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NCLEX-RN #119 Question and Answer w/ Rationale #usrn🇺🇸 #nle #usrngoals #nclexstudying #nclexrn

NURSING REVIEW TIPS #NLE2023 #USRN #nursinglife #NCLEX #nursing #nursingstudent #NLE #studytips

20+ NCLEX Tips and Strategies Every Nursing Students Should Know

1. Never choose an answer that leaves the patient.

Always provide safety.

2. Don’t “do nothing.”

Because you always have to do something.

3. Don’t read into the question.

Never assume anything that has not been specifically mentioned and don’t add extra meaning to the question.

4. Don’t pass the buck.

Never choose an answer that passes work off to anyone else.

5. If you see an option you have never heard of, do not choose it.

It’s like a signal from your brain that that is not the correct answer.

6. When choosing which patient to see first, choose the patient who is the most unstable.

Patients who are most likely to perish, most critical, or will suffer further injury without immediate action should be prioritized first.

7. Always assume the NCLEX hospital has unlimited staff, equipment, and resources.

Know that health care facilities in the NCLEX are always ideal.

8. Restraints are always the last option and are almost always the wrong answer.

9. Choose the least invasive choice first.

Issues concerning airway, breathing, or circulation should be addressed first, then move to choose the least invasive procedures (e.g., change of position, therapeutic communication with the patient).

10. Never choose an answer that delays treatment.

These distractors do not coincide to safe and effective nursing care.

11. Assess the client first, before implementing treatment.

If there’s a choice that pertains to assessment of the patient, choose that answer.

12. Find a commonality between the choices if you encounter a question which you are unfamiliar with.

If two or more answers are alike, choose the option that is different.

13. If the question includes the words “severe” or “acute” when referring to something such as pain, choose the answer that fixes that specific problem.

14. If the question is about endorsement, always report anything new or different to the next shift.

15. In general, put clients with the same or similar diagnoses in the same room.

16. After comprehending the question, decide what is the problem then pick answer that you can do as a nurse to solve it.

17. Select an answer that is focused on the client.

18. Answer select all that apply (SATA) questions as a true or false.

Go down the list of choices one by one and ask yourself if the choice answers the question. For more tips about SATA questions, see: 12 Tips to Answer NCLEX Select All That Apply (SATA) Questions.

19. Rephrase the question.

Putting the question in your own words can pluck the necessary info to reveal the core of the stem.

20. Make educated guesses.

If you can’t make the best answer for a particular question, give it a guess. The board exams is not a “right minus wrong” type. It is important for you to answer every question even if you have to guess.

21. Extra meaning need not apply!

Test questions are made to be direct and to the point so you don’t need to read extra meaning to the question. The question asks for one particular response and you should not read or add other information into the question. Often you will find questions that require “common sense” answers and that reading into these questions may give you another interpretation. You should not search for subtle meaning about the questions or answers. Ask yourself “What is the question asking?” Look for keywords and phrases to help you understand. Interpret the question correctly first before reading into the choices.

22. Understand the question

Make sure you read the stem correctly and notice particularly the way the question is phrased. Is it asking for the best response or the initial response? Understand what the question is asking before considering the distracter.

23. Rephrase

Rephrasing technique requires you to interpret or translate the question into your own words so that it is very clear in your own mind. Rephrasing the stem of the question can assist your read the question correctly and in turn choose the appropriate response. Placing the question into your own words would help you in removing extraneous data and get into the core of the stem.

24. Isolate

When a**lyzing the distracter, isolate what is important in the answer alternatives from what is not important relative to the question. In a good test construction, all of the distracters should be feasible and reasonable and should apply directly to the stem. There should be a commonality in all of the distracter. Also, all of the distracters may be correct but not the right choice for the specific question that is being asked. The technique here is to ask yourself whether each possible alternative is true or false in relation to the stem.

25. Recheck

Many test-takers fail to recheck the answer with the stem, and they answer the question incorrectly. After choosing the correct answer alternative and separating it from the distracter, go back to the stem and make sure your choice does, in fact, answer the question. An effective strategy is to judge all four alternative choices/options against the stem and not against one another. Read the stem, then check option 1 against the stem, then check option 2 against the stem, and so on. This process will eliminate choosing an alternative that does not fit with the question.

26. Process of Elimination

When a question contains multiple variables as alternative choices, use the “elimination of variable” technique. Each question may pose different alternatives with several variables. Use the process of elimination. Study the question first and ask yourself what variable fits with this condition, or after examining the distracter underline the symptom that you know is correct. Now ask yourself what variable is not present with this condition. Again examine the distracter and cross out those variables that are incorrect. By this process, you’ve probably eliminated at least two distracters even without taking the time to consider the other two.

27. Go back to the basics

When you come across a difficult question and you cannot immediately identify the answer, go back to your body of knowledge, and draw all the information that you do know about the condition. Don’t start being anxious and especially don’t panic! If you are unfamiliar with the disease or disorder and cannot choose the right nursing action, try to generalize to other situations. For example, if the question asks about dog bites, and you’ve never learned the course of the disorder, go back to an area of knowledge that you do know, for example, circulation and body response to toxic substances. Even though you do not know exactly what to do, you might know what not to do. Eliminate distracters to increase your chances of arriving at the correct answer.

28. Educated guesses

The ability to guess correctly is both a skill and an art.

