Fundamentals of Nursing Bullets

BULLETS 1.

(R) Remove the patient.

When preparing a single injection for a

position.

(A) Activate the alarm.

10. The nurse can elicit Trousseau’s sign by

(C) Attempt to contain the fire by closing

protein Hagedorn insulin, the nurse should

occluding the brachial or radial artery.

the door.

draw the regular insulin into the syringe

Hand and finger spasms that occur during

(E) Extinguish the fire if it can be done

first so that it does not contaminate the

occlusion indicate Trousseau’s sign and

safely.

regular insulin.

suggest hypocalcemia.

Rhonchi are the rumbling sounds heard on

Gavage is forced feeding, usually through a

vocational nurse or licensed practical nurse

appropriate needle size is 16 to 20G.

to perform bedside care, such as suctioning

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

stomach through the mouth).

telegraphic means.

According to Maslow’s hierarchy of needs,

sex, activity, and comfort) have the highest priority. The safest and surest way to verify a

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

patient’s identity is to check the

consent for treatment must make an X in

identification band on his wrist.

the presence of two witnesses, such as a

In the therapeutic environment, the

nurse, priest, or physician.

patient’s safety is the primary concern.

19. A registered nurse should assign a licensed

11. For blood transfusion in an adult, the

gastric tube (a tube passed into the

physiologic needs (air, water, food, shelter,

7.

9.

18. In the event of fire, the acronym most often

Sengstaken-Blakemore tube in semi-Fowler

inspiration.

6.

longer.

reading.

pronounced during expiration than during

5.

drainage system indicates that the system

used is RACE.

lung auscultation. They are more

4.

requires a needle that’s 1″ (2.5 cm) or

The nurse should place a patient who has a

patient who takes regular and neutral

3.

Fluid oscillation in the tubing of a chest

is working properly.

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

2.

8.

17. The Z-track I.M. injection technique seals

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

the drug deep into the muscle, thereby

obtains assessment data through the

minimizing skin irritation and staining. It

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

objective and subjective data with the

40. To perform catheterization, the nurse

outcome criteria and, if needed, modifies

should place a woman in the dorsal

the nursing care plan.

recumbent position.

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

41. A positive Homan’s sign may indicate thrombophlebitis. 42. Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A

shouldn’t receive blood components

milliequivalent is the number of milligrams

donated by other people.

per 100 milliliters of a solution.

34. To test visual acuity, the nurse should ask

43. Metabolism occurs in two phases:

collects data to identify a patient’s actual

the patient to cover each eye separately

anabolism (the constructive phase) and

and potential health needs.

and to read the eye chart with glasses and

catabolism (the destructive phase).

28. Nursing diagnosis is the stage of the nursing process in which the nurse makes a

without, as appropriate.

44. The basal metabolic rate is the amount of

35. When providing oral care for an

energy needed to maintain essential body

clinical judgment about individual, family,

unconscious patient, to minimize the risk of

functions. It’s measured when the patient

or community responses to actual or

aspiration, the nurse should position the

is awake and resting, hasn’t eaten for 14 to

potential health problems or life processes.

patient on the side.

18 hours, and is in a comfortable, warm

29. Planning is the stage of the nursing process

36. During assessment of distance vision, the

in which the nurse assigns priorities to

patient should stand 20′ (6.1 m) from the

nursing diagnoses, defines short-term and

chart.

long-term goals and expected outcomes, and establishes the nursing care plan. 30. Implementation is the stage of the nursing

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

37. For a geriatric patient or one who is extremely ill, the idealROOM

temperature

is 66° to 76° F (18.8° to 24.4° C).

46. Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains

process in which the nurse puts the nursing

38. NormalROOM

care plan into action, delegates specific

39. Hand washing is the single best method of

nursing interventions to members of the

limiting the spread of microorganisms.

47. Alcohol is metabolized primarily in the liver.

nursing team, and charts patient responses

Once gloves are removed after routine

Smaller amounts are metabolized by the

to nursing interventions.

contact with a patient, hands should be

kidneys and lungs.

31. Evaluation is the stage of the nursing process in which the nurse compares

humidity is 30% to 60%.

body weight.

washed for 10 to 15 seconds.

intestinal motility, and helps to establish regular bowel habits.

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

58. Potassium (K+) is the most abundant cation in intracellular fluid. 59. In the four-point, or alternating, gait, the

hemorrhoids or has recently undergone rectal surgery. 66. In a patient who has a cardiac disorder,

patient first moves the right crutch

measuring temperature rectally may

followed by the left foot and then the left

stimulate a vagal response and lead to

crutch followed by the right foot.

vasodilation and decreased cardiac output.

60. In the three-point gait, the patient moves

67. When recording pulse amplitude and

recap needles after use. Most needle sticks

two crutches and the affected leg

rhythm, the nurse should use these

result from missed needle recapping.

simultaneously and then moves the

descriptive measures: +3, bounding pulse

unaffected leg.

(readily palpable and forceful); +2, normal

51. The nurse administers a drug by I.V. push by using a needle and syringe to deliver

61. In the two-point gait, the patient moves the

pulse (easily palpable); +1, thready or

the dose directly into a vein, I.V. tubing, or

right leg and the left crutch simultaneously

weak pulse (difficult to detect); and 0,

a catheter.

and then moves the left leg and the right

absent pulse (not detectable).

