You are on page 1of 21



(R) Remove the patient.

When preparing a single injection for a


(A) Activate the alarm.

10. The nurse can elicit Trousseaus sign by

(C) Attempt to contain the fire by closing

protein Hagedorn insulin, the nurse should

occluding the brachial or radial artery.

the door.

draw the regular insulin into the syringe

Hand and finger spasms that occur during

(E) Extinguish the fire if it can be done

first so that it does not contaminate the

occlusion indicate Trousseaus sign and


regular insulin.

suggest hypocalcemia.

Rhonchi are the rumbling sounds heard on

Gavage is forced feeding, usually through a

vocational nurse or licensed practical nurse

appropriate needle size is 16 to 20G.

to perform bedside care, such as suctioning

12. Intractable pain is pain that incapacitates a

patient and cant be relieved by drugs.
13. In an emergency, consent for treatment
can be obtained by fax, telephone, or other

stomach through the mouth).

telegraphic means.

According to Maslows hierarchy of needs,

sex, activity, and comfort) have the highest

The safest and surest way to verify a

14. Decibel is the unit of measurement of

15. Informed consent is required for any
invasive procedure.
16. A patient who cant write his name to give

patients identity is to check the

consent for treatment must make an X in

identification band on his wrist.

the presence of two witnesses, such as a

In the therapeutic environment, the

nurse, priest, or physician.

patients safety is the primary concern.

19. A registered nurse should assign a licensed

11. For blood transfusion in an adult, the

gastric tube (a tube passed into the

physiologic needs (air, water, food, shelter,



18. In the event of fire, the acronym most often

Sengstaken-Blakemore tube in semi-Fowler





pronounced during expiration than during


drainage system indicates that the system

used is RACE.

lung auscultation. They are more


requires a needle thats 1 (2.5 cm) or

The nurse should place a patient who has a

patient who takes regular and neutral


Fluid oscillation in the tubing of a chest

is working properly.

A blood pressure cuff thats too narrow can

cause a falsely elevated blood pressure



17. The Z-track I.M. injection technique seals

and drug administration.

20. If a patient cant 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
23. Assessment begins with the nurses first
encounter with the patient and continues
throughout the patients stay. The nurse

the drug deep into the muscle, thereby

obtains assessment data through the

minimizing skin irritation and staining. It

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

objective and subjective data with the

40. To perform catheterization, the nurse

outcome criteria and, if needed, modifies

should place a woman in the dorsal

the nursing care plan.

recumbent position.

32. Before administering any as needed pain

medication, the nurse should ask the
patient to indicate the location of the pain.
33. Jehovahs Witnesses believe that they

41. A positive Homans sign may indicate

42. Electrolytes in a solution are measured in
milliequivalents per liter (mEq/L). A

shouldnt receive blood components

milliequivalent is the number of milligrams

donated by other people.

per 100 milliliters of a solution.

34. To test visual acuity, the nurse should ask

43. Metabolism occurs in two phases:

collects data to identify a patients actual

the patient to cover each eye separately

anabolism (the constructive phase) and

and potential health needs.

and to read the eye chart with glasses and

catabolism (the destructive phase).

28. Nursing diagnosis is the stage of the

nursing process in which the nurse makes a

without, as appropriate.

44. The basal metabolic rate is the amount of

35. When providing oral care for an

energy needed to maintain essential body

clinical judgment about individual, family,

unconscious patient, to minimize the risk of

functions. Its measured when the patient

or community responses to actual or

aspiration, the nurse should position the

is awake and resting, hasnt eaten for 14 to

potential health problems or life processes.

patient on the side.

18 hours, and is in a comfortable, warm

29. Planning is the stage of the nursing process

36. During assessment of distance vision, the

in which the nurse assigns priorities to

patient should stand 20 (6.1 m) from the

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

45. The basal metabolic rate is expressed in
calories consumed per hour per kilogram of

37. For a geriatric patient or one who is

extremely ill, the idealROOM


is 66 to 76 F (18.8 to 24.4 C).

46. Dietary fiber (roughage), which is derived

from cellulose, supplies bulk, maintains

process in which the nurse puts the nursing

38. NormalROOM

care plan into action, delegates specific

39. Hand washing is the single best method of

nursing interventions to members of the

limiting the spread of microorganisms.

47. Alcohol is metabolized primarily in the liver.

nursing team, and charts patient responses

Once gloves are removed after routine

Smaller amounts are metabolized by the

to nursing interventions.

contact with a patient, hands should be

kidneys and lungs.

31. Evaluation is the stage of the nursing

process in which the nurse compares

humidity is 30% to 60%.

body weight.

washed for 10 to 15 seconds.

intestinal motility, and helps to establish

regular bowel habits.

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
thats caused by blood extravasation.
50. According to the standard precautions
recommended by the Centers for Disease
Control and Prevention, the nurse shouldnt

58. Potassium (K+) is the most abundant

cation in intracellular fluid.
59. In the four-point, or alternating, gait, the

hemorrhoids or has recently undergone

rectal surgery.
66. In a patient who has a cardiac disorder,

patient first moves the right crutch

measuring temperature rectally may

followed by the left foot and then the left

stimulate a vagal response and lead to

crutch followed by the right foot.

vasodilation and decreased cardiac output.

60. In the three-point gait, the patient moves

67. When recording pulse amplitude and

recap needles after use. Most needle sticks

two crutches and the affected leg

rhythm, the nurse should use these

result from missed needle recapping.

simultaneously and then moves the

descriptive measures: +3, bounding pulse

unaffected leg.

(readily palpable and forceful); +2, normal

51. The nurse administers a drug by I.V. push

by using a needle and syringe to deliver

61. In the two-point gait, the patient moves the

pulse (easily palpable); +1, thready or

the dose directly into a vein, I.V. tubing, or

right leg and the left crutch simultaneously

weak pulse (difficult to detect); and 0,

a catheter.

and then moves the left leg and the right

absent pulse (not detectable).