The board exams are not a “right minus wrong” type. It is important for you to answer every question even if you have to guess. Guessing gives you only a 25% chance of getting the correct answer. Try to eliminate at least one (or more) distracter as this will increase the percentage margin of chance for guessing correctly. Examine the distracter and if one is the exact opposite of another (e.g. complete bed rest is different from activity as tolerated; both cannot be correct since they are of opposites), choose the one that seems to be most logical. Try to identify the underlying principle that supports the question. If you can answer the question, you might then be able to guess the correct answer. This strategy is especially true with a psychosocial question. Look at the way the alternatives are presented. Are there two answers that are very close? Often when this occurs, the ability to discriminate will show evidence of judgment. Check to see if one, more than the other, is the best choice for the question. Are there any distracters that are presented not logical (which are correct in themselves but do not have anything to do with the question)? Eliminate these and focus on other alternatives.

Use your intuition. If you cannot choose an alternative from a logical point, allow yourself to feel which one might be right. Often your subconscious mind will choose correctly (based on all the conscious knowledge you have of course) so simply let yourself feel which alternative might be right. Remember, it’s better to choose one answer than none at all.

29. Choosing an answer from a hunch

There comes a time when you are faced with a certain question and you have a hunch that this particular choice is correct. Do we depend on this “hunch?”. Current studies support that hunches are often correct, for they are based on rapid subconscious connections in the brain. Your stored knowledge, recall, and experience can combine to assist you in arriving at the correct answer. So, if you have an initial hunch, go with it! Do not change the answer if and only if, upon reflection, it just doesn’t seem right. On the other hand, if later in the test you find relevant information or make a new connection of information and you feel that your answer was incorrect, do go back and change it.

30. Choosing the best answer from a strategy point-of-view.

Frequently, the most comprehensive answer is the best choice (Longest the best!). For example, if two alternatives seem reasonable but one answer includes the other (i.e., it is more detailed, more comprehensive) than this answer would be the best choice. If an answer focuses on medical knowledge, be wary, for this alternative might be just a good distractor. Remember, this is a nursing test, and questions are designed to test your nursing competency and safety. It is unlikely that a question would require a medical action for the correct answer; it may, however, offer these actions as distracters. Beware of answers that contain specific qualifiers, such as “always’ and “never,” they rarely fit within a logical framework.

31. Read Questions Carefully

Scores on tests are greatly affected by reading ability. In answering a test item, you should begin by carefully reading the stem and then asking yourself the following questions:

What is the question really asking?
Are there any keywords?
What information relevant to answering this question is included in the stem?
How would I ask this question in my own words?
How would I answer this question in my own words?
After you have answered these questions, carefully read the options, and then ask yourself the following questions:

Is there an option that is similar to my answer?
Is this option the best, most complete answer to the question?
Deal with the question as it is stated, without reading anything into it, or making assumptions about it. Answer the question asked, not the one you would like to answer. For simple recall items, the self-questioning process usually will be completed quickly. For more complex items the self-questioning process may take longer, but it should assist you in clarifying the item and selecting the best response.

32. Identify Keywords

Certain keywords in the stem, the options, or both should alert you to the need for caution in choosing your answer. Because few things are absolute without exception, avoid selecting answers that include words such as always, never, all, every, only, must, no, except, and none. Answers containing these keywords are rarely correct because they place special limitations and qualifications on potentially correct answers. For example:

All of the following are services of the National Kidney Foundation except:

1. Public education programs
2. Research about kidney disease
3. Fund-raising affairs for research activities
4. Identification of potential transplant recipients

This stem contains two keywords: all and except. They limit the correct answer choice to the one option that does not represent a service of the National Kidney Foundation. When except, not, or a phrase such as all but one of the following appears in the stem, the inappropriate option is the correct answer—in this instance, option 4.

If the options in an item do not seem to make sense because more than one option is correct, reread the question; you may have missed one of the keywords in the stem. Also, be on guard when you see one of the keywords in an option; it may limit the context in which such an option would be correct.

33. Pay Attention to Specific Details

The well-written multiple-choice question is precisely stated, providing you with only the information needed to make the question or problem clear and specific. A careful reading of details in the stem can provide important clues to the correct option. For example:

A male client is told that he will no longer be able to ingest alcohol if he wants to live. To effect a change in his behavior while he is in the hospital, the nurse should attempt to:

1. Help the client set short-term dietary goals
2. Discuss his hopes and dreams for the future
3. Discuss the pathophysiology of the liver with him
4. Withhold approval until he agrees to stop drinking

The specific clause to effect a change in his behavior while he is in the hospital is critical. Option 2 is not really related to his alcoholism. Option 3 may be part of educating the alcoholic, but you would not expect a behavioral change observable in the hospital to emerge from this discussion. Option 4 rejects the client as well as his behavior instead of only his behavior. Option 1, the correct answer, could result in an observable behavioral change while the client is hospitalized; for example, he could define ways to achieve short-term goals relating to diet and alcohol while in the hospital.

