Nursing Bullets:

Fundamentals of Nursing
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 neutral
protein Hagedorn 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. Gavage 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.
51. 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.
52. When changing the ties on a tracheostomy tube, the nurse should leave the old ties
in place until the new ones are applied.
53. A nurse should have assistance when changing the ties on a tracheostomy tube.
54. A filter is always used for blood transfusions.
55. A four-point (quad) cane is indicated when a patient needs more stability than a
regular cane can provide.
56. A good way to begin a patient interview is to ask, “What made you seek medical
help?”
57. When caring for any patient, the nurse should follow standard precautions for
handling blood and body fluids.
58. Potassium (K+) is the most abundant cation in intracellular fluid.
59. 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.
60. In the three-point gait, the patient moves two crutches and the affected leg
simultaneously and then moves the unaffected leg.
61. 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.
62. 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).
63. When being weighed, an adult patient should be lightly dressed and shoeless.
64. 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.
65. 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.
66. In a patient who has a cardiac disorder, measuring temperature rectally may
stimulate a vagal response and lead to vasodilation and decreased cardiac output.
67. 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).
68. 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.
69. 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.
70. 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.
71. 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.
72. To avoid staining the teeth, the patient should take a liquid iron preparation through
a straw.
73. The nurse should use the Z-track method to administer an I.M. injection of iron
dextran (Imferon).
74. An organism may enter the body through the nose, mouth, rectum, urinary or
reproductive tract, or skin.
75. In descending order, the levels of consciousness are alertness, lethargy, stupor, light
coma, and deep coma.
76. 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.
77. The diaphragm of the stethoscope is used to hear high-pitched sounds, such as
breath sounds.
78. A slight difference in blood pressure (5 to 10 mm Hg) between the right and the left
arms is normal.
79. The nurse should place the blood pressure cuff 1″ (2.5 cm) above the antecubital
fossa.
80. 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.
81. The nurse should use a leg cuff to measure blood pressure in an obese patient.
82. If a blood pressure cuff is applied too loosely, the reading will be falsely elevated.
83. Ptosis is drooping of the eyelid.
84. 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.
85. 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.
86. 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.
87. When being measured for crutches, a patient should wear shoes.
88. 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.
89. The mist in a mist tent should never become so dense that it obscures clear
visualization of the patient’s respiratory pattern.
90. 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.
91. For a sigmoidoscopy, the nurse should place the patient in the knee-chest position
or Sims’ position, depending on the physician’s preference.
92. 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.
93. When caring for a patient who has a nasogastric tube, the nurse should apply a
water-soluble lubricant to the nostril to prevent soreness.
94. During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and
ingested substances are removed through the tube.
95. 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”).
96. To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a
moderately sharp object, such as a thumbnail.
97. A positive Babinski’s reflex is shown by dorsiflexion of the great toe and fanning
out of the other toes.
98. When assessing a patient for bladder distention, the nurse should check the contour
of the lower abdomen for a rounded mass above the symphysis pubis.
99. The best way to prevent pressure ulcers is to reposition the bedridden patient at
least every 2 hours.
100. Antiembolism stockings decompress the superficial blood vessels, reducing the
risk of thrombus formation.