question

What can a blood pressure cuff that's too narrow cause?

answer

falsely elevated BP reading

question

this insulin should be drawn up into the syringe first so it doesn't contaminate the other type of insulin

answer

regular

question

rumbling sounds heard on lung auscultation

answer

rhonci

question

this type of adventitious lung sounds can be more pronounced during expiration than during inspiration

answer

rhonchi

question

forced feeding, usually through a gastric tube

answer

gavage

question

a tube passed into the stomach through the mouth

answer

gastric tube

question

What portion of Maslow's hierarchy of needs has the highest priority?

answer

physiologic needs (air, water, food, shelter, activity, comfort)

question

this is the safest and surest way to verify a patient's identity

answer

check the ID band on wrist

question

What is the primary concern in the therapeutic environment?

answer

patient safety

question

What does fluid oscillation in the tubing of a chest drainage system indicate?

answer

system is working properly

question

What position should a nurse place a patient who has a Sengstaken-Blakemore tube?

answer

semi-Fowlers

question

How can a nurse elicit Trousseau's sign?

answer

occluding the brachial or radial artery

question

What indicates Trousseau's sign?

answer

hand and finger spasms during occlusion

question

What does Trousseau's sign suggest?

answer

hypocalcemia

question

What is the appropriate needle size for adult blood transfusions?

answer

16 to 20G

question

this type of pain is incapacitating and can't be relieved by drugs

answer

intractable pain

question

How can a consent for treatment be obtained in an emergency?

answer

fax, telephone (or other telegraphic means)

question

the unit of measurement of sound

answer

decibel

question

this is required for any invasive procedure

answer

informed consent

question

What must a patient do who can't write their name to give consent for treatment?

answer

make an X in the presence of two witnesses (such as a nurse, priest, or physician)

question

this IM injection method seals the drug deep into the muscle

answer

Z-track method

question

this IM injection method minimizes skin irritation and staining

answer

Z-track method

question

What length needle is required for the Z-track IM injection method?

answer

1" or longer

question

What acronym is often used in the event of a fire?

answer

RACE (Remove the patient, Activate the alarm, Attempt to contain the fire by closing the door, Extinguish the fire if it can be done safely)

question

Who should be assigned to a registered nurse to perform bedside care, such as suctioning or drug administration?

answer

LPN (or licensed vocational nurse)

question

What must be done if the patient cannot void?

answer

bladder palpation to assess for bladder distention

question

What side should the patient who uses a cane carry it on?

answer

unaffected side

question

How should a patient use a cane?

answer

advance it at the same time as the affected extremity

question

How is a supine patient fitted for crutches?

answer

measure from the axilla to the sole and add 2" to the measurement

question

What is the timeline for assessment?

answer

begins with the nurse's first encounter with the patient and continues through the patient's stay

question

How does the nurse obtain assessment data?

answer

health history, physical examination, review of diagnostic studies

question

What is the appropriate size needle for insulin injection?

answer

25G and 5/8" long

question

What is urine called that remains in the bladder after voiding?

answer

residual urine

question

normal amount of residual urine

answer

50 to 100 mL

question

5 stages of the nursing process

answer

assessment, nursing diagnosis, planning, implementation, evaluation (ADPIE)

question

this stage of the nursing process is when the nurse continuously collects data to identify a patient's actual and potential health needs

answer

assessment

question

this stage of the nursing process is then the nurse makes a clinical judgement about individual, family, or community responses to actual or potential health problems or life processes

answer

nursing diagnosis

question

this stage of the nursing process is the stage 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

answer

planning

question

this stage of the nursing process is the stage 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

answer

implementation

question

this stage of the nursing process is the stage in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan

answer

evaluation

question

What should the nurse do before administering any "as needed" pain medication?

answer

indicate the location of the pain

question

this religious belief believes that they shouldn't receive blood components donated by other people

answer

Jehovah's Witness

question

to test this, the nurse should ask the patient to cover each eye separately and to read the eye chart with glasses and without, as appropriate

answer

visual acuity

question

What must be done when providing oral care for an unconscious patient to minimize the risk of aspiration?

answer

position the patient on the side

question

How far away must a patient stand from the chart when assessing distance vision?

answer

20 feet

question

What is the ideal room temperature for a geriatric patient or one who is extremely ill?

answer

66 to 76 F

question

What is normal room humidity?

answer

30% to 60%

question

this is the single best method of limiting the spread of microorganisms

answer

hand washing

question

How long must hands be washed once gloves are removed after routine contact with a patient?

answer

10 to 15 seconds

question

What position should a nurse place a woman to perform catheterization?

