BULLET QUESTIONS
1.
A blood pressure cuff that’s too
narrow can cause a falsely elevated blood pressure reading.
2.
When preparing a single injection
for a patient who takes regular and basal
insulin, the nurse should draw the regular insulin into the syringe
first so that it does not contaminate the regular insulin.
3.
Rhonchi are the rumbling sounds
heard on lung auscultation. They are more pronounced during expiration than
during inspiration.
4.
Gavaage is forced feeding, usually through a gastric
tube (a tube passed into the stomach through the mouth).
5.
According to Maslow’s hierarchy
of needs, physiologic needs (air, water, food, shelter, sex, activity, and
comfort) have the highest priority.
6.
The safest and surest way to
verify a patient’s identity is to check the identification band on his wrist.
7.
In the therapeutic environment,
the patient’s safety is the primary concern.
8.
Fluid oscillation in the tubing
of a chest drainage system indicates that the system is working properly.
9.
The nurse should place a patient
who has a Sengstaken-Blakemore tube in semi-Fowler position.
10.
The nurse can elicit Trousseau’s
sign by occluding the brachial or radial artery. Hand and finger spasms that
occur during occlusion indicate Trousseau’s sign and suggest hypocalcemia.
11.
For blood transfusion in an adult,
the appropriate needle size is 16 to 20G.
12.
Intractable pain is pain that
incapacitates a patient and can’t be relieved by drugs.
13.
In an emergency, consent for
treatment can be obtained by fax, telephone, or other telegraphic means.
14.
Decibel is the unit of
measurement of sound.
15.
Informed consent is required for
any invasive procedure.
16.
A patient who can’t write his
name to give consent for treatment must make an X in the presence of two
witnesses, such as a nurse, priest, or physician.
17.
The Z-track I.M. injection
technique seals the drug deep into the muscle, thereby minimizing skin
irritation and staining. It requires a needle that’s 1″ (2.5 cm) or longer.
18.
In the event of fire, the acronym
most often used is RACE. (R) Remove the patient. (A) Activate the alarm. (C)
Attempt to contain the fire by closing the door. (E) Extinguish the fire if it
can be done safely.
19.
A registered nurse should assign
a licensed vocational nurse or licensed practical nurse to perform bedside
care, such as suctioning and drug administration.
20.
If a patient can’t void, the
first nursing action should be bladder palpation to assess for bladder
distention.
21.
The patient who uses a cane
should carry it on the unaffected side and advance it at the same time as the
affected extremity.
22.
To fit a supine patient for
crutches, the nurse should measure from the axilla to the sole and add 2″ (5
cm) to that measurement.
23.
Assessment begins with the
nurse’s first encounter with the patient and continues throughout the patient’s
stay. The nurse obtains assessment data through the health history, physical
examination, and review of diagnostic studies.
24.
The appropriate needle size for
insulin injection is 25G and 5/8″ long.
25.
Residual urine is urine that
remains in the bladder after voiding. The amount of residual urine is normally
50 to 100 ml.
26.
The five stages of the nursing
process are assessment, nursing diagnosis, planning, implementation, and
evaluation.
27.
Assessment is the stage of the
nursing process in which the nurse continuously collects data to identify a patient’s
actual and potential health needs.
28.
Nursing diagnosis is the stage of
the nursing process in which the nurse makes a clinical judgment about
individual, family, or community responses to actual or potential health
problems or life processes.
29.
Planning is the stage of the
nursing process in which the nurse assigns priorities to nursing diagnoses,
defines short-term and long-term goals and expected outcomes, and establishes
the nursing care plan.
30.
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.
31.
Evaluation is the stage of the
nursing process in which the nurse compares objective and subjective data with
the outcome criteria and, if needed, modifies the nursing care plan.
32.
Before administering any “as
needed” pain medication, the nurse should ask the patient to indicate the
location of the pain.
33.
Jehovah’s Witnesses believe that
they shouldn’t receive blood components donated by other people.
34.
To test visual acuity, the nurse
should ask the patient to cover each eye separately and to read the eye chart
with glasses and without, as appropriate.
35.
When providing oral care for an
unconscious patient, to minimize the risk of aspiration, the nurse should
position the patient on the side.
36.
During assessment of distance
vision, the patient should stand 20′ (6.1 m) from the chart.
37.
For a geriatric patient or one
who is extremely ill, the ideal room temperature is 66° to 76° F (18.8° to
24.4° C).
38.
Normal room humidity is 30% to
60%.
39.
Hand washing is the single best
method of limiting the spread of microorganisms. Once gloves are removed after
routine contact with a patient, hands should be washed for 10 to 15 seconds.
40.
To perform catheterization, the
nurse should place a woman in the dorsal recumbent position.
41.
A positive Homan’s sign may
indicate thrombophlebitis.
42.
Electrolytes in a solution are
measured in milliequivalents per liter (mEq/L). A milliequivalent is the number
of milligrams per 100 milliliters of a solution.
43.
Metabolism occurs in two phases:
anabolism (the constructive phase) and catabolism (the destructive phase).
44.
The basal metabolic rate is the
amount of energy needed to maintain essential body functions. It’s measured
when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is
in a comfortable, warm environment.
45.
The basal metabolic rate is
expressed in calories consumed per hour per kilogram of body weight.
46.
Dietary fiber (roughage), which
is derived from cellulose, supplies bulk, maintains intestinal motility, and
helps to establish regular bowel habits.
47.
Alcohol is metabolized primarily
in the liver. Smaller amounts are metabolized by the kidneys and lungs.
48.
Petechiae are tiny, round,
purplish red spots that appear on the skin and mucous membranes as a result of
intradermal or submucosal hemorrhage.
49.
Purpura is a purple discoloration
of the skin that’s caused by blood extravasation.
50.
According to the standard precautions
recommended by the Centers for Disease Control and Prevention, the nurse
shouldn’t recap needles after use. Most needle sticks result from missed needle
recapping.
