The nurse administers a drug by I.V. push by using a needle and syringe to deliver the dose directly into a vein, I.V. tubing, or a catheter.
When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied.
A nurse should have assistance when changing the ties on a tracheostomy tube.
A filter is always used for blood transfusions.
A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide.
A good way to begin a patient interview is to ask, “What made you seek medical help?”
When caring for any patient, the nurse should follow standard precautions for handling blood and body fluids.
Potassium (K+) is the most abundant cation in intracellular fluid.
In the four-point, or alternating, gait, the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot.
In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg.
In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch simultaneously.
The vitamin B complex, the water-soluble vitamins that are essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12).
When being weighed, an adult patient should be lightly dressed and shoeless.
Before taking an adult’s temperature orally, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the previous 15 minutes.
The nurse shouldn’t take an adult’s temperature rectally if the patient has a cardiac disorder, anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery.
In a patient who has a cardiac disorder, measuring temperature rectally may stimulate a vagal response and lead to vasodilation and decreased cardiac output.
When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3, bounding pulse (readily palpable and forceful); +2, normal pulse (easily palpable); +1, thready or weak pulse (difficult to detect); and 0, absent pulse (not detectable).
The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia care unit.
On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water), has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have been taken and recorded. Artificial limbs and other prostheses are usually removed.
Comfort measures, such as positioning the patient, rubbing the patient’s back, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness.
A drug has three names: generic name, which is used in official publications; trade, or brand, name (such as Tylenol), which is selected by the drug company; and chemical name, which describes the drug’s chemical composition.
To avoid staining the teeth, the patient should take a liquid iron preparation through a straw.
The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon).
An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin.
In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma.
To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if needed; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet.
The diaphragm of the stethoscope is used to hear high-pitched sounds, such as breath sounds.
A slight difference in blood pressure (5 to 10 mm Hg) between the right and the left arms is normal.
The nurse should place the blood pressure cuff 1″ (2.5 cm) above the antecubital fossa.
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.
The nurse should use a leg cuff to measure blood pressure in an obese patient.
If a blood pressure cuff is applied too loosely, the reading will be falsely elevated.
Ptosis is drooping of the eyelid.
A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position.
To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle.
To move a patient to the edge of the bed for transfer, the nurse should follow these steps: Move the patient’s head and shoulders toward the edge of the bed. Move the patient’s feet and legs to the edge of the bed (crescent position). Place both arms well under the patient’s hips, and straighten the back while moving the patient toward the edge of the bed.
When being measured for crutches, a patient should wear shoes.
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.
The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern.
To administer heparin subcutaneously, the nurse should follow these steps: Clean, but don’t rub, the site with alcohol. Stretch the skin taut or pick up a well-defined skin fold. Hold the shaft of the needle in a dart position. Insert the needle into the skin at a right (90-degree) angle. Firmly depress the plunger, but don’t aspirate. Leave the needle in place for 10 seconds. Withdraw the needle gently at the angle of insertion. Apply pressure to the injection site with an alcohol pad.
For a sigmoidoscopy, the nurse should place the patient in the knee-chest position or Sims’ position, depending on the physician’s preference.
Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort), safety and security, love and belonging, self-esteem and recognition, and self-actualization.
When caring for a patient who has a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness.
During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube.
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”).
To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as a thumbnail.
A positive Babinski’s reflex is shown by dorsiflexion of the great toe and fanning out of the other toes.
When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis.
The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours.
Antiembolism stockings decompress the superficial blood vessels, reducing the risk of thrombus formation.