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.

crutch simultaneously. 62. The vitamin B complex, the water-soluble

68. The intraoperative period begins when a patient is transferred to the operating

vitamins that are essential for metabolism,

room bed and ends when the patient is

include thiamine (B1), riboflavin (B2),

admitted to the post-anesthesia care unit.

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

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

orally, the nurse should ensure that the

antimicrobial soap, has had mouth care

patient hasn’t smoked or consumed hot or

(without swallowing the water), has

to ask, “What made you seek medical

cold substances in the previous 15

removed common jewelry, and has

help?”

minutes.

received preoperative medication as

56. A good way to begin a patient interview is

57. When caring for any patient, the nurse

65. The nurse shouldn’t take an adult’s

prescribed; and that vital signs have been

should follow standard precautions for

temperature rectally if the patient has a

taken and recorded. Artificial limbs and

handling blood and body fluids.

cardiac disorder, anal lesions, or bleeding

other prostheses are usually removed.

70. Comfort measures, such as positioning the

77. The diaphragm of the stethoscope is used

86. To move a patient to the edge of the bed

patient, rubbing the patient’s back, and

to hear high-pitched sounds, such as

for transfer, the nurse should follow these

providing a restful environment, may

breath sounds.

steps: Move the patient’s head and

decrease the patient’s need for analgesics or may enhance their effectiveness. 71. A drug has three names: generic name,

78. A slight difference in blood pressure (5 to

shoulders toward the edge of the bed.

10 mm Hg) between the right and the left

Move the patient’s feet and legs to the

arms is normal.

edge of the bed (crescent position). Place

which is used in official publications; trade,

79. The nurse should place the blood pressure

or brand, name (such as Tylenol), which is

cuff 1″ (2.5 cm) above the antecubital

and straighten the back while moving the

selected by the drug company; and

fossa.

patient toward the edge of the bed.

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.

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 lowered. 83. Ptosis is drooping of the eyelid. 84. A tilt table is useful for a patient with a

both arms well under the patient’s hips,

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

spinal cord injury, orthostatic hypotension,

nurse should follow these steps: Clean, but

or brain damage because it can move the

don’t rub, the site with alcohol. Stretch the

consciousness are alertness, lethargy,

patient gradually from a horizontal to a

skin taut or pick up a well-defined skin fold.

stupor, light coma, and deep coma.

vertical (upright) position.

Hold the shaft of the needle in a dart

75. In descending order, the levels of

76. To turn a patient by logrolling, the nurse

85. To perform venipuncture with the least

position. Insert the needle into the skin at a

folds the patient’s arms across the chest;

injury to the vessel, the nurse should turn

right (90-degree) angle. Firmly depress the

extends the patient’s legs and inserts a

the bevel upward when the vessel’s lumen

plunger, but don’t aspirate. Leave the

pillow between them, if needed; places a

is larger than the needle and turn it

needle in place for 10 seconds. Withdraw

draw sheet under the patient; and turns

downward when the lumen is only slightly

the needle gently at the angle of insertion.

the patient by slowly and gently pulling on

larger than the needle.

Apply pressure to the injection site with an

the draw sheet.

alcohol pad.

91. For a sigmoidoscopy, the nurse should

98. When assessing a patient for bladder

108. If a patient is menstruating when a urine

place the patient in the knee-chest position

distention, the nurse should check the

sample is collected, the nurse should

or Sims’ position, depending on the

contour of the lower abdomen for a

note this on the laboratory request.

physician’s preference.

rounded mass above the symphysis pubis.

92. Maslow’s hierarchy of needs must be met

99. The best way to prevent pressure ulcers is

in the following order: physiologic (oxygen,

to reposition the bedridden patient at least

food, water, sex, rest, and comfort), safety

every 2 hours.

and security, love and belonging, self-

100. Antiembolism stockings decompress the

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

esteem and recognition, and self-

superficial blood vessels, reducing the

aerosol treatment can be used to help to

actualization.

risk of thrombus formation.

obtain a sample.

93. When caring for a patient who has a

101. In adults, the most convenient veins for

111. If eye ointment and eye drops must be

nasogastric tube, the nurse should apply a

venipuncture are the basilic and median

instilled in the same eye, the eye drops

water-soluble lubricant to the nostril to

cubital veins in the antecubital space.

should be instilled first.

prevent soreness. 94. During gastric lavage, a nasogastric tube is

102. Two to three hours before beginning a

112. When leaving an isolation room, the

tube feeding, the nurse should aspirate

nurse should remove her gloves before

inserted, the stomach is flushed, and

the patient’s stomach contents to verify

her mask because fewer pathogens are

ingested substances are removed through

that gastric emptying is adequate.

on the mask.

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

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

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

the sole of the patient’s foot with a

sound intensity exceeds 84 dB. Double

pain, hypothermia, venous spasm, and

moderately sharp object, such as a

hearing protection is required if it

venous constriction.

thumbnail.

exceeds 104 dB.

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

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

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

116. When caring for a comatose patient, the

125. A patient’s bed bath should proceed in

134. Wheezing is an abnormal, high-pitched

nurse should explain each action to the

this order: face, neck, arms, hands,

breath sound that’s accentuated on

patient in a normal voice.

chest, abdomen, back, legs, perineum.

expiration.

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

126. To prevent injury when lifting and

135. Wax or a foreign body in the ear should

moving a patient, the nurse should

be flushed out gently by irrigation with

primarily use the upper leg muscles.

warm saline solution.

