Fundamentals of Nursing Bullets

1. A blood pressure cuff that’s too narrow can cause a falsely elevated blood pressure reading.

2. When preparing a single injection for a patient who takes regular and neutral protein Hagedorn insulin, the nurse should draw the regular insulin into the syringe first so that it does not contaminate the regular insulin.

3. Rhonchi are the rumbling sounds heard on lung auscultation. They are more pronounced during expiration than during inspiration.

4. Gavage is forced feeding, usually through a gastric tube (a tube passed into the stomach through the mouth).

5. According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority.

6. The safest and surest way to verify a patient’s identity is to check the identification band on his wrist.

7. In the therapeutic environment, the patient’s safety is the primary concern.

8. Fluid oscillation in the tubing of a chest drainage system indicates that the system is workingproperly.

9. The nurse should place a patient who has a Sengstaken-Blakemore tube in semi-Fowler position.

10. The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery. Hand and finger spasms that occur during occlusion indicate Trousseau’s sign and suggest hypocalcemia.

11. For blood transfusion in an adult, the appropriate needle size is 16 to 20G.

12. Intractable pain is pain that incapacitates a patient and can’t be relieved by drugs.

13. In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic means.

14. Decibel is the unit of measurement of sound.

15. Informed consent is required for any invasive procedure.

16. A patient who can’t write his name to give consent for treatment must make an X in the presence of two witnesses, such as a nurse, priest, or physician.

17. The Z-track I.M. injection technique seals the drug deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle that’s 1″ (2.5 cm) or longer.

18. In the event of fire, the acronym most often used is RACE. (R) Remove the patient. (A) Activate the alarm. (C) Attempt to contain the fire by closing the door. (E) Extinguish the fire if it can be done safely.

19. A registered nurse should assign a licensed vocational nurse or licensed practical nurse to perform bedside care, such as suctioning and drug administration.

20. If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention.

21. The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity.

22. To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2″ (5 cm) to that measurement.

23. Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies.

24. The appropriate needle size for insulin injection is 25G and 5/8″ long.

25. Residual urine is urine that remains in the bladder after voiding. The amount of residual urine is normally 50 to 100 ml.

26. The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation.

27. Assessment is the stage of the nursing process in which the nurse continuously collects data to identify a patient’s actual and potential health needs.

28. Nursing diagnosis is the stage of the nursing process in which the nurse makes a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes.

29. 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 thenursing care plan.

30. Implementation is the stage of the nursing process in which the nurse puts the nursing care planinto action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions.

31. Evaluation is the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan.

32. Before administering any “as needed” pain medication, the nurse should ask the patient to indicate the location of the pain.

33. Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people.

34. To test visual acuity, the nurse should ask the patient to cover each eye separately and to read the eye chart with glasses and without, as appropriate.

35. When providing oral care for an unconscious patient, to minimize the risk of aspiration, the nurse should position the patient on the side.

36. During assessment of distance vision, the patient should stand 20′ (6.1 m) from the chart.

37. For a geriatric patient or one who is extremely ill, the ideal room temperature is 66° to 76° F (18.8° to 24.4° C).

38. Normal room humidity is 30% to 60%.

39. Hand washing is the single best method of limiting the spread of microorganisms. Once gloves are removed after routine contact with a patient, hands should be washed for 10 to 15 seconds.

40. To perform catheterization, the nurse should place a woman in the dorsal recumbent position.

41. A positive Homan’s sign may indicate thrombophlebitis.

42. Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent is the number of milligrams per 100 milliliters of a solution.

43. Metabolism occurs in two phases: anabolism (the constructive phase) and catabolism (the destructive phase).

44. The basal metabolic rate is the amount of energy needed to maintain essential body functions. It’s measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment.

45. The basal metabolic rate is expressed in calories consumed per hour per kilogram of body weight.

46. Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains intestinal motility, and helps to establish regular bowel habits.

47. Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs.