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
55. A four-point (quad) cane is indicated when
a patient needs more stability than a
regular cane can provide.

crutch simultaneously.
62. The vitamin B complex, the water-soluble

68. The intraoperative period begins when a

patient is transferred to the operating

vitamins that are essential for metabolism,

room bed and ends when the patient is

include thiamine (B1), riboflavin (B2),

admitted to the post-anesthesia care unit.

niacin (B3), pyridoxine (B6), and

cyanocobalamin (B12).
63. When being weighed, an adult patient
should be lightly dressed and shoeless.
64. Before taking an adults temperature

69. On the morning of surgery, the nurse

should ensure that the informed consent
form has been signed; that the patient
hasnt taken anything by mouth since
midnight, has taken a shower with

orally, the nurse should ensure that the

antimicrobial soap, has had mouth care

patient hasnt smoked or consumed hot or

(without swallowing the water), has

to ask, What made you seek medical

cold substances in the previous 15

removed common jewelry, and has



received preoperative medication as

56. A good way to begin a patient interview is

57. When caring for any patient, the nurse

65. The nurse shouldnt take an adults

prescribed; and that vital signs have been

should follow standard precautions for

temperature rectally if the patient has a

taken and recorded. Artificial limbs and

handling blood and body fluids.

cardiac disorder, anal lesions, or bleeding

other prostheses are usually removed.

70. Comfort measures, such as positioning the

77. The diaphragm of the stethoscope is used

86. To move a patient to the edge of the bed

patient, rubbing the patients back, and

to hear high-pitched sounds, such as

for transfer, the nurse should follow these

providing a restful environment, may

breath sounds.

steps: Move the patients head and

decrease the patients need for analgesics

or may enhance their effectiveness.
71. A drug has three names: generic name,

78. A slight difference in blood pressure (5 to

shoulders toward the edge of the bed.

10 mm Hg) between the right and the left

Move the patients feet and legs to the

arms is normal.

edge of the bed (crescent position). Place

which is used in official publications; trade,

79. The nurse should place the blood pressure

or brand, name (such as Tylenol), which is

cuff 1 (2.5 cm) above the antecubital

and straighten the back while moving the

selected by the drug company; and


patient toward the edge of the bed.

chemical name, which describes the drugs

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.

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 lowered.
83. Ptosis is drooping of the eyelid.
84. A tilt table is useful for a patient with a

both arms well under the patients hips,

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 patients respiratory
90. To administer heparin subcutaneously, the

spinal cord injury, orthostatic hypotension,

nurse should follow these steps: Clean, but

or brain damage because it can move the

dont rub, the site with alcohol. Stretch the

consciousness are alertness, lethargy,

patient gradually from a horizontal to a

skin taut or pick up a well-defined skin fold.

stupor, light coma, and deep coma.

vertical (upright) position.

Hold the shaft of the needle in a dart

75. In descending order, the levels of

76. To turn a patient by logrolling, the nurse

85. To perform venipuncture with the least

position. Insert the needle into the skin at a

folds the patients arms across the chest;

injury to the vessel, the nurse should turn

right (90-degree) angle. Firmly depress the

extends the patients legs and inserts a

the bevel upward when the vessels lumen

plunger, but dont aspirate. Leave the

pillow between them, if needed; places a

is larger than the needle and turn it

needle in place for 10 seconds. Withdraw

draw sheet under the patient; and turns

downward when the lumen is only slightly

the needle gently at the angle of insertion.

the patient by slowly and gently pulling on

larger than the needle.

Apply pressure to the injection site with an

the draw sheet.

alcohol pad.

91. For a sigmoidoscopy, the nurse should

98. When assessing a patient for bladder

108. If a patient is menstruating when a urine

place the patient in the knee-chest position

distention, the nurse should check the

sample is collected, the nurse should

or Sims position, depending on the

contour of the lower abdomen for a

note this on the laboratory request.

physicians preference.

rounded mass above the symphysis pubis.

92. Maslows hierarchy of needs must be met

99. The best way to prevent pressure ulcers is

in the following order: physiologic (oxygen,

to reposition the bedridden patient at least

food, water, sex, rest, and comfort), safety

every 2 hours.

and security, love and belonging, self-

100. Antiembolism stockings decompress the

109. During lumbar puncture, the nurse must

note the initial intracranial pressure and
the color of the cerebrospinal fluid.
110. If a patient cant cough to provide a
sputum sample for culture, a heated

esteem and recognition, and self-

superficial blood vessels, reducing the

aerosol treatment can be used to help to


risk of thrombus formation.

obtain a sample.

93. When caring for a patient who has a

101. In adults, the most convenient veins for

111. If eye ointment and eye drops must be

nasogastric tube, the nurse should apply a

venipuncture are the basilic and median

instilled in the same eye, the eye drops

water-soluble lubricant to the nostril to

cubital veins in the antecubital space.

should be instilled first.

prevent soreness.
94. During gastric lavage, a nasogastric tube is

102. Two to three hours before beginning a

112. When leaving an isolation room, the

tube feeding, the nurse should aspirate

nurse should remove her gloves before

inserted, the stomach is flushed, and

the patients stomach contents to verify

her mask because fewer pathogens are

ingested substances are removed through

that gastric emptying is adequate.

on the mask.

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 Babinskis reflex, the nurse strokes

103. People with type O blood are considered

universal donors.
104. People with type AB blood are
considered universal recipients.
105. Hertz (Hz) is the unit of measurement of
sound frequency.
106. Hearing protection is required when the

113. Skeletal traction, which is applied to a

bone with wire pins or tongs, is the most
effective means of traction.
114. The total parenteral nutrition solution
should be stored in a refrigerator and
removed 30 to 60 minutes before use.
Delivery of a chilled solution can cause

the sole of the patients foot with a

sound intensity exceeds 84 dB. Double

pain, hypothermia, venous spasm, and

moderately sharp object, such as a

hearing protection is required if it

venous constriction.


exceeds 104 dB.

97. A positive Babinskis reflex is shown by

dorsiflexion of the great toe and fanning
out of the other toes.

107. Prothrombin, a clotting factor, is

produced in the liver.

115. Drugs arent routinely injected

intramuscularly into edematous tissue
because they may not be absorbed.

116. When caring for a comatose patient, the

125. A patients bed bath should proceed in

134. Wheezing is an abnormal, high-pitched

nurse should explain each action to the

this order: face, neck, arms, hands,

breath sound thats accentuated on

patient in a normal voice.

chest, abdomen, back, legs, perineum.