34. Eliminate Clearly Wrong or Incorrect Answers

Eliminate clearly incorrect, inappropriate, and unlikely answers to the question asked in the stem. By systematically eliminating distractors that are unlikely in the context of a given question, you increase the probability of selecting the correct answer. Eliminating. obvious distractors also allow you more time to focus on the options that appear to be potentially sound answers to the question. For example:

The four levels of cognitive ability are:

1. Assessing, a**lyzing, applying, evaluating
2. Knowledge, a**lysis, assessing, comprehension
3. Knowledge, comprehension, application, a**lysis
4. Medical-surgical nursing, obstetric nursing, psychiatric nursing

Option 1 contains both cognitive levels and nursing behaviors, thus eliminating it from consideration. Option 4 is clearly inappropriate since the choices are all clinical areas. Both options 2 and 3 contain levels of cognitive ability; however, option 2 includes assessing, which is a nursing behavior. Therefore option 3 is correct. By reducing the plausible options, you reduce the material to consider and increase the probability of selecting the correct option.

35. Identify Similar Options

When an item contains two or more options that are similar in meaning, the successful test taker knows that all are correct, in which case it is a poor question, or that none is correct, which is more likely to be the case. The correct option usually will either include all the similar options or exclude them entirely. For example:

When teaching newly diagnosed diabetic clients about their condition, it is important for the nurse to focus on:

1. Dietary modifications
2. Use of sugar substitutes
3. Their present understanding of diabetes
4. Use of diabetic nutritional exchange lists

Options 1, 2, and 4 deal only with the diabetic diet, involving no other aspect of diabetic teaching; it is impossible to select the most correct option because each represents equally plausible, though limited, answers to the question. Option 3 is the best choice because it is most complete and allows the other three options to be excluded. As another example:

A child’s intelligence is influenced by:

1. A variety of factors
2. Socioeconomic factors
3. Heredity and environment
4. Environment and experience

The most correct answer is option 1. It includes the material covered by the other options, eliminating the need for an impossible choice, since each of the other options is only partially correct.

36. Identify Answer (Option) Components

When an answer contains two or more parts, you can reduce the number of potentially correct answers by identifying one part as incorrect. For example:

After a cholecystectomy the postoperative diet is usually:

1. High fat, low calorie
2. High fat, low protein
3. Low fat, high calorie
4. Low fat, high protein

If you know, for instance, that the diet after cholecystectomy is usually low or moderate in fat, you can eliminate options 1 and 2 from consideration. If you know that the cholecystectomy client usually is overweight, you can eliminate option 3 from consideration. Therefore option 4 is correct.

37. Identify Specific Determiners

When the options of a test item contain words that are identical or similar to words in the stem, the alert test taker recognizes the similarities as clues about the likely answer to the question. The stem word that clues you to a similar word in the option or that limits potential options is known as a specific determiner. For example:

The government agency responsible for administering the nursing practice act in each state is the:

1. Board of regents
2. Board of nursing
3. State nurses’ association
4. State hospital association

Options 2 and 3 contain the closely related words nurse and nursing. The word nursing, used both in the stem and in option 2, is a clue to the correct answer.

38. Identify Words in the Options That Are Closely Associated With Words in the Stem

Be alert to words in the options that may be closely associated with but not identical to a word or words in the stem. For example:

When a person develops symptoms of physical illness for which psychogenic factors act as causative agents, the resulting illness is classified as:

1. Dissociative
2. Compensatory
3. Psychophysiologic
4. Reaction formation

Option 3 should strike you as a likely answer since it combines physical and psychologic factors, like those referred to in the stem.

39. Watch for Grammatical Inconsistencies

If one or more of the options are not grammatically consistent with the stem, the alert test taker usually can eliminate these distractors. The correct option must be consistent with the form of the question. If the question demands a response in the singular, plural options usually can be safely eliminated. When the stem is in the form of an incomplete sentence, each option should complete the sentence in a grammatically correct way. For example:

Communicating with a male client who is deaf will be facilitated by:

1. Use gestures
2. Speaking loudly
3. Find out if he has a hearing aid
4. Facing the client while speaking

Options 1 and 3 do not complete the sentence in a grammatically correct way and can therefore be eliminated. Option 2 would be of no assistance with a deaf client, so option 4 is the correct answer.

40. Be Alert to Relevant Information From Earlier Questions

Occasionally, remembering information from one question may provide you with a clue for answering a later question. For example:

A client has an intestinal tube inserted for treatment of intestinal obstruction. Intestinal suction can result in excessive loss of:

1. Protein enzymes
2. Energy carbohydrates
3. Water and electrolytes
4. Vitamins and minerals

If you determined that the correct answer to this question was option 3, it may help you to answer a later question. For example:

Critical assessment of a client with intestinal suction should include observation for:

1. Edema
2. Nausea
3. Belching
4. Dehydration

The correct answer is option 4. If you knew that excessive loss of water and electrolytes may lead to dehydration, you could have used the clue provided in the earlier question to assist you in answering the latter question.

41. Make Educated Guesses

When you are unsure about the correct answer to a question, it is better to make an educated guess than not to answer the question. You generally can eliminate one or more of the distractors by using partial knowledge and the methods just listed. The elimination process increases your chances of selecting the correct option from those remaining. Elimination of two distractors on a four-option multiple-choice item increases your probability of selecting the correct answer from 25% to 50%.

42. Beware of ‘Always’ and ‘Never’

Be cautious of the ‘always’ and ‘never’ questions. Very few times does the answer include these words. It implies that there is no room for exception.

43. Watch out for Negative Modifiers

An example would be “Which of these answers is NOT the best response?”

If you miss those keywords, you will likely miss the question. The correct answer could possibly be a negative response.

44. Focus on the Patient

The focus of care should always be on the patient. The opinions of coworkers or physicians are not as important.