48. Petechiae are tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage.

49. Purpura is a purple discoloration of the skin that’s caused by blood extravasation.

50. According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldn’t recap needles after use. Most needle sticks result from missed needle recapping.

51. The nurse administers a drug by I.V. push by using a needle and syringe to deliver the dose directly into a vein, I.V. tubing, or a catheter.

52. When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied.

53. A nurse should have assistance when changing the ties on a tracheostomy tube.

54. A filter is always used for blood transfusions.

55. A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide.

56. A good way to begin a patient interview is to ask, “What made you seek medical help?”

57. When caring for any patient, the nurse should follow standard precautions for handling blood and body fluids.
58. Potassium (K+) is the most abundant cation in intracellular fluid.

59. In the four-point, or alternating, gait, the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot.

60. In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg.

61. 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.

62. The vitamin B complex, the water-soluble vitamins that are essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12).

63. When being weighed, an adult patient should be lightly dressed and shoeless.

64. Before taking an adult’s temperature orally, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the previous 15 minutes.

65. 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.

66. In a patient who has a cardiac disorder, measuring temperature rectally may stimulate a vagal response and lead to vasodilation and decreased cardiac output.

67. When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3, bounding pulse (readily palpable and forceful); +2, normal pulse (easily palpable); +1, thready or weak pulse (difficult to detect); and 0, absent pulse (not detectable).

68. The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia care unit.

69. On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water), has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have been taken and recorded. Artificial limbs and other prostheses are usually removed.

70. Comfort measures, such as positioning the patient, rubbing the patient’s back, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness.

71. A drug has three names: generic name, which is used in official publications; trade, or brand, name (such as Tylenol), which is selected by the drug company; and chemical name, which describes the drug’s chemical composition.

72. To avoid staining the teeth, the patient should take a liquid iron preparation through a straw.

73. The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon).

74. An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin.

75. In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma.

76. To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if needed; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet.

77. The diaphragm of the stethoscope is used to hear high-pitched sounds, such as breath sounds.

78. A slight difference in blood pressure (5 to 10 mm Hg) between the right and the left arms is normal.

79. The nurse should place the blood pressure cuff 1″ (2.5 cm) above the antecubital fossa.

80. When instilling ophthalmic ointments, the nurse should waste the first bead of ointment and then apply the ointment from the inner canthus to the outer canthus.

81. The nurse should use a leg cuff to measure blood pressure in an obese patient.

82. If a blood pressure cuff is applied too loosely, the reading will be falsely elevated.

83. Ptosis is drooping of the eyelid.

84. A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position.

85. To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle.

86. To move a patient to the edge of the bed for transfer, the nurse should follow these steps: Move the patient’s head and shoulders toward the edge of the bed. Move the patient’s feet and legs to the edge of the bed (crescent position). Place both arms well under the patient’s hips, and straighten the back while moving the patient toward the edge of the bed.

87. When being measured for crutches, a patient should wear shoes.

88. The nurse should attach a restraint to the part of the bed frame that moves with the head, not to the mattress or side rails.

89. The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern.

90. To administer heparin subcutaneously, the nurse should follow these steps: Clean, but don’t rub, the site with alcohol. Stretch the skin taut or pick up a well-defined skin fold. Hold the shaft of the needle in a dart position. Insert the needle into the skin at a right (90-degree) angle. Firmly depress the plunger, but don’t aspirate. Leave the needle in place for 10 seconds. Withdraw the needle gently at the angle of insertion. Apply pressure to the injection site with an alcohol pad.

91. For a sigmoidoscopy, the nurse should place the patient in the knee-chest position or Sims’ position, depending on the physician’s preference.

92. Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort), safety and security, love and belonging, self-esteem and recognition, and self-actualization.

93. When caring for a patient who has a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness.

94. During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube.

95. In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage (for example, “10 mm of brown mucoid drainage noted on dressing”).