117. Dentures should be cleaned in a sink

thats lined with a washcloth.
118. A patient should void within 8 hours
after surgery.
119. An EEG identifies normal and abnormal
brain waves.
120. Samples of feces for ova and parasite
tests should be delivered to the

126. To prevent injury when lifting and

135. Wax or a foreign body in the ear should

moving a patient, the nurse should

be flushed out gently by irrigation with

primarily use the upper leg muscles.

warm saline solution.

127. Patient preparation for

136. If a patient complains that his hearing

cholecystography includes ingestion of a

aid is not working, the nurse should

contrast medium and a low-fat evening

check the switch first to see if its turned


on and then check the batteries.

128. While an occupied bed is being

137. The nurse should grade hyperactive

laboratory without delay and without

changed, the patient should be covered

biceps and triceps reflexes as +4.


with a bath blanket to promote warmth

138. If two eye medications are prescribed

121. The autonomic nervous system

regulates the cardiovascular and
respiratory systems.
122. When providing tracheostomy care, the
nurse should insert the catheter gently

and prevent exposure.

129. Anticipatory grief is mourning that
occurs for an extended time when the
patient realizes that death is inevitable.
130. The following foods can alter the color of

for twice-daily instillation, they should be

administered 5 minutesAPART .
139. In a postoperative patient, forcing fluids
helps prevent constipation.
140. A nurse must provide care in

into the tracheostomy tube. When

the feces: beets (red), cocoa (dark red or

accordance with standards of care

withdrawing the catheter, the nurse

brown), licorice (black), spinach (green),

established by the American Nurses

should apply intermittent suction for no

and meat protein (dark brown).

Association, state regulations, and facility

more than 15 seconds and use a slight

twisting motion.
123. A low-residue diet includes such foods
as roasted chicken, rice, and pasta.
124. A rectal tube shouldnt be inserted for
longer than 20 minutes because it can

131. When preparing for a skull X-ray, the

patient should remove all jewelry and
132. The fight-or-flight response is a
sympathetic nervous system response.
133. Bronchovesicular breath sounds in

141. The kilocalorie (kcal) is a unit of energy
measurement that represents the
amount of heat needed to raise the
temperature of 1 kilogram of water 1 C.
142. As nutrients move through the body,

irritate the rectal mucosa and cause loss

peripheral lung fields are abnormal and

they undergo ingestion, digestion,

of sphincter control.

suggest pneumonia.

absorption, transport, cell metabolism,

and excretion.

143. The body metabolizes alcohol at a fixed

rate, regardless of serum concentration.
144. In an alcoholic beverage, proof reflects

nitroglycerin should be used to relieve

acute anginal attacks.
151. The implementation phase of the

157. After receiving preoperative medication,

a patient isnt competent to sign an
informed consent form.

the percentage of alcohol multiplied by 2.

nursing process involves recording the

For example, a 100-proof beverage

patients response to the nursing plan,

weight of her body instead of the

contains 50% alcohol.

putting the nursing plan into action,

strength in her arms.

145. A living will is a witnessed document

that states a patients desire for certain
types of care and treatment. These

delegating specific nursing interventions,

and coordinating the patients activities.
152. The Patients Bill of Rights offers

158. When lifting a patient, a nurse uses the

159. A nurse may clarify a physicians

explanation about an operation or a
procedure to a patient, but must refer

decisions are based on the patients

patients guidance and protection by

questions about informed consent to the

wishes and views on quality of life.

stating the responsibilities of the hospital


146. The nurse should flush a peripheral

heparin lock every 8 hours (if it wasnt
used during the previous 8 hours) and as

and its staff toward patients and their

families during hospitalization.
153. To minimize omission and distortion of

needed with normal saline solution to

facts, the nurse should record

maintain patency.

information as soon as its gathered.

147. Quality assurance is a method of

154. When assessing a patients health

determining whether nursing actions and

history, the nurse should record the

practices meet established standards.

current illness chronologically, beginning

148. The five rights of medication

administration are the right patient, right

acutely ill or agitated patient, the nurse

should limit questions to those that
provide necessary information.
161. If a chest drainage system line is broken
or interrupted, the nurse should clamp
the tube immediately.
162. The nurse shouldnt use her thumb to

with the onset of the problem and

take a patients pulse rate because the

continuing to the present.

thumb has a pulse that may be confused

drug, right dose, right route of

155. When assessing a patients health

administration, and right time.

history, the nurse should record the

149. The evaluation phase of the nursing

160. When obtaining a health history from an

current illness chronologically, beginning

with the patients pulse.

163. An inspiration and an expiration count
as one respiration.

process is to determine whether nursing

with the onset of the problem and

164. Eupnea is normal respiration.

interventions have enabled the patient to

continuing to the present.

165. During blood pressure measurement,

meet the desired goals.

150. Outside of the hospital setting, only the
sublingual and translingual forms of

156. A nurse shouldnt give false assurance

to a patient.

the patient should rest the arm against a

surface. Using muscle strength to hold up
the arm may raise the blood pressure.

166. Major, unalterable risk factors for

174. Normal gait has two phases: the stance

182. A correctly written patient goal

coronary artery disease include heredity,

phase, in which the patients foot rests

expresses the desired patient behavior,

sex, race, and age.

on the ground, and the swing phase, in

criteria for measurement, time frame for

which the patients foot moves forward.

achievement, and conditions under which

167. Inspection is the most frequently used

assessment technique.
168. Family members of an elderly person in
a long-term care facility should transfer

175. The phases of mitosis are prophase,

metaphase, anaphase, and telophase.
176. The nurse should follow standard

the behavior will occur. Its developed in

collaboration with the patient.
183. Percussion causes five basic notes:

some personal items (such as

precautions in the routine care of all

tympany (loud intensity, as heard over a

photographs, a favorite chair, and


gastric air bubble or puffed out cheek),

knickknacks) to the persons room to

provide a comfortable atmosphere.
169. Pulsus alternans is a regular pulse
rhythm with alternating weak and strong

177. The nurse should use the bell of the

hyperresonance (very loud, as heard over

stethoscope to listen for venous hums

an emphysematous lung), resonance

and cardiac murmurs.