45. Safety is a priority

Patient safety is always a top priority. The safety of the patient takes precedence over patient satisfaction. The correct answer is likely the answer that addresses patient safety.

46. FIRST actions

Look for the keyword ‘first.’ All answers may be correct, but the question is what the nurse’s FIRST action should be. Don’t skim past the seemingly meaningless word.

47. Assess Before Action

When in doubt, assess the patient before acting upon the problem. Rule of nursing-assess first!

48. Eliminate Obviously Wrong Answers

Oftentimes, there is at least one “duh” option. Eliminate those first. Then, you’re looking at a 33% chance of success.

49. Don’t Overlook Obviously Correct Answers

Sometimes, the correct answer is too easy. Consider it a freebie. The test makers are giving you a break.

50. Don’t Spend Too Much Time

Pace yourself. Don’t spend too much time on one question. If you absolutely DO NOT know the answer, give it your best guess and move on. You will have more time to answer the questions that you DO know.

51. Go with Your Gut

You are smart. You have all the knowledge that you need. DON’T change your answers unless you are 110% sure the answer that you have already selected is incorrect. Most of the time, your first instinct is correct.

So, there you have it! I hope these tips have eased a little of your test-taking anxiety. Good luck! You’ve got this!

These tips and strategies are just one way of preparing for the NCLEX. To come fully equipped for the exam, try out our practice NCLEX questions.

NURSING BULLETS FUNDAMENTALS OF NURSING.