127. Patient preparation for

136. If a patient complains that his hearing

cholecystography includes ingestion of a

aid is “not working,” the nurse should

contrast medium and a low-fat evening

check the switch first to see if it’s turned

meal.

on and then check the batteries.

128. While an occupied bed is being

137. The nurse should grade hyperactive

laboratory without delay and without

changed, the patient should be covered

biceps and triceps reflexes as +4.

refrigeration.

with a bath blanket to promote warmth

138. If two eye medications are prescribed

121. The autonomic nervous system regulates the cardiovascular and respiratory systems. 122. When providing tracheostomy care, the nurse should insert the catheter gently

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

for twice-daily instillation, they should be administered 5 minutesAPART . 139. In a postoperative patient, forcing fluids helps prevent constipation. 140. A nurse must provide care in

into the tracheostomy tube. When

the feces: beets (red), cocoa (dark red or

accordance with standards of care

withdrawing the catheter, the nurse

brown), licorice (black), spinach (green),

established by the American Nurses

should apply intermittent suction for no

and meat protein (dark brown).

Association, state regulations, and facility

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

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

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,

irritate the rectal mucosa and cause loss

peripheral lung fields are abnormal and

they undergo ingestion, digestion,

of sphincter control.

suggest pneumonia.

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

nitroglycerin should be used to relieve acute anginal attacks. 151. The implementation phase of the

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

the percentage of alcohol multiplied by 2.

nursing process involves recording the

For example, a 100-proof beverage

patient’s response to the nursing plan,

weight of her body instead of the

contains 50% alcohol.

putting the nursing plan into action,

strength in her arms.

145. A living will is a witnessed document that states a patient’s desire for certain types of care and treatment. These

delegating specific nursing interventions, and coordinating the patient’s activities. 152. The Patient’s Bill of Rights offers

158. When lifting a patient, a nurse uses the

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

decisions are based on the patient’s

patients guidance and protection by

questions about informed consent to the

wishes and views on quality of life.

stating the responsibilities of the hospital

physician.

146. The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as

and its staff toward patients and their families during hospitalization. 153. To minimize omission and distortion of

needed with normal saline solution to

facts, the nurse should record

maintain patency.

information as soon as it’s gathered.

147. Quality assurance is a method of

154. When assessing a patient’s health

determining whether nursing actions and

history, the nurse should record the

practices meet established standards.

current illness chronologically, beginning

148. The five rights of medication administration are the right patient, right

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

with the onset of the problem and

take a patient’s pulse rate because the

continuing to the present.

thumb has a pulse that may be confused

drug, right dose, right route of

155. When assessing a patient’s health

administration, and right time.

history, the nurse should record the

149. The evaluation phase of the nursing

160. When obtaining a health history from an

current illness chronologically, beginning

with the patient’s pulse. 163. An inspiration and an expiration count as one respiration.

process is to determine whether nursing

with the onset of the problem and

164. Eupnea is normal respiration.

interventions have enabled the patient to

continuing to the present.

165. During blood pressure measurement,

meet the desired goals. 150. Outside of the hospital setting, only the sublingual and translingual forms of

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

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

174. Normal gait has two phases: the stance

182. A correctly written patient goal

coronary artery disease include heredity,

phase, in which the patient’s foot rests

expresses the desired patient behavior,

sex, race, and age.

on the ground, and the swing phase, in

criteria for measurement, time frame for

which the patient’s foot moves forward.

achievement, and conditions under which

167. Inspection is the most frequently used assessment technique. 168. Family members of an elderly person in a long-term care facility should transfer

175. The phases of mitosis are prophase, metaphase, anaphase, and telophase. 176. The nurse should follow standard

the behavior will occur. It’s developed in collaboration with the patient. 183. Percussion causes five basic notes:

some personal items (such as

precautions in the routine care of all

tympany (loud intensity, as heard over a

photographs, a favorite chair, and

patients.

gastric air bubble or puffed out cheek),

knickknacks) to the person’s room to provide a comfortable atmosphere. 169. Pulsus alternans is a regular pulse rhythm with alternating weak and strong

177. The nurse should use the bell of the

hyperresonance (very loud, as heard over

stethoscope to listen for venous hums

an emphysematous lung), resonance

and cardiac murmurs.

(loud, as heard over a normal lung),

178. The nurse can assess a patient’s

dullness (medium intensity, as heard

beats. It occurs in ventricular

general knowledge by asking questions

over the liver or other solid organ), and

enlargement because the stroke volume

such as “Who is the president of the

flatness (soft, as heard over the thigh).

varies with each heartbeat.

United States?”

170. The upper respiratory tract warms and

184. The optic disk is yellowish pink and

179. Cold packs are applied for the first 20 to

circular, with a distinct border.

humidifies inspired air and plays a role in

48 hours after an injury; then heat is

185. A primary disability is caused by a

taste, smell, and mastication.

applied. During cold application, the pack

pathologic process. A secondary

is applied for 20 minutes and then

disability is caused by inactivity.

171. Signs of accessory muscle use include shoulder elevation, intercostal muscle

removed for 10 to 15 minutes to prevent

retraction, and scalene and

reflex dilation (rebound phenomenon)

failing to keep an accurate count of

sternocleidomastoid muscle use during

and frostbite injury.

sponges and other devices during

respiration. 172. When patients use axillary crutches,

180. The pons is located above the medulla and consists of white matter (sensory

186. Nurses are commonly held liable for

surgery. 187. The best dietary sources of vitamin B6

their palms should bear the brunt of the

and motor tracts) and gray matter (reflex

are liver, kidney, pork, soybeans, corn,

weight.

centers).

and whole-grain cereals.

