to pro!ide a comfortable atmosphere.
115. Pulsus alternans is a regular pulse rhythm ith
alternating ea% and strong beats. 3t occurs in !entricular
enlargement because the stro%e !olume !aries ith each
heartbeat.
128. The upper respiratory tract arms and humidifies
inspired air and plays a role in taste' smell' and
mastication.
121. Signs of accessory muscle use include shoulder
ele!ation' intercostal muscle retraction' and scalene and
sternocleidomastoid muscle use during respiration.
12". #hen patients use a*illary crutches' their palms should
bear the brunt of the eight.
12(. Acti!ities of daily li!ing include eating' bathing'
dressing' grooming' toileting' and interacting socially.
12+. Normal gait has to phases: the stance phase' in hich
the patients foot rests on the ground' and the sing
phase' in hich the patients foot mo!es forard.
12/. The phases of mitosis are prophase' metaphase'
anaphase' and telophase.
121. The nurse should follo standard precautions in the
routine care of all patients.
122. The nurse should use the bell of the stethoscope to listen
for !enous hums and cardiac murmurs.
124. The nurse can assess a patients general %noledge by
as%ing ;uestions such as B#ho is the president of the
Onited StatesJC
125. ?old pac%s are applied for the first "8 to +4 hours after
an in$uryM then heat is applied. :uring cold application'
the pac% is applied for "8 minutes and then remo!ed for
18 to 1/ minutes to pre!ent refle* dilation -rebound
phenomenon. and frostbite in$ury.
148. The pons is located abo!e the medulla and consists of
hite matter -sensory and motor tracts. and gray matter
-refle* centers..
141. The autonomic ner!ous system controls the smooth
muscles.
14". A correctly ritten patient goal e*presses the desired
patient beha!ior' criteria for measurement' time frame
for achie!ement' and conditions under hich the
beha!ior ill occur. 3ts de!eloped in collaboration ith
the patient.
14(. Percussion causes fi!e basic notes: tympany -loud
intensity' as heard o!er a gastric air bubble or puffed out
chee%.' hyperresonance -!ery loud' as heard o!er an
emphysematous lung.' resonance -loud' as heard o!er a
normal lung.' dullness -medium intensity' as heard o!er
the li!er or other solid organ.' and flatness -soft' as heard
o!er the thigh..
14+. The optic dis% is yelloish pin% and circular' ith a
distinct border.
14/. A primary disability is caused by a pathologic process. A
secondary disability is caused by inacti!ity.
141. Nurses are commonly held liable for failing to %eep an
accurate count of sponges and other de!ices during
surgery.
142. The best dietary sources of !itamin 71 are li!er' %idney'
por%' soybeans' corn' and hole6grain cereals.
144. 3ron6rich foods' such as organ meats' nuts' legumes'
dried fruit' green leafy !egetables' eggs' and hole
grains' commonly ha!e a lo ater content.
145. ?ollaboration is $oint communication and decision
ma%ing beteen nurses and physicians. 3ts designed to
meet patients needs by integrating the care regimens of
both professions into one comprehensi!e approach.
158. 7radycardia is a heart rate of feer than 18 beatsAminute.
151. A nursing diagnosis is a statement of a patients actual or
potential health problem that can be resol!ed'
diminished' or otherise changed by nursing
inter!entions.
15". :uring the assessment phase of the nursing process' the
nurse collects and analy9es three types of data: health
history' physical e*amination' and laboratory and
diagnostic test data.
15(. The patients health history consists primarily of
sub$ecti!e data' information thats supplied by the
patient.
15+. The physical e*amination includes ob$ecti!e data
obtained by inspection' palpation' percussion' and
auscultation.
15/. #hen documenting patient care' the nurse should rite
legibly' use only standard abbre!iations' and sign each
entry. The nurse should ne!er destroy or attempt to
obliterate documentation or lea!e !acant lines.
151. Factors that affect body temperature include time of day'
age' physical acti!ity' phase of menstrual cycle' and
pregnancy.
152. The most accessible and commonly used artery for
measuring a patients pulse rate is the radial artery. To
ta%e the pulse rate' the artery is compressed against the
radius.
154. 3n a resting adult' the normal pulse rate is 18 to 188
beatsAminute. The rate is slightly faster in omen than in
men and much faster in children than in adults.
155. Iaboratory test results are an ob$ecti!e form of
assessment data.
"88. The measurement systems most commonly used in
clinical practice are the metric system' apothecaries
system' and household system.
"81. 7efore signing an informed consent form' the patient
should %no hether other treatment options are
a!ailable and should understand hat ill occur during
the preoperati!e' intraoperati!e' and postoperati!e
phasesM the ris%s in!ol!edM and the possible
complications. The patient should also ha!e a general
idea of the time re;uired from surgery to reco!ery. 3n
addition' he should ha!e an opportunity to as% ;uestions.
"8". A patient must sign a separate informed consent form for
each procedure.
"8(. :uring percussion' the nurse uses ;uic%' sharp tapping of
the fingers or hands against body surfaces to produce
sounds. This procedure is done to determine the si9e'
shape' position' and density of underlying organs and
tissuesM elicit tendernessM or assess refle*es.
"8+. 7allottement is a form of light palpation in!ol!ing
gentle' repetiti!e bouncing of tissues against the hand
and feeling their rebound.
"8/. A foot cradle %eeps bed linen off the patients feet to
pre!ent s%in irritation and brea%don' especially in a
patient ho has peripheral !ascular disease or
neuropathy.
"81. ,astric la!age is flushing of the stomach and remo!al of
ingested substances through a nasogastric tube. 3ts used
to treat poisoning or drug o!erdose.
"82. :uring the e!aluation step of the nursing process' the
nurse assesses the patients response to therapy.
"84. 7ruits commonly indicate life6 or limb6threatening
!ascular disease.
"85. H.O. means each eye. H.:. is the right eye' and H.S. is
the left eye.
"18. To remo!e a patients artificial eye' the nurse depresses
the loer lid.
"11. The nurse should use a arm saline solution to clean an
artificial eye.
"1". A thready pulse is !ery fine and scarcely perceptible.
"1(. A*illary temperature is usually 1F F loer than oral
temperature.
"1+. After suctioning a tracheostomy tube' the nurse must
document the color' amount' consistency' and odor of
secretions.
"1/. Hn a drug prescription' the abbre!iation p.c. means that
the drug should be administered after meals.
"11. After bladder irrigation' the nurse should document the
amount' color' and clarity of the urine and the presence
of clots or sediment.
"12. After bladder irrigation' the nurse should document the
amount' color' and clarity of the urine and the presence
of clots or sediment.
"14. Ias regarding patient self6determination !ary from
state to state. Therefore' the nurse must be familiar ith
the las of the state in hich she or%s.
"15. ,auge is the inside diameter of a needle: the smaller the
gauge' the larger the diameter.
""8. An adult normally has (" permanent teeth.