(loud, as heard over a normal lung),

178. The nurse can assess a patients

dullness (medium intensity, as heard

beats. It occurs in ventricular

general knowledge by asking questions

over the liver or other solid organ), and

enlargement because the stroke volume

such as Who is the president of the

flatness (soft, as heard over the thigh).

varies with each heartbeat.

United States?

170. The upper respiratory tract warms and

184. The optic disk is yellowish pink and

179. Cold packs are applied for the first 20 to

circular, with a distinct border.

humidifies inspired air and plays a role in

48 hours after an injury; then heat is

185. A primary disability is caused by a

taste, smell, and mastication.

applied. During cold application, the pack

pathologic process. A secondary

is applied for 20 minutes and then

disability is caused by inactivity.

171. Signs of accessory muscle use include

shoulder elevation, intercostal muscle

removed for 10 to 15 minutes to prevent

retraction, and scalene and

reflex dilation (rebound phenomenon)

failing to keep an accurate count of

sternocleidomastoid muscle use during

and frostbite injury.

sponges and other devices during

172. When patients use axillary crutches,

180. The pons is located above the medulla

and consists of white matter (sensory

186. Nurses are commonly held liable for

187. The best dietary sources of vitamin B6

their palms should bear the brunt of the

and motor tracts) and gray matter (reflex

are liver, kidney, pork, soybeans, corn,



and whole-grain cereals.

173. Activities of daily living include eating,

bathing, dressing, grooming, toileting,
and interacting socially.

181. The autonomic nervous system controls

the smooth muscles.

188. Iron-rich foods, such as organ meats,

nuts, legumes, dried fruit, green leafy

vegetables, eggs, and whole grains,

attempt to obliterate documentation or

recovery. In addition, he should have an

commonly have a low water content.

leave vacant lines.

opportunity to ask questions.

189. Collaboration is joint communication

196. Factors that affect body temperature

and decision making between nurses and

include time of day, age, physical

physicians. Its designed to meet

activity, phase of menstrual cycle, and

patients needs by integrating the care


regimens of both professions into one

comprehensive approach.
190. Bradycardia is a heart rate of fewer than
60 beats/minute.
191. A nursing diagnosis is a statement of a
patients actual or potential health

197. The most accessible and commonly

202. A patient must sign a separate informed

consent form for each procedure.
203. During percussion, the nurse uses quick,
sharp tapping of the fingers or hands
against body surfaces to produce sounds.

used artery for measuring a patients

This procedure is done to determine the

pulse rate is the radial artery. To take the

size, shape, position, and density of

pulse rate, the artery is compressed

underlying organs and tissues; elicit

against the radius.

tenderness; or assess reflexes.

198. In a resting adult, the normal pulse rate

204. Ballottement is a form of light palpation

problem that can be resolved,

is 60 to 100 beats/minute. The rate is

involving gentle, repetitive bouncing of

diminished, or otherwise changed by

slightly faster in women than in men and

tissues against the hand and feeling their

nursing interventions.

much faster in children than in adults.


192. During the assessment phase of the

nursing process, the nurse collects and
analyzes three types of data: health

199. Laboratory test results are an objective

form of assessment data.
200. The measurement systems most

205. A foot cradle keeps bed linen off the

patients feet to prevent skin irritation
and breakdown, especially in a patient

history, physical examination, and

commonly used in clinical practice are

who has peripheral vascular disease or

laboratory and diagnostic test data.

the metric system, apothecaries system,


193. The patients health history consists

primarily of subjective data, information
thats supplied by the patient.
194. The physical examination includes

and household system.

201. Before signing an informed consent

206. Gastric lavage is flushing of the stomach

and removal of ingested substances

form, the patient should know whether

through a nasogastric tube. Its used to

other treatment options are available and

treat poisoning or drug overdose.

objective data obtained by inspection,

should understand what will occur during

palpation, percussion, and auscultation.

the preoperative, intraoperative, and

nursing process, the nurse assesses the

postoperative phases; the risks involved;

patients response to therapy.

195. When documenting patient care, the

nurse should write legibly, use only

and the possible complications. The

standard abbreviations, and sign each

patient should also have a general idea

entry. The nurse should never destroy or

of the time required from surgery to

207. During the evaluation step of the

208. Bruits commonly indicate life- or limbthreatening vascular disease.

209. O.U. means each eye. O.D. is the right

eye, and O.S. is the left eye.
210. To remove a patients artificial eye, the
nurse depresses the lower lid.
211. The nurse should use a warm saline

219. Gauge is the inside diameter of a

needle: the smaller the gauge, the larger
the diameter.
220. An adult normally has 32 permanent

should use a 5/8 25G needle.

8. The notation AA & O 3 indicates that the
patient is awake, alert, and oriented to
person (knows who he is), place (knows

solution to clean an artificial eye.

where he is), and time (knows the date and

212. A thready pulse is very fine and scarcely



213. Axillary temperature is usually 1 F
lower than oral temperature.

7. For a subcutaneous injection, the nurse

9. Fluid intake includes all fluids taken by

mouth, including foods that are liquid at

1. After turning a patient, the nurse should

room temperature, such as gelatin, custard,

214. After suctioning a tracheostomy tube,

document the position used, the time that

and ice cream; I.V. fluids; and fluids

the nurse must document the color,

the patient was turned, and the findings of

administered in feeding tubes. Fluid output

amount, consistency, and odor of

skin assessment.

includes urine, vomitus, and drainage (such

215. On a drug prescription, the abbreviation
p.c. means that the drug should be
administered after meals.
216. After bladder irrigation, the nurse should
document the amount, color, and clarity
of the urine and the presence of clots or
217. After bladder irrigation, the nurse should
document the amount, color, and clarity

2. PERRLA is an abbreviation for normal pupil

assessment findings: pupils equal, round,

as well as blood loss, diarrhea or feces, and

and reactive to light with accommodation.


3. When percussing a patients chest for

injection, the nurse shouldnt massage the

be cupped.

area because massage can irritate the site

4. When measuring a patients pulse, the nurse

should assess its rate, rhythm, quality, and
5. Before transferring a patient from a bed to a
wheelchair, the nurse should push the


wheelchair footrests to the sides and lock its

determination vary from state to state.

10. After administering an intradermal

postural drainage, the nurses hands should

of the urine and the presence of clots or

218. Laws regarding patient self-

as from a nasogastric tube or from a wound)

6. When assessing respirations, the nurse

and interfere with results.