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

181. The autonomic nervous system controls the smooth muscles.

188. Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, green leafy

vegetables, eggs, and whole grains,

attempt to obliterate documentation or

recovery. In addition, he should have an

commonly have a low water content.

leave vacant lines.

opportunity to ask questions.

189. Collaboration is joint communication

196. Factors that affect body temperature

and decision making between nurses and

include time of day, age, physical

physicians. It’s designed to meet

activity, phase of menstrual cycle, and

patients’ needs by integrating the care

pregnancy.

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

197. The most accessible and commonly

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.

used artery for measuring a patient’s

This procedure is done to determine the

pulse rate is the radial artery. To take the

size, shape, position, and density of

pulse rate, the artery is compressed

underlying organs and tissues; elicit

against the radius.

tenderness; or assess reflexes.

198. In a resting adult, the normal pulse rate

204. Ballottement is a form of light palpation

problem that can be resolved,

is 60 to 100 beats/minute. The rate is

involving gentle, repetitive bouncing of

diminished, or otherwise changed by

slightly faster in women than in men and

tissues against the hand and feeling their

nursing interventions.

much faster in children than in adults.

rebound.

192. During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health

199. Laboratory test results are an objective form of assessment data. 200. The measurement systems most

205. A foot cradle keeps bed linen off the patient’s feet to prevent skin irritation and breakdown, especially in a patient

history, physical examination, and

commonly used in clinical practice are

who has peripheral vascular disease or

laboratory and diagnostic test data.

the metric system, apothecaries’ system,

neuropathy.

193. The patient’s health history consists primarily of subjective data, information that’s supplied by the patient. 194. The physical examination includes

and household system. 201. Before signing an informed consent

206. Gastric lavage is flushing of the stomach and removal of ingested substances

form, the patient should know whether

through a nasogastric tube. It’s used to

other treatment options are available and

treat poisoning or drug overdose.

objective data obtained by inspection,

should understand what will occur during

palpation, percussion, and auscultation.

the preoperative, intraoperative, and

nursing process, the nurse assesses the

postoperative phases; the risks involved;

patient’s response to therapy.

195. When documenting patient care, the nurse should write legibly, use only

and the possible complications. The

standard abbreviations, and sign each

patient should also have a general idea

entry. The nurse should never destroy or

of the time required from surgery to

207. During the evaluation step of the

208. Bruits commonly indicate life- or limbthreatening 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

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.

should use a 5/8″ 25G needle. 8. The notation “AA & O × 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows

solution to clean an artificial eye.

where he is), and time (knows the date and

212. A thready pulse is very fine and scarcely

time).

BULLETS II

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

7. For a subcutaneous injection, the nurse

9. Fluid intake includes all fluids taken by mouth, including foods that are liquid at

1. After turning a patient, the nurse should

room temperature, such as gelatin, custard,

214. After suctioning a tracheostomy tube,

document the position used, the time that

and ice cream; I.V. fluids; and fluids

the nurse must document the color,

the patient was turned, and the findings of

administered in feeding tubes. Fluid output

amount, consistency, and odor of

skin assessment.

includes urine, vomitus, and drainage (such

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

2. PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round,

as well as blood loss, diarrhea or feces, and

and reactive to light with accommodation.

perspiration.

3. When percussing a patient’s chest for

injection, the nurse shouldn’t massage the

be cupped.

area because massage can irritate the site

4. When measuring a patient’s pulse, the nurse should assess its rate, rhythm, quality, and strength. 5. Before transferring a patient from a bed to a wheelchair, the nurse should push the

sediment.

wheelchair footrests to the sides and lock its

determination vary from state to state.

10. After administering an intradermal

postural drainage, the nurse’s hands should

of the urine and the presence of clots or

218. Laws regarding patient self-

as from a nasogastric tube or from a wound)

wheels. 6. When assessing respirations, the nurse

and interfere with results. 11. When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle), with the bevel up. 12. To obtain an accurate blood pressure, the nurse should inflate the manometer to 20 to 30 mm Hg above the disappearance of the

Therefore, the nurse must be familiar

should document their rate, rhythm, depth,

radial pulse before releasing the cuff

with the laws of the state in which she

and quality.

pressure.

works.

13. The nurse should count an irregular pulse for 1 full minute.

22. States have enacted Good Samaritan laws

29. To minimize interruptions during a patient

to encourage professionals to provide

interview, the nurse should select a private

medical assistance at the scene of an

room, preferably one with a door that can

should be placed in a lateral position to

accident without fear of a lawsuit arising

be closed.

prevent aspiration of vomitus.

from the assistance. These laws don’t apply

14. A patient who is vomiting while lying down

15. Prophylaxis is disease prevention. 16. Body alignment is achieved when body

to care provided in a health care facility. 23. A physician should sign verbal and

parts are in proper relation to their natural

telephone orders within the time established

position.

by facility policy, usually 24 hours.

17. Trust is the foundation of a nurse-patient relationship. 18. Blood pressure is the force exerted by the circulating volume of blood on the arterial walls. 19. Malpractice is a professional’s wrongful conduct, improper discharge of duties, or failure to meet standards of care that causes harm to another. 20. As a general rule, nurses can’t refuse a patient care assignment; however, in most states, they may refuse to participate in abortions.