After turning a patient, the nurse should document the position used, the time that the patient was turned, and the findings of skin assessment.
PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation.
When percussing a patient’s chest for postural drainage, the nurse’s hands should be cupped.
When measuring a patient’s pulse, the nurse should assess its rate, rhythm, quality, and strength.
Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair footrests to the sides and lock its wheels.
When assessing respirations, the nurse should document their rate, rhythm, depth, and quality.
For a subcutaneous injection, the nurse should use a 5/8″ to 1″ 25G needle.
The notation “AA & O × 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time).
Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or f***s, and perspiration.
After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results.
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.
To obtain an accurate blood pressure, the nurse should inflate the manometer to 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure.
The nurse should count an irregular pulse for 1 full minute.
A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus.
Prophylaxis is disease prevention.
Body alignment is achieved when body parts are in proper relation to their natural position.
Trust is the foundation of a nurse-patient relationship.
Blood pressure is the force exerted by the circulating volume of blood on the arterial walls.
Malpractice is a professional’s wrongful conduct, improper discharge of duties, or failure to meet standards of care that causes harm to another.
As a general rule, nurses can’t refuse a patient care assignment; however, in most states, they may refuse to participate in abortions.
A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform.
States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from the assistance. These laws don’t apply to care provided in a health care facility.
A physician should sign verbal and telephone orders within the time established by facility policy, usually 24 hours.
A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of his refusal.
Although a patient’s health record, or chart, is the health care facility’s physical property, its contents belong to the patient.
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.
Under the Controlled Substances Act, every dose of a controlled drug that’s dispensed by the pharmacy must be accounted for, whether the dose was administered to a patient or discarded accidentally.
A nurse can’t perform duties that violate a rule or regulation established by a state licensing board, even if they are authorized by a health care facility or physician.
To minimize interruptions during a patient interview, the nurse should select a private room, preferably one with a door that can be closed.
In categorizing nursing diagnoses, the nurse addresses life-threatening problems first, followed by potentially life-threatening concerns.
The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions.
Standing orders, or protocols, establish guidelines for treating a specific disease or set of symptoms.
In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostal space, near the apex.
The S1 heard on auscultation is caused by closure of the mitral and tricuspid valves.
To maintain package sterility, the nurse should open a wrapper’s top flap away from the body, open each side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body.
The nurse shouldn’t dry a patient’s ear ca**l or remove wax with a cotton-tipped applicator because it may force cerumen against the tympanic membrane.
A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises.
The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse potential.
Schedule I drugs, such as he**in, have a high abuse potential and have no currently accepted medical use in the United States.
Schedule II drugs, such as morphine, o***m, and meperidine (Demerol), have a high abuse potential, but currently have accepted medical uses. Their use may lead to physical or psychological dependence.
Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both.
Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs.
Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances.
Activities of daily living are actions that the patient must perform every day to provide self-care and to interact with society.
Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI.
The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with the stethoscope slightly raised from the chest.
The most important goal to include in a care plan is the patient’s goal.
Fruits are high in fiber and low in protein, and should be omitted from a low-residue diet.
The nurse should use an objective scale to assess and quantify pain. Postoperative pain varies greatly among individuals.
Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings.
The nurse should provide honest answers to the patient’s questions.
Milk shouldn’t be included in a clear liquid diet.
When caring for an infant, a child, or a confused patient, consistency in nursing personnel is paramount.
The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland.
The three membranes that enclose the brain and spinal cord are the dura mater, pia mater, and arachnoid.
A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively.
Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for drugs.
The area around a stoma is cleaned with mild soap and water.
Vegetables have a high fiber content.
The nurse should use a tuberculin syringe to administer a subcutaneous injection of less than 1 ml.
For adults, subcutaneous injections require a 25G 5/8″ to 1″ needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½” needle.
Before administering a drug, the nurse should identify the patient by checking the identification band and asking the patient to state his name.
To clean the skin before an injection, the nurse uses a sterile alcohol swab to wipe from the center of the site outward in a circular motion.
The nurse should inject heparin deep into subcutaneous tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation.
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.
The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative.
If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops. If bruising occurs, the nurse should monitor the site for an enlarging hematoma.
When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head.
The frequency of patient hair care depends on the length and texture of the hair, the duration of hospitalization, and the patient’s condition.
Proper function of a hearing aid requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries.
The hearing aid that’s marked with a blue dot is for the left ear; the one with a red dot is for the right ear.
A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water.
The nurse should instruct the patient to avoid using hair spray while wearing a hearing aid.
The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy.
The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown.
Heat is applied to promote vasodilation, which reduces pain caused by inflammation.
A sutured surgical incision is an example of healing by first intention (healing directly, without granulation).
Healing by secondary intention (healing by granulation) is closure of the wound when granulation tissue fills the defect and allows reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered.
Keloid formation is an abnormality in healing that’s characterized by overgrowth of scar tissue at the wound site.
The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site.
An ascending colostomy drains fluid f***s. A descending colostomy drains solid f***l matter.
A folded towel (scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis.
When giving an injection to a patient who has a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection.
Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation.
To insert a nasogastric tube, the nurse instructs the patient to tilt the head back slightly and then inserts the tube. When the nurse feels the tube curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.)
Families with loved ones in intensive care units report that their four most important needs are to have their questions answered honestly, to be assured that the best possible care is being provided, to know the patient’s prognosis, and to feel that there is hope of recovery.
Double-bind communication occurs when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to.
A nonjudgmental attitude displayed by a nurse shows that she neither approves nor disapproves of the patient.
Target symptoms are those that the patient finds most distressing.
A patient should be advised to take aspirin on an empty stomach, with a full glass of water, and should avoid acidic foods such as coffee, citrus fruits, and cola.
For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for the problem, and selecting the intervention from the choices provided that will enable the patient to reach that goal.
Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient.