11. When administering an intradermal
injection, the nurse should hold the syringe
almost flat against the patients skin (at
about a 15-degree angle), with the bevel up.
12. To obtain an accurate blood pressure, the
nurse should inflate the manometer to 20 to
30 mm Hg above the disappearance of the

Therefore, the nurse must be familiar

should document their rate, rhythm, depth,

radial pulse before releasing the cuff

with the laws of the state in which she

and quality.



13. The nurse should count an irregular pulse

for 1 full minute.

22. States have enacted Good Samaritan laws

29. To minimize interruptions during a patient

to encourage professionals to provide

interview, the nurse should select a private

medical assistance at the scene of an

room, preferably one with a door that can

should be placed in a lateral position to

accident without fear of a lawsuit arising

be closed.

prevent aspiration of vomitus.

from the assistance. These laws dont apply

14. A patient who is vomiting while lying down

15. Prophylaxis is disease prevention.

16. Body alignment is achieved when body

to care provided in a health care facility.

23. A physician should sign verbal and

parts are in proper relation to their natural

telephone orders within the time established


by facility policy, usually 24 hours.

17. Trust is the foundation of a nurse-patient

18. Blood pressure is the force exerted by the
circulating volume of blood on the arterial
19. Malpractice is a professionals wrongful
conduct, improper discharge of duties, or
failure to meet standards of care that
causes harm to another.
20. As a general rule, nurses cant refuse a
patient care assignment; however, in most
states, they may refuse to participate in

24. A competent adult has the right to refuse

lifesaving medical treatment; however, the
individual should be fully informed of the
consequences of his refusal.
25. Although a patients health record, or chart,
is the health care facilitys physical
property, its contents belong to the patient.
26. Before a patients health record can be
released to a third party, the patient or the
patients legal guardian must give written
27. Under the Controlled Substances Act, every

30. In categorizing nursing diagnoses, the

nurse addresses life-threatening problems
first, followed by potentially life-threatening
31. The major components of a nursing care
plan are outcome criteria (patient goals) and
nursing interventions.
32. Standing orders, or protocols, establish
guidelines for treating a specific disease or
set of symptoms.
33. In assessing a patients heart, the nurse
normally finds the point of maximal impulse
at the fifth intercostal space, near the apex.
34. The S1 heard on auscultation is caused by
closure of the mitral and tricuspid valves.
35. To maintain package sterility, the nurse
should open a wrappers top flap away from

dose of a controlled drug thats dispensed

the body, open each side flap by touching

by the pharmacy must be accounted for,

only the outer part of the wrapper, and open

is injured because the nurse failed to

whether the dose was administered to a

the final flap by grasping the turned-down

perform a duty that a reasonable and

patient or discarded accidentally.

corner and pulling it toward the body.

21. A nurse can be found negligent if a patient

prudent person would perform or because

28. A nurse cant perform duties that violate a

36. The nurse shouldnt dry a patients ear

the nurse performed an act that a

rule or regulation established by a state

canal or remove wax with a cotton-tipped

reasonable and prudent person wouldnt

licensing board, even if they are authorized

applicator because it may force cerumen


by a health care facility or physician.

against the tympanic membrane.

37. A patients identification bracelet should

44. Activities of daily living are actions that the

54. The hypothalamus secretes vasopressin

remain in place until the patient has been

patient must perform every day to provide

and oxytocin, which are stored in the

discharged from the health care facility and

self-care and to interact with society.

pituitary gland.

has left the premises.

38. The Controlled Substances Act designated

45. Testing of the six cardinal fields of gaze

55. The three membranes that enclose the

evaluates the function of all extraocular

brain and spinal cord are the dura mater,

five categories, or schedules, that classify

muscles and cranial nerves III, IV, and VI.

pia mater, and arachnoid.

controlled drugs according to their abuse

46. The six types of heart murmurs are graded

56. A nasogastric tube is used to remove fluid


from 1 to 6. A grade 6 heart murmur can be

and gas from the small intestine

39. Schedule I drugs, such as heroin, have a

heard with the stethoscope slightly raised

preoperatively or postoperatively.

high abuse potential and have no currently

from the chest.

accepted medical use in the United States.

40. Schedule II drugs, such as morphine,
opium, and meperidine (Demerol), have a

47. The most important goal to include in a

care plan is the patients goal.
48. Fruits are high in fiber and low in protein,

high abuse potential, but currently have

and should be omitted from a low-residue

accepted medical uses. Their use may lead


to physical or psychological dependence.

41. Schedule III drugs, such as paregoric and
butabarbital (Butisol), have a lower abuse
potential than Schedule I or II drugs. Abuse

49. The nurse should use an objective scale to

57. Psychologists, physical therapists, and

chiropractors arent authorized to write
prescriptions for drugs.
58. The area around a stoma is cleaned with
mild soap and water.
59. Vegetables have a high fiber content.
60. The nurse should use a tuberculin syringe

assess and quantify pain. Postoperative pain

to administer a subcutaneous injection of

varies greatly among individuals.

less than 1 ml.

50. Postmortem care includes cleaning and

61. For adults, subcutaneous injections require

of Schedule III drugs may lead to moderate

preparing the deceased patient for family

a 25G 1 needle; for infants, children,

or low physical or psychological

viewing, arranging transportation to the

elderly, or very thin patients, they require a

dependence, or both.

morgue or funeral home, and determining

25G to 27G needle.

42. Schedule IV drugs, such as chloral hydrate,

have a low abuse potential compared with
Schedule III drugs.
43. Schedule V drugs, such as cough syrups
that contain codeine, have the lowest abuse
potential of the controlled substances.

the disposition of belongings.

51. The nurse should provide honest answers
to the patients questions.
52. Milk shouldnt be included in a clear liquid
53. When caring for an infant, a child, or a

62. Before administering a drug, the nurse

should identify the patient by checking the
identification band and asking the patient to
state his name.
63. To clean the skin before an injection, the
nurse uses a sterile alcohol swab to wipe

confused patient, consistency in nursing

from the center of the site outward in a

personnel is paramount.

circular motion.