24. A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of his refusal. 25. Although a patient’s health record, or chart, is the health care facility’s physical property, its contents belong to the patient. 26. Before a patient’s health record can be released to a third party, the patient or the patient’s legal guardian must give written consent. 27. Under the Controlled Substances Act, every

30. In categorizing nursing diagnoses, the nurse addresses life-threatening problems first, followed by potentially life-threatening concerns. 31. The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions. 32. Standing orders, or protocols, establish guidelines for treating a specific disease or set of symptoms. 33. In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostal space, near the apex. 34. The S1 heard on auscultation is caused by closure of the mitral and tricuspid valves. 35. To maintain package sterility, the nurse should open a wrapper’s top flap away from

dose of a controlled drug that’s dispensed

the body, open each side flap by touching

by the pharmacy must be accounted for,

only the outer part of the wrapper, and open

is injured because the nurse failed to

whether the dose was administered to a

the final flap by grasping the turned-down

perform a duty that a reasonable and

patient or discarded accidentally.

corner and pulling it toward the body.

21. A nurse can be found negligent if a patient

prudent person would perform or because

28. A nurse can’t perform duties that violate a

36. The nurse shouldn’t dry a patient’s ear

the nurse performed an act that a

rule or regulation established by a state

canal or remove wax with a cotton-tipped

reasonable and prudent person wouldn’t

licensing board, even if they are authorized

applicator because it may force cerumen

perform.

by a health care facility or physician.

against the tympanic membrane.

37. A patient’s identification bracelet should

44. Activities of daily living are actions that the

54. The hypothalamus secretes vasopressin

remain in place until the patient has been

patient must perform every day to provide

and oxytocin, which are stored in the

discharged from the health care facility and

self-care and to interact with society.

pituitary gland.

has left the premises. 38. The Controlled Substances Act designated

45. Testing of the six cardinal fields of gaze

55. The three membranes that enclose the

evaluates the function of all extraocular

brain and spinal cord are the dura mater,

five categories, or schedules, that classify

muscles and cranial nerves III, IV, and VI.

pia mater, and arachnoid.

controlled drugs according to their abuse

46. The six types of heart murmurs are graded

56. A nasogastric tube is used to remove fluid

potential.

from 1 to 6. A grade 6 heart murmur can be

and gas from the small intestine

39. Schedule I drugs, such as heroin, have a

heard with the stethoscope slightly raised

preoperatively or postoperatively.

high abuse potential and have no currently

from the chest.

accepted medical use in the United States. 40. Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a

47. The most important goal to include in a care plan is the patient’s goal. 48. Fruits are high in fiber and low in protein,

high abuse potential, but currently have

and should be omitted from a low-residue

accepted medical uses. Their use may lead

diet.

to physical or psychological dependence. 41. Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse

49. The nurse should use an objective scale to

57. Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for drugs. 58. The area around a stoma is cleaned with mild soap and water. 59. Vegetables have a high fiber content. 60. The nurse should use a tuberculin syringe

assess and quantify pain. Postoperative pain

to administer a subcutaneous injection of

varies greatly among individuals.

less than 1 ml.

50. Postmortem care includes cleaning and

61. For adults, subcutaneous injections require

of Schedule III drugs may lead to moderate

preparing the deceased patient for family

a 25G 1″ needle; for infants, children,

or low physical or psychological

viewing, arranging transportation to the

elderly, or very thin patients, they require a

dependence, or both.

morgue or funeral home, and determining

25G to 27G ½” needle.

42. Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. 43. Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances.

the disposition of belongings. 51. The nurse should provide honest answers to the patient’s questions. 52. Milk shouldn’t be included in a clear liquid diet. 53. When caring for an infant, a child, or a

62. Before administering a drug, the nurse should identify the patient by checking the identification band and asking the patient to state his name. 63. To clean the skin before an injection, the nurse uses a sterile alcohol swab to wipe

confused patient, consistency in nursing

from the center of the site outward in a

personnel is paramount.

circular motion.

64. The nurse should inject heparin deep into

71. The hearing aid that’s marked with a blue

80. The nurse should administer procaine

subcutaneous tissue at a 90-degree angle

dot is for the left ear; the one with a red dot

penicillin by deep I.M. injection in the upper

(perpendicular to the skin) to prevent skin

is for the right ear.

outer portion of the buttocks in the adult or

irritation. 65. If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure. 66. The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative. 67. If bleeding occurs after an injection, the

72. A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water. 73. The nurse should instruct the patient to avoid using hair spray while wearing a hearing aid. 74. The five branches of pharmacology are

in the midlateral thigh in the child. The nurse shouldn’t massage the injection site. 81. An ascending colostomy drains fluid feces. A descending colostomy drains solid fecal matter. 82. A folded towel (scrotal bridge) can provide scrotal support for the patient with scrotal

pharmacokinetics, pharmacodynamics,

edema caused by vasectomy, epididymitis,

pharmacotherapeutics, toxicology, and

or orchitis.

nurse should apply pressure until the

pharmacognosy.

bleeding stops. If bruising occurs, the nurse

75. The nurse should remove heel

has a bleeding disorder, the nurse should

should monitor the site for an enlarging

protectors every 8 hours to inspect the foot

use a small-gauge needle and apply

hematoma.

for signs of skin breakdown.

pressure to the site for 5 minutes after the

68. When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. 69. The frequency of patient hair care depends on the length and texture of the hair, the duration of hospitalization, and the patient’s condition.