answer

dorsal recumbent (lithotomy)

question

How are electrolytes measured in a solution?

answer

milliequivalents per liter

question

What is a milliequivalent?

answer

number of milligrams per 100 mL of a solution

question

What might a positive Homan's sign indicate?

answer

thrombophlebitis

question

2 phases of metabolism

answer

anabolism, catabolism

question

the constructive phase of metabolism

answer

anabolism

question

the destructive phase of metabolism

answer

catabolism

question

the amount of energy needed to maintain essential body functions

answer

basal metabolic rate

question

When is basal metabolic rate measured?

answer

patient awake and resting, not eaten in 14-18 hours, in a comfortable and warm environment

question

how basal metabolic rate is expressed

answer

calories consumed per hour per kilogram of body weight

question

this supplies bulk, maintains intestinal motility, helps to establish bowel habits

answer

dietary fiber (roughage)

question

Where is alcohol metabolized primary? Where is it metabolized in smaller amounts?

answer

primarily in the liver, smaller amounts by the kidney and lungs

question

tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage

answer

petechiae

question

a purple discoloration of the skin that's caused by blood extravasation

answer

purpura

question

this should never be done with needles after using them and is the cause of most needle sticks

answer

recap needles

question

what a nurse uses to administer a drug by IV push to deliver the dose directly into a vein, IV tubing, or catheter

answer

needle and syringe

question

What should be done when changing the ties on a tracheostomy tube?

answer

leave the old ties in place until the new ones are applied

question

What is always used for blood transfusions?

answer

filter

question

this ambulatory device is indicated when a patient needs more stability than a regular cane can provide

answer

quad (four-point) cane

question

a good way to begin a patient interview

answer

"What made you seek medical help?"

question

the most abundant cation in intracellular fluid

answer

potassium (K+)

question

in this gait, the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot

answer

four-point or alternating gait

question

in this gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg

answer

three-point gait

question

in this gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch simultaneously

answer

two-point gait

question

the Vitamin B complex, water soluble vitamins that are essential for metabolism

answer

thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), cyanocobalamin (B12)

question

how the patient should be dressed when being weighed

answer

lightly dressed and shoeless

question

what should be done before taking an adult's oral temp

answer

nurse should ensure that the patient hasn't smoked or consumed any hot/cold substances in the previous 15 minutes

question

when the nurse should not take an adult's rectal temp

answer

patient has cardiac disorder, anal lesions, bleeding hemorrhoids, or recently undergone rectal surgery

question

taking adult's rectal temp in a patient that has a cardiac disorder

answer

may stimulate a vagal response and lead to vasodilation and decreased cardiac output

question

how the nurse should record pulse amplitude and rhythm

answer

0 absent pulse; 1+ thready or weak pulse; 2+ normal pulse; 3+ bounding pulse

question

this period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia care unit

answer

intraoperative period

question

what should be done the morning of a patient's surgery

answer

consent form signed, patient hasn't taken anything by mouth since midnight, taken a shower in microbial soap, mouth care w/o swallowing water, removed common jewelry, received preoperative meds as prescribed, vital signs taken and recorded, (artificial limbs and other prostheses are usually removed)

question

comfort measures that may decrease the patient's need for analgesics or may enhance their effectiveness

answer

positioning, rubbing the patient's back, providing a restful environment

question

a drug's three names

answer

generic, trade/brand, chemcial

question

how a patient should take a liquid iron preparation

answer

through a straw to avoid teeth staining

question

what injection method should be used when administering iron dextran (Imferon) IM

answer

Z-track method (IM)

question

where an organism can enter the body

answer

nose, mouth, rectum, urinary or reproductive tract, skin

question

levels of consciousness in order

answer

alertness, lethargy, stupor, light coma, deep coma

question

portion of the stethoscope used to hear high-pitched sounds, such as breath sounds

answer

diaphragm

question

differences in the BP between the right and left arms

answer

slight difference is normal (5-10 Hg)

question

where to place BP cuff

answer

1" above the antecubital fossa

question

what to do when instilling ophthalmic ointments

answer

waste the first bead of ointment, then apply the ointment from the inner canthus to the outer canthus

question

measuring BP in an obese patient

answer

use leg cuff

question

if a BP cuff is applied too loosely

answer

false lower reading

question

drooping of the eyelid

answer

ptosis

question

this type of 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

answer

tilt table

question

how to perform a venipuncture with the least injury to the vessel

answer

turn the bevel upward when the vessel's lumen is larger than the needle, turn it downward when the lumen is only slightly larger than the needle