64. The nurse should inject heparin deep into

71. The hearing aid thats marked with a blue

80. The nurse should administer procaine

subcutaneous tissue at a 90-degree angle

dot is for the left ear; the one with a red dot

penicillin by deep I.M. injection in the upper

(perpendicular to the skin) to prevent skin

is for the right ear.

outer portion of the buttocks in the adult or

65. If blood is aspirated into the syringe before
an I.M. injection, the nurse should withdraw
the needle, prepare another syringe, and
repeat the procedure.
66. The nurse shouldnt cut the patients hair
without written consent from the patient or
an appropriate relative.
67. If bleeding occurs after an injection, the

72. A hearing aid shouldnt be exposed to heat

or humidity and shouldnt be immersed in
73. The nurse should instruct the patient to
avoid using hair spray while wearing a
hearing aid.
74. The five branches of pharmacology are

in the midlateral thigh in the child. The

nurse shouldnt massage the injection site.
81. An ascending colostomy drains fluid feces.
A descending colostomy drains solid fecal
82. A folded towel (scrotal bridge) can provide
scrotal support for the patient with scrotal

pharmacokinetics, pharmacodynamics,

edema caused by vasectomy, epididymitis,

pharmacotherapeutics, toxicology, and

or orchitis.

nurse should apply pressure until the


bleeding stops. If bruising occurs, the nurse

75. The nurse should remove heel

has a bleeding disorder, the nurse should

should monitor the site for an enlarging

protectors every 8 hours to inspect the foot

use a small-gauge needle and apply


for signs of skin breakdown.

pressure to the site for 5 minutes after the

68. When providing hair and scalp care, the

nurse should begin combing at the end of
the hair and work toward the head.
69. The frequency of patient hair care depends
on the length and texture of the hair, the
duration of hospitalization, and the patients

76. Heat is applied to promote vasodilation,

which reduces pain caused by inflammation.
77. A sutured surgical incision is an example of
healing by first intention (healing directly,
without granulation).
78. Healing by secondary intention (healing by

83. When giving an injection to a patient who

84. Platelets are the smallest and most fragile
formed element of the blood and are
essential for coagulation.
85. To insert a nasogastric tube, the nurse
instructs the patient to tilt the head back

granulation) is closure of the wound when

slightly and then inserts the tube. When the

granulation tissue fills the defect and allows

nurse feels the tube curving at the pharynx,

careful handling during insertion and

reepithelialization to occur, beginning at the

the nurse should tell the patient to tilt the

removal, regular cleaning of the ear piece to

wound edges and continuing to the center,

head forward to close the trachea and open

prevent wax buildup, and prompt

until the entire wound is covered.

the esophagus by swallowing. (Sips of water

replacement of dead batteries.

79. Keloid formation is an abnormality in

can facilitate this action.)

70. Proper function of a hearing aid requires

healing thats characterized by overgrowth

of scar tissue at the wound site.

86. Families with loved ones in intensive care

units report that their four most important

needs are to have their questions answered

92. Fidelity means loyalty and can be shown as

101. The two nursing diagnoses that have the

honestly, to be assured that the best

a commitment to the profession of nursing

highest priority that the nurse can assign

possible care is being provided, to know the

and to the patient.

are Ineffective airway clearance and

patients prognosis, and to feel that there is

hope of recovery.
87. Double-bind communication occurs when
the verbal message contradicts the
nonverbal message and the receiver is
unsure of which message to respond to.
88. A nonjudgmental attitude displayed by a

93. Administering an I.M. injection against the

patients will and without legal authority is
94. An example of a third-party payer is an
insurance company.
95. The formula for calculating the drops per
minute for an I.V. infusion is as follows:

nurse shows that she neither approves nor

(volume to be infused drip factor) time

disapproves of the patient.

in minutes = drops/minute

89. Target symptoms are those that the patient

finds most distressing.
90. A patient should be advised to take aspirin

96. On-call medication should be given within 5

minutes of the call.
97. Usually, the best method to determine a

on an empty stomach, with a full glass of

patients cultural or spiritual needs is to ask

water, and should avoid acidic foods such as


coffee, citrus fruits, and cola.

91. For every patient problem, there is a

98. An incident report or unusual occurrence

report isnt part of a patients record, but is

nursing diagnosis; for every nursing

an in-house document thats used for the

diagnosis, there is a goal; and for every

purpose of correcting the problem.

goal, there are interventions designed to

make the goal a reality. The keys to

99. Critical pathways are a multidisciplinary

guideline for patient care.

answering examination questions correctly

are identifying the problem presented,

Ineffective breathing pattern.

102. A subjective sign that a sitz bath has been
effective is the patients expression of
decreased pain or discomfort.
103. For the nursing diagnosis Deficient
diversional activity to be valid, the
patient must state that hes bored, that
he has nothing to do, or words to that
104. The most appropriate nursing diagnosis
for an individual who doesnt speak
English is Impaired verbal communication
related to inability to speak dominant
language (English).
105. The family of a patient who has been
diagnosed as hearing impaired should be
instructed to face the individual when
they speak to him.

100. When prioritizing nursing diagnoses, the

formulating a goal for the problem, and

following hierarchy should be used:

selecting the intervention from the choices

Problems associated with the airway,

a patient who is up to age 3, the nurse

provided that will enable the patient to

those concerning breathing, and those

should pull the pinna down and back to

reach that goal.

related to circulation.

straighten the eustachian tube.

106. Before instilling medication into the ear of

107. To prevent injury to the cornea when

114. When feeding an elderly patient, the

121. A shift to the right is evident when the

administering eyedrops, the nurse should

nurse should limit high-carbohydrate

number of mature cells in the blood

waste the first drop and instill the drug in

foods because of the risk of glucose

increases, as seen in advanced liver

the lower conjunctival sac.


disease and pernicious anemia.

108. After administering eye ointment, the

nurse should twist the medication tube to

115. When feeding an elderly patient, essential

foods should be given first.

detach the ointment.

mask, she should remove the gloves first.

mobility. Resistive exercises increase

signed and attached to the patients


muscle mass.

They are soiled and are likely to contain


medication, the nurse should ensure that

an informed consent form has been

116. Passive range of motion maintains joint

109. When the nurse removes gloves and a

122. Before administering preoperative

123. A nurse should spend no more than 30

117. Isometric exercises are performed on an
extremity thats in a cast.

minutes per 8-hour shift providing care to

a patient who has a radiation implant.