76. Heat is applied to promote vasodilation, which reduces pain caused by inflammation. 77. A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). 78. Healing by secondary intention (healing by

83. When giving an injection to a patient who

injection. 84. Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation. 85. To insert a nasogastric tube, the nurse instructs the patient to tilt the head back

granulation) is closure of the wound when

slightly and then inserts the tube. When the

granulation tissue fills the defect and allows

nurse feels the tube curving at the pharynx,

careful handling during insertion and

reepithelialization to occur, beginning at the

the nurse should tell the patient to tilt the

removal, regular cleaning of the ear piece to

wound edges and continuing to the center,

head forward to close the trachea and open

prevent wax buildup, and prompt

until the entire wound is covered.

the esophagus by swallowing. (Sips of water

replacement of dead batteries.

79. Keloid formation is an abnormality in

can facilitate this action.)

70. Proper function of a hearing aid requires

healing that’s characterized by overgrowth of scar tissue at the wound site.

86. Families with loved ones in intensive care units report that their four most important

needs are to have their questions answered

92. Fidelity means loyalty and can be shown as

101. The two nursing diagnoses that have the

honestly, to be assured that the best

a commitment to the profession of nursing

highest priority that the nurse can assign

possible care is being provided, to know the

and to the patient.

are Ineffective airway clearance and

patient’s prognosis, and to feel that there is hope of recovery. 87. Double-bind communication occurs when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to. 88. A nonjudgmental attitude displayed by a

93. Administering an I.M. injection against the patient’s will and without legal authority is battery. 94. An example of a third-party payer is an insurance company. 95. The formula for calculating the drops per minute for an I.V. infusion is as follows:

nurse shows that she neither approves nor

(volume to be infused × drip factor) ÷ time

disapproves of the patient.

in minutes = drops/minute

89. Target symptoms are those that the patient finds most distressing. 90. A patient should be advised to take aspirin

96. On-call medication should be given within 5 minutes of the call. 97. Usually, the best method to determine a

on an empty stomach, with a full glass of

patient’s cultural or spiritual needs is to ask

water, and should avoid acidic foods such as

him.

coffee, citrus fruits, and cola. 91. For every patient problem, there is a

98. An incident report or unusual occurrence report isn’t part of a patient’s record, but is

nursing diagnosis; for every nursing

an in-house document that’s used for the

diagnosis, there is a goal; and for every

purpose of correcting the problem.

goal, there are interventions designed to make the goal a reality. The keys to

99. Critical pathways are a multidisciplinary guideline for patient care.

answering examination questions correctly are identifying the problem presented,

Ineffective breathing pattern. 102. A subjective sign that a sitz bath has been effective is the patient’s expression of decreased pain or discomfort. 103. For the nursing diagnosis Deficient diversional activity to be valid, the patient must state that he’s “bored,” that he has “nothing to do,” or words to that effect. 104. The most appropriate nursing diagnosis for an individual who doesn’t speak English is Impaired verbal communication related to inability to speak dominant language (English). 105. The family of a patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him.

100. When prioritizing nursing diagnoses, the

formulating a goal for the problem, and

following hierarchy should be used:

selecting the intervention from the choices

Problems associated with the airway,

a patient who is up to age 3, the nurse

provided that will enable the patient to

those concerning breathing, and those

should pull the pinna down and back to

reach that goal.

related to circulation.

straighten the eustachian tube.

106. Before instilling medication into the ear of

107. To prevent injury to the cornea when

114. When feeding an elderly patient, the

121. A “shift to the right” is evident when the

administering eyedrops, the nurse should

nurse should limit high-carbohydrate

number of mature cells in the blood

waste the first drop and instill the drug in

foods because of the risk of glucose

increases, as seen in advanced liver

the lower conjunctival sac.

intolerance.

disease and pernicious anemia.

108. After administering eye ointment, the nurse should twist the medication tube to

115. When feeding an elderly patient, essential foods should be given first.

detach the ointment.

mask, she should remove the gloves first.

mobility. Resistive exercises increase

signed and attached to the patient’s record.

muscle mass.

They are soiled and are likely to contain pathogens.

medication, the nurse should ensure that an informed consent form has been

116. Passive range of motion maintains joint 109. When the nurse removes gloves and a

122. Before administering preoperative

123. A nurse should spend no more than 30 117. Isometric exercises are performed on an extremity that’s in a cast.

minutes per 8-hour shift providing care to a patient who has a radiation implant.

110. Crutches should be placed 6″ (15.2 cm) in front of the patient and 6″ to the side to form a tripod arrangement. 111. Listening is the most effective communication technique. 112. Before teaching any procedure to a

118. A back rub is an example of the gatecontrol theory of pain. 119. Anything that’s located below the waist is considered unsterile; a sterile field

124. A nurse shouldn’t be assigned to care for more than one patient who has a radiation implant. 125. Long-handled forceps and a lead-lined

becomes unsterile when it comes in

container should be available in the room

contact with any unsterile item; a sterile

of a patient who has a radiation implant.

patient, the nurse must assess the

field must be monitored continuously;

patient’s current knowledge and

and a border of 1″ (2.5 cm) around a

willingness to learn.

sterile field is considered unsterile.

126. Usually, patients who have the same infection and are in strict isolation can share a room.

113. Process recording is a method of

120. A “shift to the left” is evident when the

evaluating one’s communication

number of immature cells (bands) in the

effectiveness.

blood increases to fight an infection.