Administering an I.M. injection against the patient’s will and without legal authority is battery.
An example of a third-party payer is an insurance company.
The formula for calculating the drops per minute for an I.V. infusion is as follows: (volume to be infused × drip factor) ÷ time in minutes = drops/minute
On-call medication should be given within 5 minutes of the call.
Usually, the best method to determine a patient’s cultural or spiritual needs is to ask him.
An incident report or unusual occurrence report isn’t part of a patient’s record, but is an in-house document that’s used for the purpose of correcting the problem.
Critical pathways are a multidisciplinary guideline for patient care.
When prioritizing nursing diagnoses, the following hierarchy should be used: Problems associated with the airway, those concerning breathing, and those related to circulation.
The two nursing diagnoses that have the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern.
A subjective sign that a sitz bath has been effective is the patient’s expression of decreased pain or discomfort.
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.
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).
The family of a patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him.
Before instilling medication into the ear of a patient who is up to age 3, the nurse should pull the pinna down and back to straighten the eustachian tube.
To prevent injury to the cornea when administering eyedrops, the nurse should waste the first drop and instill the drug in the lower conjunctival sac.
After administering eye ointment, the nurse should twist the medication tube to detach the ointment.
When the nurse removes gloves and a mask, she should remove the gloves first. They are soiled and are likely to contain pathogens.
Crutches should be placed 6″ (15.2 cm) in front of the patient and 6″ to the side to form a tripod arrangement.
Listening is the most effective communication technique.
Before teaching any procedure to a patient, the nurse must assess the patient’s current knowledge and willingness to learn.
Process recording is a method of evaluating one’s communication effectiveness.
When feeding an elderly patient, the nurse should limit high-carbohydrate foods because of the risk of glucose intolerance.
When feeding an elderly patient, essential foods should be given first.
Passive range of motion maintains joint mobility. Resistive exercises increase muscle mass.
Isometric exercises are performed on an extremity that’s in a cast.
A back rub is an example of the gate-control theory of pain.
Anything that’s located below the waist is considered unsterile; a sterile field becomes unsterile when it comes in contact with any unsterile item; a sterile field must be monitored continuously; and a border of 1″ (2.5 cm) around a sterile field is considered unsterile.
A “shift to the left” is evident when the number of immature cells (bands) in the blood increases to fight an infection.
A “shift to the right” is evident when the number of mature cells in the blood increases, as seen in advanced liver disease and pernicious anemia.
Before administering preoperative medication, the nurse should ensure that an informed consent form has been signed and attached to the patient’s record.
A nurse should spend no more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant.
A nurse shouldn’t be assigned to care for more than one patient who has a radiation implant.
Long-handled forceps and a lead-lined container should be available in the room of a patient who has a radiation implant.
Usually, patients who have the same infection and are in strict isolation can share a room.
Diseases that require strict isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease.
For the patient who abides by Jewish custom, milk and meat shouldn’t be served at the same meal.
Whether the patient can perform a 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).
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), intimacy versus isolation (ages 18 to 25), generativity versus stagnation (ages 25 to 60), and ego integrity versus despair (older than age 60).
When communicating with a hearing impaired patient, the nurse should face him.
An appropriate nursing intervention for the spouse of a patient who has a serious incapacitating disease is to help him to mobilize a support system.
Hyperpyrexia is extreme elevation in temperature above 106° F (41.1° C).
Milk is high in sodium and low in iron.
When a patient expresses concern about a health-related issue, before addressing the concern, the nurse should assess the patient’s level of knowledge.
The most effective way to reduce a fever is to administer an antipyretic, which lowers the temperature set point.
When a patient is ill, it’s essential for the members of his family to maintain communication about his health needs.
Ethnocentrism is the universal belief that one’s way of life is superior to others.
When a nurse is communicating with a patient through an interpreter, the nurse should speak to the patient and the interpreter.
In accordance with the “hot-cold” system used by some Mexicans, Puerto Ricans, and other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are described as “cold.”
Prejudice is a hostile attitude toward individuals of a particular group.
Discrimination is preferential treatment of individuals of a particular group. It’s usually discussed in a negative sense.
Increased gastric motility interferes with the absorption of oral drugs.
The three phases of the therapeutic relationship are orientation, working, and termination.
Patients often exhibit resistive and challenging behaviors in the orientation phase of the therapeutic relationship.
Abdominal assessment is performed in the following order: inspection, auscultation, percussion & palpation.
When measuring blood pressure in a neonate, the nurse should select a cuff that’s no less than one-half and no more than two-thirds the length of the extremity that’s used.
When administering a drug by Z-track, the nurse shouldn’t use the same needle that was used to draw the drug into the syringe because doing so could stain the skin.
Sites for intradermal injection include the inner arm, the upper chest, and on the back, under the scapula.
When evaluating whether an answer on an examination is correct, the nurse should consider whether the action that’s described promotes autonomy (independence), safety, self-esteem, and a sense of belonging.
When answering a question on the NCLEX examination, the student should consider the cue (the stimulus for a thought) and the inference (the thought) to determine whether the inference is correct. When in doubt, the nurse should select an answer that indicates the need for further information to eliminate ambiguity. For example, the patient complains of chest pain (the stimulus for the thought) and the nurse infers that the patient is having cardiac pain (the thought). In this case, the nurse hasn’t confirmed whether the pain is cardiac. It would be more appropriate to make further assessments.
Veracity is truth and is an essential component of a therapeutic relationship between a health care provider and his patient.
Beneficence is the duty to do no harm and the duty to do good. There’s an obligation in patient care to do no harm and an equal obligation to assist the patient.
Nonmaleficence is the duty to do no harm.
Frye’s ABCDE cascade provides a framework for prioritizing care by identifying the most important treatment concerns.
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.
B = Breathing. This category includes everything that affects the breathing pattern, including hyperventilation or hypoventilation and abnormal breathing patterns, such as Korsakoff’s, Biot’s, or Cheyne-Stokes respiration.
C = Circulation. This category includes everything that affects the circulation, including fluid and electrolyte disturbances and disease processes that affect cardiac output.
D = Disease processes. If the patient has no problem with the airway, breathing, or circulation, then the nurse should evaluate the disease processes, giving priority to the disease process that poses the greatest immediate risk. For example, if a patient has terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern.
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.
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 implementation phase of nursing and one or two reflect the assessment phase. In this case, the best choice is an assessment response unless a specific course of action is clearly indicated.
Rule utilitarianism is known as the “greatest good for the greatest number of people” theory.
Egalitarian theory emphasizes that equal access to goods and services must be provided to the less fortunate by an affluent society.
Active euthanasia is actively helping a person to die.
Brain death is irreversible cessation of all brain function.
Passive euthanasia is stopping the therapy that’s sustaining life.
A third-party payer is an insurance company.
Utilization review is performed to determine whether the care provided to a patient was appropriate and cost-effective.