question

patient should wear _______ when being measured for crutches

answer

shoes

question

never attach a restraint to this portion of the bed

answer

mattress, side rails (always the bed frame)

question

position for a sigmoidoscopy

answer

knee-chest or Sims

question

order of Maslow's hierarchy of needs

answer

physiologic, safety and security, love and belonging, self-esteem and recognition, self-actualization

question

this should be applied to the nostril to prevent soreness when caring for a patient with a nasogastric tube

answer

water-soluble lubricant

question

gastric lavage procedure (stomach pump)

answer

nasogastric tube inserted, stomach is flushed, ingested substances removed through tube

question

documenting drainage of a surgical dressing

answer

size, color, consistency of drainage

question

to elicit this reflex, the nurse strokes the sole of the patient's foot with a moderately sharp object

answer

Babinski's reflex

question

positive Babinski's reflex

answer

fanning toes

question

assessing for bladder distension

answer

check the contour of the lower abdomen for a rounded mass above the symphysis pubis

question

best way to prevent pressure ulcers

answer

reposition bedridden patient at least every 2 hours

question

this decompresses the superficial blood vessels, reducing the risk of thrombus formation

answer

antiembolism stockings

question

most convenient veins for venipuncture for adults

answer

basilic, median cubital

question

what must be done 2-3 hours before beginning a tube feeding

answer

aspirate the patient's stomach to verify that gastric emptying is adequate

question

universal blood donors

answer

type O

question

universal blood recipients

answer

type AB

question

unit of measurement of sound frequency

answer

Hz (Hertz)

question

sound intensity level when hearing protection is required

answer

exceeds 84 db

question

sound intensity level when double hearing protection is required

answer

exceeds 104 db

question

where prothombin, a clotting factor, is produced

answer

liver

question

what should be done if a patient is menstruating when a urine sample is collected

answer

note on lab request

question

what must be noted during a lumbar puncture

answer

initial intracranial pressure, color of cerebrospinal fluid

question

this type of treatment can be used to help obtain a sample if a patient can't cough to provide a sputum sample for culture

answer

heated aerosal treatment

question

What must be instilled first in eye ointment and eyedrops must be instilled in the same eye?

answer

eyedrops

question

first to be removed for PPE

answer

gloves before mask (because fewer pathogens are on mask)

question

the most effective means of traction, applying to a bone with wire pins or tongs

answer

skeletal traction

question

preparation of TPN

answer

stored in a refrigerator, removed 30-60 minutes before use

question

symptoms of delivering a chilled solution

answer

pain, hypothermia, venous spasm, venous constriction

question

where drugs aren't routinely injected intramuscularly because they may not be absorbed

answer

edematous tissue

question

explaining actions when caring for a comatose patient

answer

explain in a normal voice

question

cleaning dentures

answer

in a sink that's lined with a washcloth

question

patient should void within ____ hours after surgery

answer

8 hours

question

an _____ identifies normal and abnormal brain waves

answer

EEG

question

these types of lab tests should be delivered to the lab without delay and without refrigeration

answer

feces (for ova) samples, parasite tests

question

this nervous system regulates the cardiovascular and respiratory systems

answer

autonomic nervous system

question

intermittent suction should be applied no more than ___ seconds using a slight twisting motion when providing tracheostomy care

answer

15 seconds

question

low-residue diet foods

answer

roasted chicken, rice, pasta

question

why a rectal tube shouldn't be inserted no longer than 20 minutes

answer

irritation of the rectal mucosa, can cause loss of sphincter control

question

order of bed bath

answer

face, neck, arms, hands, chest, abdomen, back, legs, perineum

question

muscles the nurse uses to prevent injury when lifting and moving a patient

answer

upper leg muscles

question

patient prep for cholecystography

answer

ingestion of a contrast medium and a low-fat evening meal

question

what to do while an occupied bed is being changed

answer

cover patient with a bath blanket to promote warmth and prevent exposure

question

mourning that occurs for an extended time when the patient realizes death is inevitable

answer

anticipatory grief

question

foods that can alter the color of feces

answer

beets (red), cocoa (dark red/brown), licorice (black), spinach (green), meat protein (dark brown)

question

patient should remove all jewelry and dentures when preparing for a ______ x-ray

answer

skull x-ray

question

the flight-or-flight response comes a response from this nervous system

answer

sympathetic nervous system

question

if bronchovesicular sounds are heard in peripheral lung fields

answer

abnormal

question

what bronchovesicular lung sounds suggest if heard in peripheral lung fields

answer

pneumonia

question

an abnormal, high-pitched breath sound that's acccentuated on expiration

answer

wheezing

question

this in the ear should be flushed out gently by irrigation with warn saline solution

answer

wax or a foreign body

question

what should be done if a patient complains that their hearing aid is "not working"

answer

check the switch to see if it's turned on, check batteries

question

grading hyperactive biceps and triceps reflexes

answer

4+

question

if two eye medications are prescribed for twice-daily instillation

answer

should be administered 5 minutes apart

question

forcing fluids in a post-op patient

answer

helps prevent constipation

question

Who establishes the standards of care?