96. To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as a thumbnail.

97. A positive Babinski’s reflex is shown by dorsiflexion of the great toe and fanning out of the other toes.

98. When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis.

99. The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours.

100. Antiembolism stockings decompress the superficial blood vessels, reducing the risk of thrombus formation.

101. In adults, the most convenient veins for venipuncture are the basilic and median cubital veins in the antecubital space.

102. Two to three hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify that gastric emptying is adequate.

103. People with type O blood are considered universal donors.

104. People with type AB blood are considered universal recipients.

105. Hertz (Hz) is the unit of measurement of sound frequency.

106. Hearing protection is required when the sound intensity exceeds 84 dB. Double hearing protection is required if it exceeds 104 dB.

107. Prothrombin, a clotting factor, is produced in the liver.

108. If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory request.

109. During lumbar puncture, the nurse must note the initial intracranial pressure and the color of the cerebrospinal fluid.

110. If a patient can’t cough to provide a sputum sample for culture, a heated aerosol treatment can be used to help to obtain a sample.

111. If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first.

112. When leaving an isolation room, the nurse should remove her gloves before her mask because fewer pathogens are on the mask.

113. Skeletal traction, which is applied to a bone with wire pins or tongs, is the most effective means of traction.

114. The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use. Delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction.

115. Drugs aren’t routinely injected intramuscularly into edematous tissue because they may not be absorbed.

116. When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice.

117. Dentures should be cleaned in a sink that’s lined with a washcloth.

118. A patient should void within 8 hours after surgery.

119. An EEG identifies normal and abnormal brain waves.

120. Samples of feces for ova and parasite tests should be delivered to the laboratory without delay and without refrigeration.

121. The autonomic nervous system regulates the cardiovascular and respiratory systems.

122. 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.

123. A low-residue diet includes such foods as roasted chicken, rice, and pasta.

124. A rectal tube shouldn’t be inserted for longer than 20 minutes because it can irritate the rectal mucosa and cause loss of sphincter control.

125. A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum.

126. To prevent injury when lifting and moving a patient, the nurse should primarily use the upper leg muscles.

127. Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal.

128. While an occupied bed is being changed, the patient should be covered with a bath blanket to promote warmth and prevent exposure.

129. Anticipatory grief is mourning that occurs for an extended time when the patient realizes that death is inevitable.
130. 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).

131. When preparing for a skull X-ray, the patient should remove all jewelry and dentures.

132. The fight-or-flight response is a sympathetic nervous system response.

133. Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia.

134. Wheezing is an abnormal, high-pitched breath sound that’s accentuated on expiration.

135. Wax or a foreign body in the ear should be flushed out gently by irrigation with warm saline solution.

136. If a patient complains that his hearing aid is “not working,” the nurse should check the switch first to see if it’s turned on and then check the batteries.

137. The nurse should grade hyperactive biceps and triceps reflexes as +4.

138. If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart.

139. In a postoperative patient, forcing fluids helps prevent constipation.

140. A nurse must provide care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy.

141. The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1° C.

142. As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion.

143. The body metabolizes alcohol at a fixed rate, regardless of serum concentration.

144. In an alcoholic beverage, proof reflects the percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol.

145. A living will is a witnessed document that states a patient’s desire for certain types of care and treatment. These decisions are based on the patient’s wishes and views on quality of life.

146. The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as needed with normal saline solution to maintain patency.

147. Quality assurance is a method of determining whether nursing actions and practices meet established standards.

148. The five rights of medication administration are the right patient, right drug, right dose, right route of administration, and right time.

149. The evaluation phase of the nursing process is to determine whether nursing interventions have enabled the patient to meet the desired goals.

150. Outside of the hospital setting, only the sublingual and translingual forms of nitroglycerin should be used to relieve acute anginal attacks.

151. The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities.

152. The Patient’s Bill of Rights offers patients guidance and protection by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization.

153. To minimize omission and distortion of facts, the nurse should record information as soon as it’s gathered.

154. When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present.

155. When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present.

156. A nurse shouldn’t give false assurance to a patient.

157. After receiving preoperative medication, a patient isn’t competent to sign an informed consent form.

158. When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms.

159. A nurse may clarify a physician’s explanation about an operation or a procedure to a patient, but must refer questions about informed consent to the physician.