110. Crutches should be placed 6 (15.2 cm) in

front of the patient and 6 to the side to
form a tripod arrangement.
111. Listening is the most effective
communication technique.
112. Before teaching any procedure to a

118. A back rub is an example of the gatecontrol theory of pain.

119. Anything thats located below the waist is
considered unsterile; a sterile field

124. A nurse shouldnt be assigned to care for

more than one patient who has a
radiation implant.
125. Long-handled forceps and a lead-lined

becomes unsterile when it comes in

container should be available in the room

contact with any unsterile item; a sterile

of a patient who has a radiation implant.

patient, the nurse must assess the

field must be monitored continuously;

patients current knowledge and

and a border of 1 (2.5 cm) around a

willingness to learn.

sterile field is considered unsterile.

126. Usually, patients who have the same

infection and are in strict isolation can
share a room.

113. Process recording is a method of

120. A shift to the left is evident when the

evaluating ones communication

number of immature cells (bands) in the


blood increases to fight an infection.

127. Diseases that require strict isolation

include chickenpox, diphtheria, and viral
hemorrhagic fevers such as Marburg

128. For the patient who abides by Jewish

custom, milk and meat shouldnt be

incapacitating disease is to help him to

and other Hispanic and Latino groups,

mobilize a support system.

most foods, beverages, herbs, and drugs

served at the same meal.

are described as cold.

133. Hyperpyrexia is extreme elevation in

129. Whether the patient can perform a

temperature above 106 F (41.1 C).

procedure (psychomotor domain of

learning) is a better indicator of the
effectiveness of patient teaching than
whether the patient can simply state the
steps involved in the procedure
(cognitive domain of learning).
130. According to Erik Erikson, developmental
stages are trust versus mistrust (birth to
18 months), autonomy versus shame and
doubt (18 months to age 3), initiative
versus guilt (ages 3 to 5), industry versus
inferiority (ages 5 to 12), identity versus
identity diffusion (ages 12 to 18),

individuals of a particular group.

134. Milk is high in sodium and low in iron.
142. Discrimination is preferential treatment of
135. When a patient expresses concern about a
health-related issue, before addressing

to 60), and ego integrity versus despair

patients level of knowledge.

usually discussed in a negative sense.

143. Increased gastric motility interferes with
the absorption of oral drugs.

136. The most effective way to reduce a fever

is to administer an antipyretic, which
lowers the temperature set point.

144. The three phases of the therapeutic

relationship are orientation, working, and

137. When a patient is ill, its essential for the

members of his family to maintain
communication about his health needs.

145. Patients often exhibit resistive and

challenging behaviors in the orientation
phase of the therapeutic relationship.

138. Ethnocentrism is the universal belief that

ones way of life is superior to others.

(older than age 60).

146. Abdominal assessment is performed in the

following order: inspection, auscultation,

139. When a nurse is communicating with a

131. When communicating with a hearing

individuals of a particular group. Its

the concern, the nurse should assess the

intimacy versus isolation (ages 18 to 25),

generativity versus stagnation (ages 25

141. Prejudice is a hostile attitude toward

percussion & palpation.

patient through an interpreter, the nurse

impaired patient, the nurse should face

should speak to the patient and the



147. When measuring blood pressure in a

neonate, the nurse should select a cuff
thats no less than one-half and no more

132. An appropriate nursing intervention for

the spouse of a patient who has a serious

140. In accordance with the hot-cold system

used by some Mexicans, Puerto Ricans,

than two-thirds the length of the

extremity thats used.

148. When administering a drug by Z-track, the

pain is cardiac. It would be more

hypoventilation and abnormal breathing

nurse shouldnt use the same needle that

appropriate to make further

patterns, such as Korsakoffs, Biots, or

was used to draw the drug into the


Cheyne-Stokes respiration.

syringe because doing so could stain the

149. Sites for intradermal injection include the
inner arm, the upper chest, and on the

152. Veracity is truth and is an essential

158. C = Circulation. This category includes

component of a therapeutic relationship

everything that affects the circulation,

between a health care provider and his

including fluid and electrolyte


disturbances and disease processes that

back, under the scapula.

affect cardiac output.

153. Beneficence is the duty to do no harm and

150. When evaluating whether an answer on

the duty to do good. Theres an

159. D = Disease processes. If the patient has

an examination is correct, the nurse

obligation in patient care to do no harm

no problem with the airway, breathing, or

should consider whether the action thats

and an equal obligation to assist the

circulation, then the nurse should

described promotes autonomy


evaluate the disease processes, giving

(independence), safety, self-esteem, and

a sense of belonging.
151. When answering a question on the NCLEX

priority to the disease process that poses

154. Nonmaleficence is the duty to do no harm.
155. Fryes ABCDE cascade provides a

examination, the student should consider

framework for prioritizing care by

the cue (the stimulus for a thought) and

identifying the most important treatment

the inference (the thought) to determine


whether the inference is correct. When in

doubt, the nurse should select an answer
that indicates the need for further
information to eliminate ambiguity. For
example, the patient complains of chest
pain (the stimulus for the thought) and
the nurse infers that the patient is having
cardiac pain (the thought). In this case,
the nurse hasnt confirmed whether the

156. A = Airway. This category includes

everything that affects a patent airway,
including a foreign object, fluid from an
upper respiratory infection, and edema
from trauma or an allergic reaction.
157. B = Breathing. This category includes
everything that affects the breathing
pattern, including hyperventilation or

the greatest immediate risk. For

example, if a patient has terminal cancer
and hypoglycemia, hypoglycemia is a
more immediate concern.
160. E = Everything else. This category
includes such issues as writing an
incident report and completing the
patient chart. When evaluating needs,
this category is never the highest priority.
161. When answering a question on an NCLEX
examination, the basic rule is assess
before action. The student should
evaluate each possible answer carefully.

Usually, several answers reflect the


implementation phase of nursing and one

169. A value cohort is a group of people

or two reflect the assessment phase. In

who experienced an out-of-the-ordinary

this case, the best choice is an

event that shaped their values.

