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NURSING BULLETS _____________ ___________________________________________________________
FUNDAMENTALS OF NURSINGMATERNAL AND CHILD HEALTH NURSINGMEDICAL – SURGICAL NURSINGPSYCHIATRIC NURSING
Compiled by:ROBERT C. REÑA, BSN
\
2009
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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 shoulddraw 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 duringinspiration.
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) havethe 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 duringocclusion indicate Trousseau’s sign and suggest hypocalcemia.
For blood transfusion in an adult, the appropriate needle size is 16 to 20G.
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, suchas 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 1" (2.5 cm) or longer.
In the event of fire, the acronym most often used is RACE. (R) Remove the patient. (A) Activate the alarm. (C) Attemptto contain the fire by closing the door. (E) 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 assuctioning 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 affectedextremity.
To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2" (5 cm) to thatmeasurement.
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NURSING BULLETS _____________ ___________________________________________________________
Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurseobtains assessment data through the health history, physical examination, and review of diagnostic studies.
The appropriate needle size for insulin injection is 25G and 5/8" long.
Residual urine is urine that remains in the bladder after voiding. The amount of residual urine is normally 50 to 100 ml.
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 actualand 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-termand 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, delegatesspecific 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 theoutcome 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 glassesand 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 20' (6.1 m) from the chart.
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).
Normal room humidity is 30% to 60%.
Hand washing is the single best method of limiting the spread of microorganisms. Once gloves are removed after routinecontact with a patient, hands should be washed for 10 to 15 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 (mEq/L). A milliequivalent is the number of milligrams per 100 milliliters of a solution.
Metabolism occurs in two phases: anabolism (the constructive phase) and catabolism (the destructive phase).
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