160. When obtaining a health history from an acutely ill or agitated patient, the nurse should limit questions to those that provide necessary information.

161. If a chest drainage system line is broken or interrupted, the nurse should clamp the tube immediately.

162. The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a pulse that may be confused with the patient’s pulse.

163. An inspiration and an expiration count as one respiration.

164. Eupnea is normal respiration.

165. During blood pressure measurement, the patient should rest the arm against a surface. Using muscle strength to hold up the arm may raise the blood pressure.

166. Major, unalterable risk factors for coronary artery disease include heredity, sex, race, and age.

167. Inspection is the most frequently used assessment technique.

168. Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a comfortable atmosphere.

169. Pulsus alternans is a regular pulse rhythm with alternating weak and strong beats. It occurs in ventricular enlargement because the stroke volume varies with each heartbeat.

170. The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication.

171. Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidomastoid muscle use during respiration.

172. When patients use axillary crutches, their palms should bear the brunt of the weight.

173. Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially.

174. Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in which the patient’s foot moves forward.

175. The phases of mitosis are prophase, metaphase, anaphase, and telophase.

176. The nurse should follow standard precautions in the routine care of all patients.

177. The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs.

178. The nurse can assess a patient’s general knowledge by asking questions such as “Who is the president of the United States?”

179. Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury.
180. The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers).

181. The autonomic nervous system controls the smooth muscles.

182. A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It’s developed in collaboration with the patient.

183. 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).

184. The optic disk is yellowish pink and circular, with a distinct border.

185. A primary disability is caused by a pathologic process. A secondary disability is caused by inactivity.

186. Nurses are commonly held liable for failing to keep an accurate count of sponges and other devices during surgery.

187. The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals.

188. Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, green leafy vegetables, eggs, and whole grains, commonly have a low water content.

189. Collaboration is joint communication and decision making between nurses and physicians. It’s designed to meet patients’ needs by integrating the care regimens of both professions into one comprehensive approach.

190. Bradycardia is a heart rate of fewer than 60 beats/minute.

191. A nursing diagnosis is a statement of a patient’s actual or potential health problem that can be resolved, diminished, or otherwise changed by nursing interventions.

192. During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data.

193. The patient’s health history consists primarily of subjective data, information that’s supplied by the patient.

194. The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation.

195. When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign each entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines.

196. Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy.

197. The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery. To take the pulse rate, the artery is compressed against the radius.

198. In a resting adult, the normal pulse rate is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults.

199. Laboratory test results are an objective form of assessment data.

200. The measurement systems most commonly used in clinical practice are the metric system, apothecaries’ system, and household system.

201. Before signing an informed consent form, the patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phases; the risks involved; and the possible complications. The patient should also have a general idea of the time required from surgery to recovery. In addition, he should have an opportunity to ask questions.

202. A patient must sign a separate informed consent form for each procedure.

203. During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds. This procedure is done to determine the size, shape, position, and density of underlying organs and tissues; elicit tenderness; or assess reflexes.

204. Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound.

205. 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.

206. Gastric lavage is flushing of the stomach and removal of ingested substances through a nasogastric tube. It’s used to treat poisoning or drug overdose.

207. During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy.

208. Bruits commonly indicate life- or limb-threatening vascular disease.

209. O.U. means each eye. O.D. is the right eye, and O.S. is the left eye.

210. To remove a patient’s artificial eye, the nurse depresses the lower lid.

211. The nurse should use a warm saline solution to clean an artificial eye.

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

213. Axillary temperature is usually 1° F lower than oral temperature.

214. After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions.

215. On a drug prescription, the abbreviation p.c. means that the drug should be administered after meals.

216. After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment.

217. After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment.

218. Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works.

219. Gauge is the inside diameter of a needle: the smaller the gauge, the larger the diameter.

220. An adult normally has 32 permanent teeth.