NURSING BULLETS FUNDAMENTALS OF NURSING

NURSING BULLETS FUNDAMENTALS OF NURSING

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, sex, 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 sixteen to twenty gauge.

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 one inch or longer.

In the event of fire, the acronym most often used is RACE. R is Remove the patient. A is Activate the alarm. C is Attempt to contain the fire by closing the door. E is 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 two inches 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 twenty-five gauge and five-eighths inch long.

Residual urine is urine that remains in the bladder after voiding. The amount of residual urine is normally fifty to one hundred milliliters.

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 twenty feet from the chart.

For a geriatric patient or one who is extremely ill, the ideal room temperature is sixty-six to seventy-six degrees Fahrenheit.

Normal room humidity is thirty to sixty percent.

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 ten to fifteen 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. A milliequivalent is the number of milligrams per one hundred 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 fourteen to eighteen 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

NURSING BULLETS

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 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 (B one), riboflavin (B two), niacin (B three), pyridoxine (B six), and cyanocobalamin (B twelve).

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 fifteen minutes.

The nurse shouldn't take an adult's temperature rectally if the patient has a cardiac disorder, anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery.

In a patient who has a cardiac disorder, measuring temperature rectally 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: plus three, bounding pulse (readily palpable and forceful); plus two, normal pulse (easily palpable); plus one, thready or weak pulse (difficult to detect); and zero, 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 analgesics 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, rectum, 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 (five to ten millimeters of mercury) between the right and the left arms is normal.

The nurse should place the blood pressure cuff one inch 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 elevated.

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 (ninety-degree) angle. Firmly depress the plunger, but don't aspirate. Leave the needle in place for ten 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, sex, 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.