answer

American Nurses association, state regulations, facility policy

question

a unit of energy measurement that represents the amount of heat needed to raise the temperature 1 kilogram of water 1 degree C

answer

kilocalorie (kcal)

question

What do nutrients undergo as they move through the body?

answer

ingestion, digestion, absorption, transport, cell metabolism, excretion

question

how the body metabolizes alcohol

answer

fixed rate, regardless of serum concentration

question

this reflects the percentage of alcohol multiplied 2 in an alcohol beverage (a 100-proof beverage contains 50% alcohol)

answer

proof

question

a witnessed document that states a patient's desire for certain types of care and treatment

answer

living will

question

what decisions in a living will are based on

answer

patient's wishes and views on quality of life

question

how often nurse should flush a peripheral heparin lock

answer

every 8 hours (if it wasn't used during the previous 8 hours) and as needed with normal saline solution to maintain patency

question

a method of determining whether nursing actions and practices meet established standards

answer

quality assurance

question

five rights of medication administration

answer

right drug, right dose, right documentation, right route, right time, right patient

question

this phase of the nursing process is to determine whether nursing interventions have enabled the patient to meet the desired goals

answer

evaluation

question

only these forms of nitroglycerine should be used to relieve acute anginal attacks outside the hospital setting

answer

sublingual, translingual

question

this phase of the nursing process involves recording the patient's response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating patient's activities

answer

implementation

question

this offers patients guidance and protection by stating the responsibilities of the hospital and its staff toward and their families during hospitalization

answer

Patient's Bill of Rights

question

the nurse should record this as soon as it's gathered to minimize omission and distortion of fats

answer

information

question

the nurse should record current illness this way when assessing a patient's health history

answer

chronologically, beginning with the onset of the problem and continuing to the present

question

never give ____ ________ to a patient

answer

false assurance

question

after receiving preoperative medication, a patient isn't competent to do this

answer

sign an informed consent form

question

a nurse uses this instead of the strength in her arms when lifting a patient

answer

weight of her body

question

What must be done if a patient has questions about informed consent?

answer

refer to the physician

question

a nurse can do this about an operation or a procedure to a patient

answer

clarify a physician's explanation

question

the nurse should limit questions to those that provide necessary information when obtaining a health history from these patients

answer

acutely ill or agitated patient

question

what to do if a chest drainage system line is broken or interrupted

answer

clamp tube immediately

question

why you should never use the thumb to take a patient's pulse rate

answer

thumb has a pulse that can be confused with the patient's pulse

question

these 2 things count as one respiration

answer

inspiration, expiration

question

term for normal respiration

answer

eupnea

question

positioning of a patient's arm during blood pressure measurement

answer

rest arm against a surface

question

if a patient uses muscle strength to hold up the arm when taking blood pressure

answer

may raise BP

question

major, unalterable risk factors for coronary artery disease

answer

heredity, sex, race, age

question

the most frequently used assessment technique

answer

inspection

question

What should family members of an elderly person in a long-term care facility do to provide a comfortable atmosphere?

answer

transfer some personal items to the person's room (such as photographs, a favorite chair, knickknacks, etc.)

question

a regular pulse rhythm with alternating weak and strong beats that occurs in ventricular enlargement because the stroke volume varies with each heartbeat

answer

pulsus alternans

question

What does the upper respiratory tract do to inspired air?

answer

warms and humidifies

question

What does the upper respiratory tract play a part in?

answer

taste, smell, mastication

question

What are shoulder elevation, intercostal muscle retraction, and scalene and sternocleidomastoid muscle use signs of during respiration?

answer

accessory muscle use

question

What should bear the brunt of the weight with patients using axillary crutches?

answer

palms

question

What are eating, bathing, dressing, grooming, toileting, and interacting socially examples of?

answer

activities of daily living (ADLs)

question

2 phases of a normal gait

answer

stance phase (patient's foot rests on the ground), swing phase (patient's foot moves forward)

question

4 phases of mitosis

answer

prophase, metaphase, anaphase, telophase

question

What should the nurse follow when providing routine care for all patients?