127. Diseases that require strict isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease.

128. For the patient who abides by Jewish custom, milk and meat shouldn’t be

incapacitating disease is to help him to

and other Hispanic and Latino groups,

mobilize a support system.

most foods, beverages, herbs, and drugs

served at the same meal.

are described as “cold.” 133. Hyperpyrexia is extreme elevation in

129. Whether the patient can perform a

temperature above 106° F (41.1° C).

procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps involved in the procedure (cognitive domain of learning). 130. According to Erik Erikson, developmental stages are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to age 3), initiative versus guilt (ages 3 to 5), industry versus inferiority (ages 5 to 12), identity versus identity diffusion (ages 12 to 18),

individuals of a particular group. 134. Milk is high in sodium and low in iron. 142. Discrimination is preferential treatment of 135. When a patient expresses concern about a health-related issue, before addressing

to 60), and ego integrity versus despair

patient’s level of knowledge.

usually discussed in a negative sense. 143. Increased gastric motility interferes with the absorption of oral drugs.

136. The most effective way to reduce a fever is to administer an antipyretic, which lowers the temperature set point.

144. The three phases of the therapeutic relationship are orientation, working, and termination.

137. When a patient is ill, it’s essential for the members of his family to maintain communication about his health needs.

145. Patients often exhibit resistive and challenging behaviors in the orientation phase of the therapeutic relationship.

138. Ethnocentrism is the universal belief that one’s way of life is superior to others.

(older than age 60).

146. Abdominal assessment is performed in the following order: inspection, auscultation,

139. When a nurse is communicating with a 131. When communicating with a hearing

individuals of a particular group. It’s

the concern, the nurse should assess the

intimacy versus isolation (ages 18 to 25), generativity versus stagnation (ages 25

141. Prejudice is a hostile attitude toward

percussion & palpation.

patient through an interpreter, the nurse

impaired patient, the nurse should face

should speak to the patient and the

him.

interpreter.

147. When measuring blood pressure in a neonate, the nurse should select a cuff that’s no less than one-half and no more

132. An appropriate nursing intervention for the spouse of a patient who has a serious

140. In accordance with the “hot-cold” system used by some Mexicans, Puerto Ricans,

than two-thirds the length of the extremity that’s used.

148. When administering a drug by Z-track, the

pain is cardiac. It would be more

hypoventilation and abnormal breathing

nurse shouldn’t use the same needle that

appropriate to make further

patterns, such as Korsakoff’s, Biot’s, or

was used to draw the drug into the

assessments.

Cheyne-Stokes respiration.

syringe because doing so could stain the skin. 149. Sites for intradermal injection include the inner arm, the upper chest, and on the

152. Veracity is truth and is an essential

158. C = Circulation. This category includes

component of a therapeutic relationship

everything that affects the circulation,

between a health care provider and his

including fluid and electrolyte

patient.

disturbances and disease processes that

back, under the scapula.

affect cardiac output. 153. Beneficence is the duty to do no harm and

150. When evaluating whether an answer on

the duty to do good. There’s an

159. D = Disease processes. If the patient has

an examination is correct, the nurse

obligation in patient care to do no harm

no problem with the airway, breathing, or

should consider whether the action that’s

and an equal obligation to assist the

circulation, then the nurse should

described promotes autonomy

patient.

evaluate the disease processes, giving

(independence), safety, self-esteem, and a sense of belonging. 151. When answering a question on the NCLEX

priority to the disease process that poses 154. Nonmaleficence is the duty to do no harm. 155. Frye’s ABCDE cascade provides a

examination, the student should consider

framework for prioritizing care by

the cue (the stimulus for a thought) and

identifying the most important treatment

the inference (the thought) to determine

concerns.

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

156. A = Airway. This category includes everything that affects a patent airway, including a foreign object, fluid from an upper respiratory infection, and edema from trauma or an allergic reaction. 157. B = Breathing. This category includes everything that affects the breathing pattern, including hyperventilation or

the greatest immediate risk. For example, if a patient has terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern. 160. E = Everything else. This category includes such issues as writing an incident report and completing the patient chart. When evaluating needs, this category is never the highest priority. 161. When answering a question on an NCLEX examination, the basic rule is “assess before action.” The student should evaluate each possible answer carefully.

Usually, several answers reflect the

effective.

implementation phase of nursing and one

169. A value cohort is a group of people

or two reflect the assessment phase. In

who experienced an out-of-the-ordinary

this case, the best choice is an

event that shaped their values.

163. Egalitarian theory emphasizes that equal access to goods and services must be provided to the less fortunate by an affluent society. 164. Active euthanasia is actively helping a person to die. 165. Brain death is irreversible cessation of all brain function. 166. Passive euthanasia is stopping the therapy that’s sustaining life.

171. Bananas, citrus fruits, and potatoes are good sources of potassium. 172. Good sources of magnesium include fish,

control theory.

nuts, and grains. 188. Romberg’s test is a test for balance or 173. Beef, oysters, shrimp, scallops, spinach,

gait.

beets, and greens are good sources of iron.

189. Pain seems more intense at night because the patient isn’t distracted by daily

174. Intrathecal injection is administering a

activities.

drug through the spine. 190. Older patients commonly don’t report pain 175. When a patient asks a question or makes a statement that’s emotionally charged,

because of fear of treatment, lifestyle changes, or dependency.

the nurse should respond to the emotion

than to what’s being said or asked.

company. 183. A Hindu patient is likely to request a 168. Utilization review is performed to

187. Alleviating pain by performing a back massage is consistent with the gate

behind the statement or question rather 167. A third-party payer is an insurance

186. Referred pain is pain that’s felt at a site other than its origin.

162. Rule utilitarianism is known as the

of people” theory.

185. The difference between acute pain and

170. Voluntary euthanasia is actively helping a patient to die at the patient’s request.

“greatest good for the greatest number

initial point at which a patient feels pain.

chronic pain is its duration.

assessment response unless a specific course of action is clearly indicated.

184. Pain threshold, or pain sensation, is the

vegetarian diet.

191. No pork or pork products are allowed in a Muslim diet. 192. Two goals of Healthy People 2010 are: 193. Help individuals of all ages to

determine whether the care provided to a

increase the quality of life and the

patient was appropriate and cost-

number of years of optimal health

194. Eliminate health disparities among different segments of the population. 195. A community nurse is serving as a

202. On noticing religious artifacts and literature on a patient’s night stand, a

sample to measure glucose, ketone, pH,

culturally aware nurse would ask the

and specific gravity values.

patient the meaning of the items.

patient’s advocate if she tells a malnourished patient to go to a meal program at a local park.

212. To induce sleep, the first step is to 203. A Mexican patient may request the

the patient.

plan, the nurse should first ask why.

213. Before moving a patient, the nurse should assess the patient’s physical abilities and ability to understand instructions as well

204. In an infant, the normal hemoglobin value 197. Falls are the leading cause of injury in

minimize environmental stimuli.

intervention of a curandero, or faith healer, who involves the family in healing

196. If a patient isn’t following his treatment

211. First-morning urine provides the best

is 12 g/dl.

as the amount of strength required to move the patient.

elderly people. 205. The nitrogen balance estimates the 198. Primary prevention is true prevention. Examples are immunizations, weight

difference between the intake and use of

must decrease his weekly intake by

protein.

3,500 calories (approximately 500

control, and smoking cessation.

calories daily). To lose 2 lb (1 kg) in 1 206. Most of the absorption of water occurs in

199. Secondary prevention is early detection.

the large intestine.

Examples include purified protein derivative (PPD), breast self-examination, testicular self-examination, and chest X-

207. Most nutrients are absorbed in the small intestine.

ray. 208. When assessing a patient’s eating habits, 200. Tertiary prevention is treatment to prevent long-term complications. 201. A patient indicates that he’s coming to

the nurse should ask, “What have you eaten in the last 24 hours?” 210. A hypotonic enema softens the feces,

terms with having a chronic disease

distends the colon, and stimulates

when he says, “I’m never going to get

peristalsis.

any better.”

214. To lose 1 lb (0.5 kg) in 1 week, the patient

week, the patient must decrease his weekly caloric intake by 7,000 calories (approximately 1,000 calories daily). 215. To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet. 216. To insert a catheter from the nose through the trachea for suction, the nurse should ask the patient to swallow. 217. Vitamin C is needed for collagen production.

218. Only the patient can describe his pain accurately.

225. Exacerbations of chronic disease usually cause the patient to seek treatment and

232. Distributive justice is a principle that promotes equal treatment for all.

may lead to hospitalization. 219. Cutaneous stimulation creates the release of endorphins that block the transmission of pain stimuli.

233. Milk and milk products, poultry, grains, 226. School health programs provide costeffective health care for low-income families and those who have no health

220. Patient-controlled analgesia is a safe

insurance.

method to relieve acute pain caused by surgical incision, traumatic injury, labor and delivery, or cancer.

collaboration, development, and

profession. 228. A change agent is an individual who recognizes a need for change or is

222. The patient who believes in a scientific, or biomedical, approach to health is likely to

selected to make a change within an established entity, such as a hospital.

expect a drug, treatment, or surgery to cure illness.

229. The patients’ bill of rights was introduced by the American Hospital Association.

223. Chronic illnesses occur in very young as well as middle-aged and very old people.

230. Abandonment is premature termination of treatment without the patient’s

224. The trajectory framework for chronic illness states that preferences about

permission and without appropriate relief of symptoms.

daily life activities affect treatment decisions.

an oriented, but restless, elderly patient

227. Collegiality is the promotion of

typically places distance between himself and others when communicating.

234. The best way to prevent falls at night in

is to raise the side rails.

interdependence among members of a 221. An Asian American or European American

and fish are good sources of phosphate.

231. Values clarification is a process that individuals use to prioritize their personal values.

235. By the end of the orientation phase, the patient should begin to trust the nurse. 236. Falls in the elderly are likely to be caused by poor vision. 237. Barriers to communication include language deficits, sensory deficits, cognitive impairments, structural deficits, and paralysis. 238. The three elements that are necessary for a fire are heat, oxygen, and combustible material. 239. Sebaceous glands lubricate the skin. 240. To check for petechiae in a dark-skinned patient, the nurse should assess the oral mucosa.

241. To put on a sterile glove, the nurse should pick up the first glove at the folded

244. Seventh-Day Adventists are usually vegetarians.

border and adjust the fingers when both gloves are on.

245. Endorphins are morphine-like substances that produce a feeling of well-being.

242. To increase patient comfort, the nurse should let the alcohol dry before giving an intramuscular injection.

246. Pain tolerance is the maximum amount and duration of pain that an individual is willing to endure.

243. Treatment for a stage 1 ulcer on the heels includes heel protectors.