Bullets Fundamentals
Bullets Fundamentals
Bullets Fundamentals
insulin, the nurse should draw the regular insulin into the syringe first so that it does not contaminate
the regular insulin.
rced feeding, usually through a gastric tube (a tube passed into the stomach through the
mouth).
and surest way to verify a patient’s identity is to check the identification band on his wrist.
n elicit Trousseau’s sign by occluding the brachial or radial artery. Hand and finger spasms
that occur during occlusion indicate Trousseau’s sign and suggest hypocalcemia.
Intractable pain is pain that incapacitates a patient and can’t be relieved by drugs.
-track I.M. injection technique seals the drug deep into the muscle, thereby minimizing skin
irritation and staining. It requires a needle that’s 1" (2.5 cm) or longer.
distention.
uses a cane should carry it on the unaffected side and advance it at the same time as
the affected extremity.
ementation,
and evaluation.
defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan.
action, delegates specific nursing interventions to members of the nursing team, and charts patient
responses to nursing interventions.
on is the stage of the nursing process in which the nurse compares objective and subjective
data with the outcome criteria and, if needed, modifies the nursing care plan.
the location of the pain.
he nurse should ask the patient to cover each eye separately and to read the eye
chart with glasses and without, as appropriate.
24.4° C).
0% to 60%.
removed after routine contact with a patient, hands should be washed for 10 to 15 seconds.
measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a
comfortable, warm environment.
lungs.
on a tracheostomy tube.
ransfusions.
-point (quad) cane is indicated when a patient needs more stability than a regular cane can
provide.
ek medical help?”
-point, or alternating, gait, the patient first moves the right crutch followed by the left foot
and then the left crutch followed by the right foot.
-point gait, the patient moves two crutches and the affected leg simultaneously and then
moves the unaffected leg.
-point gait, the patient moves the right leg and the left crutch simultaneously and then
moves the left leg and the right crutch simultaneously.
he nurse shouldn’t take an adult’s temperature rectally if the patient has a cardiac disorder, anal
lesions, or bleeding hemorrhoids or has recently undergone rectal surgery.
In a patient who has a cardiac disorder, measuring temperature rectally may stimulate a vagal
response and lead to vasodilation and decreased cardiac output.
,
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).
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.
skin.
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.
essure (5 to 10 mm Hg) between the right and the left arms is normal.
should place the blood pressure cuff 1" (2.5 cm) above the antecubital fossa.
then
apply the ointment from the inner canthus to the outer canthus.
he 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.
a mist tent should never become so dense that it obscures clear visualization of the
patient’s respiratory pattern.
site with alcohol. Stretch the skin taut or pick up a well-defined skin fold. Hold the shaft of the needle in
a dart position. Insert the needle into the skin at a right (90-degree) angle. Firmly depress the plunger,
but don’t aspirate. Leave the needle in place for 10 seconds. Withdraw the needle gently at the angle of
insertion. Apply pressure to the injection site with an alcohol pad.
copy, the nurse should place the patient in the knee-chest position or Sims’ position,
depending on the physician’s preference.
rest, and comfort), safety and security, love and belonging, self-esteem and recognition, and self-
actualization.
-soluble lubricant
to the nostril to prevent soreness.
uring gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances
are removed through the tube.
consistency of the drainage (for example, “10 mm of brown mucoid drainage noted on dressing”).
formation.
tal veins in the
antecubital space.
laboratory request.
tive means of
traction.
minutes before use. Delivery of a chilled solution can cause pain, hypothermia, venous spasm, and
venous constriction.
t routinely injected intramuscularly into edematous tissue because they may not be
absorbed.
voice.
with a washcloth.
without refrigeration.
-residue diet includes such foods as roasted chicken, rice, and pasta.
ucosa
and cause loss of sphincter control.
perineum.
leg
muscles.
-fat
evening meal.
inevitable.
hearing aid is “not working,” the nurse should check the switch first to
see if it’s turned on and then check the batteries.
es as +4.
s nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell
metabolism, and excretion.
percentage of alcohol multiplied by 2. For example, a 100-
proof beverage contains 50% alcohol.
treatment. These decisions are based on the patient’s wishes and views on quality of life.
eral 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.
standards.
ilities of the
hospital and its staff toward patients and their families during hospitalization.
, the nurse should record information as soon as it’s
gathered.
ing 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.
umb to take a patient’s pulse rate because the thumb has a pulse that
may be confused with the patient’s pulse.
r, unalterable risk factors for coronary artery disease include heredity, sex, race, and age.
sessment technique.
s is a regular pulse rhythm with alternating weak and strong beats. It occurs in
ventricular enlargement because the stroke volume varies with each heartbeat.
, and
mastication.
ene
and sternocleidomastoid muscle use during respiration.
e weight.
ly.
ng 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.
ts) and
gray matter (reflex centers).
frame for achievement, and conditions under which the behavior will occur. It’s developed in
collaboration with the patient.
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).
