FUNDAMENTAL NURSING BULLETS -8

Ø  The two nursing diagnoses that have the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern.

Ø  A subjective sign that a sitz bath has been effective is the patient’s expression of decreased pain or discomfort.

Ø  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.

Ø   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).

Ø  The family of a patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him.

Ø  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.

Ø   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.

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

Ø   When the nurse removes gloves and a mask, she should remove the gloves first. They are soiled and are likely to contain pathogens.

Ø   Crutches should be placed 6″ (15.2 cm) in front of the patient and 6″ to the side to form a tripod arrangement.

Ø  Listening is the most effective communication technique.

Ø   Before teaching any procedure to a patient, the nurse must assess the patient’s current knowledge and willingness to learn.

Ø   Process recording is a method of evaluating one’s communication effectiveness.

Ø  When feeding an elderly patient, the nurse should limit high-carbohydrate foods because of the risk of glucose intolerance.

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

Ø   Passive range of motion maintains joint mobility. Resistive exercises increase muscle mass.

Ø   Isometric exercises are performed on an extremity that’s in a cast.

Ø  A back rub is an example of the gate-control theory of pain.

Ø   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.

Ø  A “shift to the left” is evident when the number of immature cells (bands) in the blood increases to fight an infection.

Ø  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.

Ø   Before administering preoperative medication, the nurse should ensure that an informed consent form has been signed and attached to the patient’s record.

Ø  A nurse should spend no more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant.

Ø  A nurse shouldn’t be assigned to care for more than one patient who has a radiation implant.

Ø  Long-handled forceps and a lead-lined container should be available in the room of a patient who has a radiation implant.

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

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

Ø  For the patient who abides by Jewish custom, milk and meat shouldn’t be served at the same meal.

Ø  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).

Ø  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).

Ø  When communicating with a hearing impaired patient, the nurse should face him.

Ø  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.

Ø  Hyperpyrexia is extreme elevation in temperature above 106° F (41.1° C).

Ø  Milk is high in sodium and low in iron.

Ø  When a patient expresses concern about a health-related issue, before addressing the concern, the nurse should assess the patient’s level of knowledge.

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

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

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

Ø  When a nurse is communicating with a patient through an interpreter, the nurse should speak to the patient and the interpreter.

Ø  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.”

Ø  Prejudice is a hostile attitude toward individuals of a particular group.

Ø  Discrimination is preferential treatment of individuals of a particular group. It’s usually discussed in a negative sense.

Ø  Increased gastric motility interferes with the absorption of oral drugs.

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

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

Ø  Abdominal assessment is performed in the following order: inspection, auscultation, percussion & palpation.

Ø  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.

Ø  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.

Ø  Sites for intradermal injection include the inner arm, the upper chest, and on the back, under the scapula.

     Ø  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