163. Egalitarian theory emphasizes that equal

access to goods and services must be
provided to the less fortunate by an
affluent society.
164. Active euthanasia is actively helping a
person to die.
165. Brain death is irreversible cessation of all
brain function.
166. Passive euthanasia is stopping the
therapy thats sustaining life.

171. Bananas, citrus fruits, and potatoes are

good sources of potassium.
172. Good sources of magnesium include fish,

control theory.

nuts, and grains.

188. Rombergs test is a test for balance or
173. Beef, oysters, shrimp, scallops, spinach,


beets, and greens are good sources of


189. Pain seems more intense at night because

the patient isnt distracted by daily

174. Intrathecal injection is administering a


drug through the spine.

190. Older patients commonly dont report pain
175. When a patient asks a question or makes
a statement thats emotionally charged,

because of fear of treatment, lifestyle

changes, or dependency.

the nurse should respond to the emotion

than to whats being said or asked.

183. A Hindu patient is likely to request a
168. Utilization review is performed to

187. Alleviating pain by performing a back

massage is consistent with the gate

behind the statement or question rather

167. A third-party payer is an insurance

186. Referred pain is pain thats felt at a site

other than its origin.

162. Rule utilitarianism is known as the

of people theory.

185. The difference between acute pain and

170. Voluntary euthanasia is actively helping a

patient to die at the patients request.

greatest good for the greatest number

initial point at which a patient feels pain.

chronic pain is its duration.

assessment response unless a specific

course of action is clearly indicated.

184. Pain threshold, or pain sensation, is the

vegetarian diet.

191. No pork or pork products are allowed in a

Muslim diet.
192. Two goals of Healthy People 2010 are:
193. Help individuals of all ages to

determine whether the care provided to a

increase the quality of life and the

patient was appropriate and cost-

number of years of optimal health

194. Eliminate health disparities among

different segments of the population.
195. A community nurse is serving as a

202. On noticing religious artifacts and

literature on a patients night stand, a

sample to measure glucose, ketone, pH,

culturally aware nurse would ask the

and specific gravity values.

patient the meaning of the items.

patients advocate if she tells a

malnourished patient to go to a meal
program at a local park.

212. To induce sleep, the first step is to

203. A Mexican patient may request the

the patient.

plan, the nurse should first ask why.

213. Before moving a patient, the nurse should

assess the patients physical abilities and
ability to understand instructions as well

204. In an infant, the normal hemoglobin value

197. Falls are the leading cause of injury in

minimize environmental stimuli.

intervention of a curandero, or faith

healer, who involves the family in healing

196. If a patient isnt following his treatment

211. First-morning urine provides the best

is 12 g/dl.

as the amount of strength required to

move the patient.

elderly people.
205. The nitrogen balance estimates the
198. Primary prevention is true prevention.
Examples are immunizations, weight

difference between the intake and use of

must decrease his weekly intake by


3,500 calories (approximately 500

control, and smoking cessation.

calories daily). To lose 2 lb (1 kg) in 1

206. Most of the absorption of water occurs in

199. Secondary prevention is early detection.

the large intestine.

Examples include purified protein

derivative (PPD), breast self-examination,
testicular self-examination, and chest X-

207. Most nutrients are absorbed in the small


208. When assessing a patients eating habits,
200. Tertiary prevention is treatment to prevent
long-term complications.
201. A patient indicates that hes coming to

the nurse should ask, What have you

eaten in the last 24 hours?
210. A hypotonic enema softens the feces,

terms with having a chronic disease

distends the colon, and stimulates

when he says, Im never going to get


any better.

214. To lose 1 lb (0.5 kg) in 1 week, the patient

week, the patient must decrease his

weekly caloric intake by 7,000 calories
(approximately 1,000 calories daily).
215. To avoid shearing force injury, a patient
who is completely immobile is lifted on a
216. To insert a catheter from the nose through
the trachea for suction, the nurse should
ask the patient to swallow.
217. Vitamin C is needed for collagen

218. Only the patient can describe his pain


225. Exacerbations of chronic disease usually

cause the patient to seek treatment and

232. Distributive justice is a principle that

promotes equal treatment for all.

may lead to hospitalization.

219. Cutaneous stimulation creates the release
of endorphins that block the transmission
of pain stimuli.

233. Milk and milk products, poultry, grains,

226. School health programs provide costeffective health care for low-income
families and those who have no health

220. Patient-controlled analgesia is a safe


method to relieve acute pain caused by

surgical incision, traumatic injury, labor
and delivery, or cancer.

collaboration, development, and

228. A change agent is an individual who
recognizes a need for change or is

222. The patient who believes in a scientific, or

biomedical, approach to health is likely to

selected to make a change within an

established entity, such as a hospital.

expect a drug, treatment, or surgery to

cure illness.

229. The patients bill of rights was introduced

by the American Hospital Association.

223. Chronic illnesses occur in very young as

well as middle-aged and very old people.

230. Abandonment is premature termination of

treatment without the patients

224. The trajectory framework for chronic

illness states that preferences about

permission and without appropriate relief

of symptoms.

daily life activities affect treatment


an oriented, but restless, elderly patient

227. Collegiality is the promotion of

typically places distance between himself

and others when communicating.

234. The best way to prevent falls at night in

is to raise the side rails.

interdependence among members of a

221. An Asian American or European American

and fish are good sources of phosphate.

231. Values clarification is a process that

individuals use to prioritize their personal

235. By the end of the orientation phase, the

patient should begin to trust the nurse.
236. Falls in the elderly are likely to be caused
by poor vision.
237. Barriers to communication include
language deficits, sensory deficits,
cognitive impairments, structural deficits,
and paralysis.
238. The three elements that are necessary for
a fire are heat, oxygen, and combustible
239. Sebaceous glands lubricate the skin.
240. To check for petechiae in a dark-skinned
patient, the nurse should assess the oral

241. To put on a sterile glove, the nurse should

pick up the first glove at the folded

244. Seventh-Day Adventists are usually


border and adjust the fingers when both

gloves are on.

245. Endorphins are morphine-like substances

that produce a feeling of well-being.

242. To increase patient comfort, the nurse

should let the alcohol dry before giving
an intramuscular injection.

246. Pain tolerance is the maximum amount

and duration of pain that an individual is
willing to endure.

243. Treatment for a stage 1 ulcer on the heels

includes heel protectors.