-rich foods, such as organ meats, nuts, legumes, dried fruit, green leafy vegetables, eggs, and
whole grains, commonly have a low water content.
hree types of
data: health history, physical examination, and laboratory and diagnostic test data.
patient.
artery.
To take the pulse rate, the artery is compressed against the radius.
inen off the patient’s feet to prevent skin irritation and breakdown, especially
in a patient who has peripheral vascular disease or neuropathy.
therapy.
consistency, and
odor of secretions.
uld be administered after meals.
bbreviation for normal pupil assessment findings: pupils equal, round, and reactive to
light with accommodation.
who he is), place (knows where he is), and time (knows the date and time).
above the disappearance of the radial pulse before releasing the cuff pressure.
of vomitus.
achieved when body parts are in proper relation to their natural position.
-patient relationship.
reasonable and prudent person would perform or because the nurse performed an act that a reasonable
and prudent person wouldn’t perform.
States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at
the scene of an accident without fear of a lawsuit arising from the assistance. These laws don’t apply to
care provided in a health care facility.
sician should sign verbal and telephone orders within the time established by facility policy,
usually 24 hours.
e individual should
be fully informed of the consequences of his refusal.
erform 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.
led Substances Act designated five categories, or schedules, that classify controlled drugs
according to their abuse potential.
-care and to
interact with society.
greatly
among individuals.
postoperatively.
ptions for drugs.
’t cut the patient’s hair without written consent from the patient or an appropriate
relative.
stops. If
bruising occurs, the nurse should monitor the site for an enlarging hematoma.
toward the head.
cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries.
ith a blue dot is for the left ear; the one with a red dot is for the right
ear.
should instruct the patient to avoid using hair spray while wearing a hearing aid.
granulation).
ion) 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.
the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the
injection site.
-gauge
needle and apply pressure to the site for 5 minutes after the injection.
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.)
the patient.
patient.
ection against the patient’s will and without legal authority is battery.
most appropriate nursing diagnosis for an individual who doesn’t speak English is Impaired verbal
communication related to inability to speak dominant language (English).
sive range of motion maintains joint mobility. Resistive exercises increase muscle mass.
shouldn’t be assigned to care for more than one patient who has a radiation implant.
-handled forceps and a lead-lined container should be available in the room of a patient who has
a radiation implant.
as Marburg disease.
he patient who abides by Jewish custom, milk and meat shouldn’t be served at the same meal.
of the effectiveness of patient teaching than whether the patient can simply state the steps involved in
the procedure (cognitive domain of learning).
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).
health needs.
thers’.
-cold” system used by some Mexicans, Puerto Ricans, and other Hispanic
and Latino groups, most foods, beverages, herbs, and drugs are described as “cold.”
ination.
percussion.
ring blood pressure in a neonate, the nurse should select a cuff that’s no less than one-
half and no more than two-thirds the length of the extremity that’s used.
-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.
ites for intradermal injection include the inner arm, the upper chest, and on the back, under the
scapula.
the action that’s described promotes autonomy (independence), safety, self-esteem, and a sense of
belonging.
tion on the NCLEX examination, the student should consider the cue (the
stimulus for a thought) and the inference (the thought) to determine whether the inference is correct.
When in doubt, the nurse should select an answer that indicates the need for further information to
eliminate ambiguity. For example, the patient complains of chest pain (the stimulus for the thought) and
the nurse infers that the patient is having cardiac pain (the thought). In this case, the nurse hasn’t
confirmed whether the pain is cardiac. It would be more appropriate to make further assessments.
ade provides a framework for prioritizing care by identifying the most important
treatment concerns.
fluid from an upper respiratory infection, and edema from trauma or an allergic reaction.
erything that affects the breathing pattern, including
hyperventilation or hypoventilation and abnormal breathing patterns, such as Korsakoff’s, Biot’s, or
Cheyne-Stokes respiration.
that equal access to goods and services must be provided to the less
fortunate by an affluent society.
ng the therapy that’s sustaining life.
and cost-effective.
shrimp, scallops, spinach, beets, and greens are good sources of iron.
egetarian diet.
ating pain by performing a back massage is consistent with the gate control theory.
– Help individuals of all ages to increase the quality of life and the number of years of optimal health
following his treatment plan, the nurse should first ask why.
in elderly people.
cessation.
-term complications.
religious artifacts and literature on a patient’s night stand, a culturally aware nurse would
ask the patient the meaning of the items.
ient may request the intervention of a curandero, or faith healer, who involves the
family in healing the patient.
in.
the small intestine.
hours?”
-morning urine provides the best sample to measure glucose, ketone, pH, and specific gravity
values.
understand instructions as well as the amount of strength required to move the patient.
b (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).
swallow.
ion.
pain accurately.
-controlled analgesia is a safe method to relieve acute pain caused by surgical incision,
traumatic injury, labor and delivery, or cancer.
communicating.
treatment decisions.
hospitalization.
-effective health care for low-income families and those who have
no health insurance.
comfort, the nurse should let the alcohol dry before giving an intramuscular
injection.