answer

standard precautions

question

part of the stethoscope used to listen for venous hums and cardiac murmurs

answer

bell

question

example of a question to assess a patient's general knowledge

answer

"Who is the president of the United States?"

question

What is applied for the first 20-48 hours after an injury?

answer

cold packs

question

What is applied after a cold pack after an injury?

answer

heat

question

how a cold application is applied after an injury

answer

20 minutes, removed 10-15 minutes (to prevent reflex dilation, a rebound phenomenon, and frostbite injury)

question

this is located above the medulla and consists of white and gray amtter

answer

pons

question

this nervous system controls the smooth muscles

answer

autonomic nervous system

question

Who collaborates with the nurse to develop a patient goal?

answer

patient

question

5 basic notes of percussion

answer

tympany (loud intensity, as heard over a gastric air bubble or puffed out cheek), hyperresonance (very loud, as heard over an emphysematous lung), resonance (loud, as heard over a normal lung), dullness (medium intensity, as heard over the liver or other solid organ), flatness (soft, as heard over the thigh)

question

description of the optic disk

answer

yellowish pink and circular, with a distinct border

question

What is a primary disability caused by?

answer

pathologic process

question

What is a secondary disability caused by?

answer

inactivity

question

this person is commonly held liable for failing to keep an accurate count of sponges and other devices during surgery

answer

nurse

question

best dietary sources of vitamin B6

answer

liver, kidney, pork soybeans, corn, whole-grain cereals

question

iron-rich foods that commonly have a low water content

answer

organ meats, nuts, legumes, dried fruit, green leafy vegetables, eggs, whole grains

question

this is a joint communication and decision making between nurses and physicians

answer

collaboration

question

this is designed to meet patients' need by integrating the care regimens of both professions into one comprehensive approach

answer

collaboration

question

a heart rate of fewer than 60 beats/minute

answer

bradycardia

question

a statement of a patient's actual or potential health problem that can be resolved, diminished, or otherwise changed by nursing interventions

answer

nursing diganosis

question

analysis of 3 types of data collected during the assessment phase

answer

health history, physical exam, lab and diagnostic test data

question

this consists primarily of subjective data, information that's supplied by the patient

answer

health history

question

this includes objective data obtained by inspection, palpation, percussion, and ausculatation

answer

physical exam

question

factors that can affect body temperature

answer

time of day, age, physical activity, phase of menstrual cycle, pregnancy

question

the most commonly used artery for measuring a patient's pulse rate

answer

radial artery

question

the normal pulse rate is slightly faster in this gender

answer

women

question

the normal pulse rate is slightly faster in this age

answer

children

question

laboratory test results are an _______ form of assessment data

answer

objective

question

3 most commonly used measurement systems in clinical practice

answer

metric system, apothecaries' system, household system

question

what the patient must know before signing an informed consent form

answer

other treatment options are available, understand what will occur, the risks involved, the possible complications, time required for surgery to recovery

question

a patient must sign one of these for each procedure

answer

informed consent form

question

this procedure is done to determine the size, shape, position, and density of underlying organs and tissues, elicit tenderness, or assess reflexes

answer

percussion

question

a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound

answer

ballottement

question

this keeps bed linen off the patient's feet to prevent skin irritation and breakdown, especially in a patient who has peripheral vascular disease or neuropathy

answer

foot cradle

question

a flushing of the stomach and removal of ingested substances through a nasogastric tube, used to treat poisoning or drug overdose

answer

gastric lavage

question

the nurse asses the patient's response to therapy during this step of the nursing process

answer

evaluation

question

this is commonly indicates a life- or limb- threatening vascular disease

answer

bruits

question

O.U. means...

answer

each eye

question

O.D. means...

answer

right eye

question

O.S. means...

answer

left eye

question

to remove a patient's artificial eye

answer

depress the lower lid

question

cleaning an artificial eye

answer

use a warm saline solution

question

this type of pulse is fine and scarcely palpable

answer

thready

question

this temp site is usually 1 degree F lower than oral temperature

answer

axillary temperature

question

what the nurse must document after suctioning a tracheostomy tube

answer

color, amount, consistency, odor of secretions

question

what P.C. means on a prescription

answer

after meals

question

what should be documented after a bladder irrigation

answer

amount, color, and clarity of urine, presence of clots or sediment

question

the inside diameter of a needle (the smaller this is, the larger the diameter)

answer

gauge

question

normal number of permanent adult teeth

answer

32

NCLEX HESI Fundamentals Bullets from Nurses Labs – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards