FUNDAMENTALS OF NURSING BULLETS

Mark Fredderick R. Abejo RN,MAN

A blood pressure cuff thats too narrow can cause a falsely elevated blood pressure reading.
When preparing a single injection for a patient who takes regular andv 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. hey arev more pronounced during e!piration than
during inspiration.
"avage is forced feeding, usually through a gastric tube #a tube passed into the stomach through the mouth$.
According to %aslows hierarchy of needs, physiologic needs #air, water, food, shelter, se!, activity, and comfort$
have the highest priority.
he safest and surest way to verify a patients identity is to check the identification band on his wrist.
&n the therapeutic environment, the patients safety is the primary concern.
'luid oscillation in the tubing of a chest drainage system indicates that the system is working properly.
he nurse should place a patient who has a (engstaken)*lakemore tube in semi)'owler position.
he nurse can elicit rousseaus sign by occluding the brachial orv radial artery. Hand and finger spasms that occur
during occlusion indicate rousseaus sign and suggest hypocalcemia.
'or blood transfusion in an adult, the appropriate needle si+e is ,- to ./".
&ntractable 0ain is 0ain that incapacitates a patient and cant be relieved by drugs.
&n an emergency, consent for treatment can be obtained by fa!, telephone, or other telegraphic means.
1ecibel is the unit of measurement of sound.
&nformed consent is re2uired for any invasive procedure.
A patient who cant write his name to give consent for treatment mustv make an 3 in the presence of two witnesses,
such as a nurse, priest, or physician.
he 4)track &.%. injection techni2ue seals the drug deep into thev muscle, thereby minimi+ing skin irritation and
staining. &t re2uires a needle thats ,5 #..6 cm$ or longer.
&n the event of fire, the acronym most often used is RA78. #R$ Removev the patient. #A$ Activate the alarm. #7$
Attempt to contain the fire by closing the door. #8$ 8!tinguish the fire if it can be done safely.
A registered nurse should assign a licensed vocational nurse orv licensed practical nurse to perform bedside care,
such as suctioning and drug administration.
&f a patient cant void, the first 9ursing action should be bladder 0alpation to assess for bladder distention.
he patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected
e!tremity.
o fit a supine patient for crutches, the nurse should measure fromv the a!illa to the sole and add .5 #6 cm$ to that
measurement.
Assessment begins with the nurses first encounter with the patientv and continues throughout the patients stay. he
nurse obtains assessment data through the Health History, physical e!amination, and review of diagnostic studies.
he appropriate needle si+e for insulin injection is .6" and 6:;5 long.
Residual urine is urine that remains in the bladder after voiding. he amount of residual urine is normally 6/ to ,//
ml.
he five stages of the 9ursing process are assessment, 9ursing diagnosis, planning, implementation, and evaluation.
Assessment is the stage of the 9ursing process in which the nursev continuously collects data to identify a patients
actual and potential health needs.
9ursing diagnosis is the stage of the nursing process in which thev nurse makes a clinical judgment about
individual, family, or community responses to actual or potential health problems or life processes.
0lanning is the stage of the nursing process in which the nursev assigns priorities to nursing diagnoses, defines
short)term and long)term goals and e!pected outcomes, and establishes the nursing care plan.
&mplementation is the stage of the nursing process in which the nursev puts the nursing care plan into action,
delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing
interventions.
8valuation is the stage of the nursing process in which the nursev compares objective and subjective data with the
outcome criteria and, if needed, modifies the nursing care plan.
*efore administering any <as needed= 0ain medication, the nurse should ask the patient to indicate the location of
the 0ain.
>ehovahs Witnesses believe that they shouldnt receive blood components donated by other people.
FUNDAMENTALS OF NURSING BULLETS
Mark Fredderick R. Abejo RN,MAN
o test visual acuity, the nurse should ask the patient to cover eachv eye separately and to read the eye chart with
glasses and without, as appropriate.
When providing oral care for an unconscious patient, to minimi+e thev risk of aspiration, the nurse should position
the patient on the side.
1uring assessment of distance vision, the patient should stand ./? #-., m$ from the chart.
'or a geriatric patient or one who is e!tremely ill, the ideal room temperature is --@ to A-@ ' #,;.;@ to .B.B@ 7$.
9ormal room humidity is C/D to -/D.
Hand washing is the single best method of limiting the spread ofv microorganisms. Ence gloves are removed after
routine contact with a patient, hands should be washed for ,/ to ,6 seconds.
o perform catheteri+ation, the nurse should place a woman in the dorsal recumbent position.
A positive Homans sign may indicate thrombophlebitis.
he vitamin * comple!, the water)soluble vitamins that are essentialv for metabolism, include thiamine #*,$,
riboflavin #*.$, niacin #*C$, pyrido!ine #*-$, and cyanocobalamin #*,.$.
When being weighed, an adult patient should be lightly dressed and shoeless.
*efore taking an adults temperature orally, the nurse should ensurev that the patient hasnt smoked or consumed hot
or cold substances in the previous ,6 minutes.
he nurse shouldnt take an adults temperature rectally if thev patient has a cardiac disorder, anal lesions, or
bleeding hemorrhoids or has recently undergone rectal surgery.
&n a patient who has a cardiac disorder, measuring temperaturev rectally may stimulate a vagal response and lead to
vasodilation and decreased cardiac output.
When recording pulse amplitude and rhythm, the nurse should use thesev descriptive measuresF GC, bounding pulse
#readily palpable and forceful$H G., normal pulse #easily palpable$H G,, thready or weak pulse #difficult to detect$H
and /, absent pulse #not detectable$.
he intraoperative period begins when a patient is transferred to thev operating room bed and ends when the patient
is admitted to the postanesthesia care unit.
En the morning of surgery, the nurse should ensure that the informedv consent form has been signedH that the patient
hasnt taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care
#without swallowing the water$, has removed common jewelry, and has received preoperative medication as
prescribedH and that vital signs have been taken and recorded. Artificial limbs and other prostheses are usually
removed.
7omfort measures, such as positioning the patient, rubbing thev patients back, and providing a restful environment,
may decrease the patients need for analgesics or may enhance their effectiveness
A drug has three namesF generic name, which is used in officialv publicationsH trade, or brand, name #such as
ylenol$, which is selected by the drug companyH and chemical name, which describes the drugs chemical
composition.
o avoid staining the teeth, the patient should take a li2uid iron preparation through a straw.
he nurse should use the 4)track method to administer an &.%. injection of iron de!tran #&mferon$.
An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin.
&n descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma.
o turn a patient by logrolling, the nurse folds the patients armsv across the chestH e!tends the patients legs and
inserts a pillow between them, if neededH places a draw sheet under the patientH and turns the patient by slowly and
gently pulling on the draw sheet.
he diaphragm of the stethoscope is used to hear high)pitched sounds, such as breath sounds.
A slight difference in blood pressure #6 to ,/ mm Hg$ between the right and the left arms is normal.
he nurse should place the blood pressure cuff ,5 #..6 cm$ above the antecubital fossa.
When instilling ophthalmic ointments, the nurse should waste thev first bead of ointment and then apply the
ointment from the inner canthus to the outer canthus.
he nurse should use a leg cuff to measure blood pressure in an obese patient.
&f a blood pressure cuff is applied too loosely, the reading will be falsely elevated.
0tosis is drooping of the eyelid.
A tilt table is useful for a patient with a spinal cord injury,v orthostatic hypotension, or brain damage because it can
move the patient gradually from a hori+ontal to a vertical #upright$ position.
o perform venipuncture with the least injury to the vessel, thev nurse should turn the bevel upward when the
vessels lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle.
o move a patient to the edge of the bed for transfer, the nursev should follow these stepsF %ove the patients head
and shoulders toward the edge of the bed. %ove the patients feet and legs to the edge of the bed #crescent position$.
0lace both arms well under the patients hips, and straighten the back while moving the patient toward the edge of
the bed.
When being measured for crutches, a patient should wear shoes.
he nurse should attach a restraint to the part of the bed frame that moves with the head, not to the mattress or side
rails.
he mist in a mist tent should never become so dense that it obscuresv clear visuali+ation of the patients respiratory
pattern.
FUNDAMENTALS OF NURSING BULLETS
Mark Fredderick R. Abejo RN,MAN
o administer heparin subcutaneously, the nurse should follow thesev stepsF 7lean, but dont rub, the site with
alcohol. (tretch the skin taut or pick up a well)defined skin fold. Hold the shaft of the needle in a dart position.
&nsert the needle into the skin at a right #I/)degree$ angle. 'irmly depress the plunger, but dont aspirate. Jeave the
needle in place for ,/ seconds. Withdraw the needle gently at the angle of insertion. Apply pressure to the injection
site with an alcohol pad.
'or a sigmoidoscopy, the nurse should place the patient in thev knee)chest position or (ims position, depending on
the physicians preference.
%aslows hierarchy of needs must be met in the following orderFv physiologic #o!ygen, food, water, se!, rest, and
comfort$, safety and security, love and belonging, self)esteem and recognition, and self)actuali+ation.
When caring for a patient who has a nasogastric tube, the nursev should apply a water)soluble lubricant to the nostril
to prevent soreness.
1uring gastric lavage, a nasogastric tube is inserted, the stomach isv flushed, and ingested substances are removed
through the tube.
&n documenting drainage on a surgical dressing, the nurse shouldv include the si+e, color, and consistency of the
drainage #for e!ample, <,/ mm of brown mucoid drainage noted on dressing=$.
o elicit *abinskis refle!, the nurse strokes the sole of thev patients foot with a moderately sharp object, such as a
thumbnail.
A positive *abinskis refle! is shown by dorsifle!ion of the great toe and fanning out of the other toes.
When assessing a patient for bladder distention, the nurse shouldv check the contour of the lower abdomen for a
rounded mass above the symphysis pubis.
he best way to prevent pressure ulcers is to reposition the bedridden patient at least every . hours.
Antiembolism stockings decompress the superficial blood vessels, reducing the risk of thrombus formation.
&n adults, the most convenient veins for venipuncture are the basilic and median cubital veins in the antecubital
space.
wo to three hours before beginning a tube feeding, the nurse shouldv aspirate the patients stomach contents to
verify that gastric emptying is ade2uate.
0eople with type E blood are considered universal donors.
0eople with type A* blood are considered universal recipients.
Hert+ #H+$ is the unit of measurement of sound fre2uency.
Hearing protection is re2uired when the sound intensity e!ceeds ;Bv d*. 1ouble hearing protection is re2uired if it
e!ceeds ,/B d*.
0rothrombin, a clotting factor, is produced in the liver.
&f a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory re2uest.
&f a patient cant cough to provide a sputum sample for culture, av heated aerosol treatment can be used to help to
obtain a sample.
&f 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.
(keletal traction, which is applied to a bone with wire pins or tongs, is the most effective means of traction.
he total parenteral nutrition solution should be stored in av refrigerator and removed C/ to -/ minutes before use.
1elivery of a chilled solution can cause 0ain, hypothermia, venous spasm, and venous constriction.
1rugs arent routinely injected intramuscularly into edematous tissue because they may not be absorbed.
When caring for a comatose patient, the nurse should e!plain each action to the patient in a normal voice.
1entures should be cleaned in a sink thats lined with a washcloth.
A patient should void within ; hours after surgery.
An 88" identifies normal and abnormal brain waves.
(amples of feces for ova and parasite tests should be delivered to the laboratory without delay and without
refrigeration.
he autonomic nervous system regulates the cardiovascular and respiratory systems.
When providing tracheostomy care, the nurse should insert thev catheter gently into the tracheostomy tube. When
withdrawing the catheter, the nurse should apply intermittent suction for no more than ,6 seconds and use a slight
twisting motion.
A low)residue diet includes such foods as roasted chicken, rice, and pasta.
A rectal tube shouldnt be inserted for longer than ./ minutesv because it can irritate the rectal mucosa and cause
loss of sphincter control.
A patients bed bath should proceed in this orderF face, neck, arms, hands, chest, abdomen, back, legs, perineum.
o prevent injury when lifting and moving a patient, the nurse should primarily use the upper leg muscles.
0atient 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 coveredv with a bath blanket to promote warmth and
prevent e!posure.
Anticipatory grief is mourning that occurs for an e!tended time when the patient reali+es that death is
inevitable.meat protein #dark brown$.
When preparing for a skull 3)ray, the patient should remove all jewelry and dentures.
FUNDAMENTALS OF NURSING BULLETS
Mark Fredderick R. Abejo RN,MAN
he fight)or)flight response is a sympathetic nervous system response.
*ronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia.
Whee+ing is an abnormal, high)pitched breath sound thats accentuated on e!piration.
Wa! or a foreign body in the ear should be flushed out gently by irrigation with warm saline solution.
&f a patient complains that his hearing aid is <not working,= thev nurse should check the switch first to see if its
turned on and then check the batteries.
he nurse should grade hyperactive biceps and triceps refle!es as GB.
&n a postoperative patient, forcing fluids helps prevent constipation.
A nurse must provide care in accordance with standards of carev established by the American 9urses Association,
state regulations, and facility policy.
he kilocalorie #kcal$ is a unit of energy measurement thatv represents the amount of heat needed to raise the
temperature of , kilogram of water ,@ 7.
As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and
e!cretion.