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Fundamentals of Nursing Bullets Nle Nclex

Fundamentals of Nursing Bullets Nle Nclex

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Published by: Ritamaria on Oct 23, 2011
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A blood pressure cuff that’s too narrow can cause a falsely elevated bloodpressure reading.When preparing a single injection for a patient who takes regular and neutralprotein Hagedorn insulin, the nurse should draw the regular insulin into the syringefirst so that it does not contaminate the regular insulin.Rhonchi are the rumbling sounds heard on lung auscultation. They are morepronounced during expiration than during inspiration.Gavage is forced feeding, usually through a gastric tube (a tube passed into thestomach 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 theidentification 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 thesystem 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 andsuggest 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, orother 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 anX 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, therebyminimizing skin irritation and staining. It requires a needle that’s 1" (2.5 cm) orlonger.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.A registered nurse should assign a licensed vocational nurse or licensed practicalnurse to perform bedside care, such as suctioning and drug administration.If a patient can’t void, the first nursing action should be bladder palpation toassess for bladder distention.The patient who uses a cane should carry it on the unaffected side and advanceit at the same time as the affected extremity.
To fit a supine patient for crutches, the nurse should measure from the axilla tothe sole and add 2" (5 cm) to that measurement.Assessment begins with the nurse’s first encounter with the patient andcontinues throughout the patient’s stay. The nurse obtains assessment data throughthe 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 continuouslycollects 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 aclinical judgment about individual, family, or community responses to actual orpotential health problems or life processes.Planning is the stage of the nursing process in which the nurse assigns prioritiesto nursing diagnoses, defines short-term and long-term goals and expectedoutcomes, and establishes the nursing care plan.Implementation is the stage of the nursing process in which the nurse puts thenursing care plan into action, delegates specific nursing interventions to membersof the nursing team, and charts patient responses to nursing interventions.

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