A value cohort is a group of people who experienced an out-of-the-ordinary event that shaped their values.
Voluntary euthanasia is actively helping a patient to die at the patient’s request.
Bananas, citrus fruits, and potatoes are good sources of potassium.
Good sources of magnesium include fish, nuts, and grains.
Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron.
Intrathecal injection is administering a drug through the spine.
When a patient asks a question or makes a statement that’s emotionally charged, the nurse should respond to the emotion behind the statement or question rather than to what’s being said or asked.
The steps of the trajectory-nursing model are as follows:
Step 1: Identifying the trajectory phase
Step 2: Identifying the problems and establishing goals
Step 3: Establishing a plan to meet the goals
Step 4: Identifying factors that facilitate or hinder attainment of the goals
Step 5: Implementing interventions
Step 6: Evaluating the effectiveness of the interventions
A Hindu patient is likely to request a vegetarian diet.
Pain threshold, or pain sensation, is the initial point at which a patient feels pain.
The difference between acute pain and chronic pain is its duration.
Referred pain is pain that’s felt at a site other than its origin.
Alleviating pain by performing a back massage is consistent with the gate control theory.
Romberg’s test is a test for balance or gait.
Pain seems more intense at night because the patient isn’t distracted by daily activities.
Older patients commonly don’t report pain because of fear of treatment, lifestyle changes, or dependency.
No pork or pork products are allowed in a Muslim diet.
Two goals of Healthy People 2010 are:
Help individuals of all ages to increase the quality of life and the number of years of optimal health
Eliminate health disparities among different segments of the population.
A community nurse is serving as a patient’s advocate if she tells a malnourished patient to go to a meal program at a local park.
If a patient isn’t following his treatment plan, the nurse should first ask why.
Falls are the leading cause of injury in elderly people.
Primary prevention is true prevention. Examples are immunizations, weight control, and smoking cessation.
Secondary prevention is early detection. Examples include purified protein derivative (PPD), breast self-examination, testicular self-examination, and chest X-ray.
Tertiary prevention is treatment to prevent long-term complications.
A patient indicates that he’s coming to terms with having a chronic disease when he says, “I’m never going to get any better.”
On noticing religious artifacts and literature on a patient’s night stand, a culturally aware nurse would ask the patient the meaning of the items.
A Mexican patient may request the intervention of a curandero, or faith healer, who involves the family in healing the patient.
In an infant, the normal hemoglobin value is 12 g/dl.
The nitrogen balance estimates the difference between the intake and use of protein.
Most of the absorption of water occurs in the large intestine.
Most nutrients are absorbed in the small intestine.
When assessing a patient’s eating habits, the nurse should ask, “What have you eaten in the last 24 hours?”
A vegan diet should include an abundant supply of fiber.
A hypotonic e***a softens the f***s, distends the colon, and stimulates peristalsis.
First-morning urine provides the best sample to measure glucose, ketone, pH, and specific gravity values.
To induce sleep, the first step is to minimize environmental stimuli.
Before moving a patient, the nurse should assess the patient’s physical abilities and ability to understand instructions as well as the amount of strength required to move the patient.
To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his weekly intake by 3,500 calories (approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly caloric intake by 7,000 calories (approximately 1,000 calories daily).
To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet.
To insert a catheter from the nose through the trachea for suction, the nurse should ask the patient to swallow.
Vitamin C is needed for collagen production.
Only the patient can describe his pain accurately.
Cutaneous stimulation creates the release of endorphins that block the transmission of pain stimuli.
Patient-controlled a**lgesia is a safe method to relieve acute pain caused by surgical incision, traumatic injury, labor and delivery, or cancer.
An Asian American or European American typically places distance between himself and others when communicating.
The patient who believes in a scientific, or biomedical, approach to health is likely to expect a drug, treatment, or surgery to cure illness.
Chronic illnesses occur in very young as well as middle-aged and very old people.
The trajectory framework for chronic illness states that preferences about daily life activities affect treatment decisions.
Exacerbations of chronic disease usually cause the patient to seek treatment and may lead to hospitalization.
School health programs provide cost-effective health care for low-income families and those who have no health insurance.
Collegiality is the promotion of collaboration, development, and interdependence among members of a profession.
A change agent is an individual who recognizes a need for change or is selected to make a change within an established entity, such as a hospital.
The patients’ bill of rights was introduced by the American Hospital Association.
Abandonment is premature termination of treatment without the patient’s permission and without appropriate relief of symptoms.
Values clarification is a process that individuals use to prioritize their personal values.
Distributive justice is a principle that promotes equal treatment for all.
Milk and milk products, poultry, grains, and fish are good sources of phosphate.
The best way to prevent falls at night in an oriented, but restless, elderly patient is to raise the side rails.
By the end of the orientation phase, the patient should begin to trust the nurse.
Falls in the elderly are likely to be caused by poor vision.
Barriers to communication include language deficits, sensory deficits, cognitive impairments, structural deficits, and paralysis.
The three elements that are necessary for a fire are heat, oxygen, and combustible material.
Sebaceous glands lubricate the skin.
To check for petechiae in a dark-skinned patient, the nurse should assess the oral mucosa.
To put on a sterile glove, the nurse should pick up the first glove at the folded border and adjust the fingers when both gloves are on.
To increase patient comfort, the nurse should let the alcohol dry before giving an intramuscular injection.
Treatment for a stage 1 ulcer on the heels includes heel protectors.
Seventh-Day Adventists are usually vegetarians.
Endorphins are morphine-like substances that produce a feeling of well-being.
Pain tolerance is the maximum amount and duration of pain that an individual is willing to endure.
A blood pressure cuff that’s too narrow can cause a falsely elevated blood pressure reading.
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.
Rhonchi are the rumbling sounds heard on lung auscultation. They are more pronounced during expiration than during inspiration.
Gavage is forced feeding, usually through a gastric tube (a tube passed into the stomach through the mouth).
According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, s*x, activity, and comfort) have the highest priority.
The safest and surest way to verify a patient’s identity is to check the identification band on his wrist.
In the therapeutic environment, the patient’s safety is the primary concern.
Fluid oscillation in the tubing of a chest drainage system indicates that the system is working properly.
The nurse should place a patient who has a Sengstaken-Blakemore tube in semi-Fowler position.
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.
For blood transfusion in an adult, the appropriate needle size is 16 to 20G.
Intractable pain is pain that incapacitates a patient and can’t be relieved by drugs.
In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic means.
Decibel is the unit of measurement of sound.
Informed consent is required for any invasive procedure.
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.
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.
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.
A registered nurse should assign a licensed vocational nurse or licensed practical nurse to perform bedside care, such as suctioning and drug administration.
If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention.
The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity.
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.
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.
The appropriate needle size for insulin injection is 25G and 5/8″ long.
Residual urine is urine that remains in the bladder after voiding. The amount of residual urine is normally 50 to 100 ml.
The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation.
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.
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.
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 the nursing care plan.
Implementation is the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions.
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.
Before administering any “as needed” pain medication, the nurse should ask the patient to indicate the location of the pain.
Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people.
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.
When providing oral care for an unconscious patient, to minimize the risk of aspiration, the nurse should position the patient on the side.
During assessment of distance vision, the patient should stand 20′ (6.1 m) from the chart.
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).
Normal room humidity is 30% to 60%.
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.
To perform catheterization, the nurse should place a woman in the dorsal recumbent position.
A positive Homan’s sign may indicate thrombophlebitis.
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.
Metabolism occurs in two phases: anabolism (the constructive phase) and catabolism (the destructive phase).
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.
The basal metabolic rate is expressed in calories consumed per hour per kilogram of body weight.
Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains intestinal motility, and helps to establish regular bowel habits.
Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs.
Petechiae are tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage.
Purpura is a purple discoloration of the skin that’s caused by blood extravasation.
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.
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.
When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied.
A nurse should have assistance when changing the ties on a tracheostomy tube.
A filter is always used for blood transfusions.
A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide.
A good way to begin a patient interview is to ask, “What made you seek medical help?”
When caring for any patient, the nurse should follow standard precautions for handling blood and body fluids.
Potassium (K+) is the most abundant cation in intracellular fluid.
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.
In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg.
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.
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).
When being weighed, an adult patient should be lightly dressed and shoeless.
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.
The nurse shouldn’t take an adult’s temperature re**ally if the patient has a cardiac disorder, a**l lesions, or bleeding hemorrhoids or has recently undergone re**al surgery.
In a patient who has a cardiac disorder, measuring temperature re**ally may stimulate a vagal response and lead to vasodilation and decreased cardiac output.
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).
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.
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.
Comfort measures, such as positioning the patient, rubbing the patient’s back, and providing a restful environment, may decrease the patient’s need for a**lgesics or may enhance their effectiveness.
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.
To avoid staining the teeth, the patient should take a liquid iron preparation through a straw.
The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon).
An organism may enter the body through the nose, mouth, re**um, urinary or reproductive tract, or skin.
In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma.
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.
The diaphragm of the stethoscope is used to hear high-pitched sounds, such as breath sounds.
A slight difference in blood pressure (5 to 10 mm Hg) between the right and the left arms is normal.
The nurse should place the blood pressure cuff 1″ (2.5 cm) above the antecubital fossa.
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.
The nurse should use a leg cuff to measure blood pressure in an obese patient.
If a blood pressure cuff is applied too loosely, the reading will be falsely lowered.
Ptosis is drooping of the eyelid.
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.
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.
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.
When being measured for crutches, a patient should wear shoes.
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.
The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern.
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.
For a sigmoidoscopy, the nurse should place the patient in the knee-chest position or Sims’ position, depending on the physician’s preference.
Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, s*x, rest, and comfort), safety and security, love and belonging, self-esteem and recognition, and self-actualization.
When caring for a patient who has a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness.
During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube.
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”).
To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as a thumbnail.
A positive Babinski’s reflex is shown by dorsiflexion of the great toe and fanning out of the other toes.
When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis p***s.
The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours.
Antiembolism stockings decompress the superficial blood vessels, reducing the risk of thrombus formation.
In adults, the most convenient veins for venipuncture are the basilic and median cubital veins in the antecubital space.
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.
People with type O blood are considered universal donors.
People with type AB blood are considered universal recipients.
Hertz (Hz) is the unit of measurement of sound frequency.
Hearing protection is required when the sound intensity exceeds 84 dB. Double hearing protection is required if it exceeds 104 dB.
Prothrombin, a clotting factor, is produced in the liver.
If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory request.
During lumbar puncture, the nurse must note the initial intracranial pressure and the color of the cerebrospinal fluid.
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.
If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first.
When leaving an isolation room, the nurse should remove her gloves before her mask because fewer pathogens are on the mask.
Skeletal traction, which is applied to a bone with wire pins or tongs, is the most effective means of traction.
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.
Drugs aren’t routinely injected intramuscularly into edematous tissue because they may not be absorbed.
When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice.
Dentures should be cleaned in a sink that’s lined with a washcloth.
A patient should void within 8 hours after surgery.
An EEG identifies normal and abnormal brain waves.
Samples of f***s for ova and parasite tests should be delivered to the laboratory without delay and without refrigeration.
The autonomic nervous system regulates the cardiovascular and respiratory systems.
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.
A low-residue diet includes such foods as roasted chicken, rice, and pasta.
A re**al tube shouldn’t be inserted for longer than 20 minutes because it can irritate the re**al mucosa and cause loss of sphincter control.
A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum.
To prevent injury when lifting and moving a patient, the nurse should primarily use the upper leg muscles.
Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal.
While an occupied bed is being changed, the patient should be covered with a bath blanket to promote warmth and prevent exposure.
Anticipatory grief is mourning that occurs for an extended time when the patient realizes that death is inevitable.
The following foods can alter the color of the f***s: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown).
When preparing for a skull X-ray, the patient should remove all jewelry and dentures.
The fight-or-flight response is a sympathetic nervous system response.
Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia.
Wheezing is an abnormal, high-pitched breath sound that’s accentuated on expiration.
Wax or a foreign body in the ear should be flushed out gently by irrigation with warm saline solution.
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.
The nurse should grade hyperactive biceps and triceps reflexes as +4.
If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart.
In a postoperative patient, forcing fluids helps prevent constipation.
A nurse must provide care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy.
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.
As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion.
The body metabolizes alcohol at a fixed rate, regardless of serum concentration.