460NURSI

NGBULLETS:
FUNDAMENTALSOFNURSI
NGREVI
EWER

Nur
singBul
l
ets

Her
e’sy
ourl
i
stof460nur
singbul
l
etsaboutf
undament
alsofnur
sing.

 Aft
ertur
ningapati
ent,
thenurseshoulddocumentt
heposi
ti
onused,
thet
imet
hatt
he
pat
ientwastur
ned,andthef
indingsofski
nassessment
.

 PERRLAisanabbrev
iat
ionf
ornor
malpupi
lassessmentf
indi
ngs:
pupi
l
sequal
,round,
andreact
ivet
oli
ghtwit
haccommodat
ion.

 Whenpercussi
ngapat
ient
’schestf
orpost
ural
drai
nage,
thenur
se’
shandsshoul
dbe
cupped.

 Whenmeasur
ingapat
ient
’spul
se,
thenur
seshoul
dassessi
tsr
ate,
rhy
thm,
qual
i
ty,
and
st
rengt
h.

 Bef
oretr
ansfer
ri
ngapat
ientf
rom abedtoawheelchai
r,t
henur
seshoul
dpusht
he
wheel
chai
rfootr
est
stot
hesidesandlocki
tswheels.

 Whenassessi
ngr
espi
rat
ions,
thenur
seshoul
ddocumentt
hei
rrat
e,r
hyt
hm,
dept
h,and
qual
i
ty.

 Forasubcut
aneousi
nject
ion,
thenur
seshoul
dusea5/
8″t
o1″25Gneedl
e.

 Thenot ation“
AA&O×3”indicat
esthatt
hepati
enti
sawake,al
ert,
andori
entedto
person( knowswhohei
s),
place(knowswher
eheis),andt
ime(knowsthedateand
ti
me) .

 Flui
dintakeincludesall
fluidstakenbymout h,i
ncludi
ngf oodst hatareliqui
datroom
temperatur
e, suchasgelat i
n,custar
d,andicecream; I
.[Link]
uids;andf l
uidsadminist
ered
i
nf eedingt
[Link] ui
dout putincl
udesuri
ne,vomitus,anddr ai
nage( suchasf r
om a
nasogastri
ctubeorf rom awound)aswel l
asbloodl oss,diarr
heaorf eces,and
perspir
ati
on.

 Aft
eradmini
ster
ingani
ntr
adermali
nject
ion,t
henurseshoul
dn’tmassaget
hear
ea
becausemassagecani
rri
tat
ethesi
teandi nt
erf
erewit
hresul
ts.

 Whenadmi ni
ster
inganint
radermalinj
ect
ion,thenurseshoul
dhol
dthesyr
ingeal
most
f
latagai
nstthepati
ent
’sskin(atabouta15-degreeangl
e),wi
tht
hebevel
up.

 Toobt
ainanaccur
atebl
oodpr
essur
e,t
henur
seshoul
dinf
lat
ethemanomet
ert
o20t
o
 30mm Hgabov
ethedi
sappear
anceoft
her
adi
alpul
sebef
orer
eleasi
ngt
hecuf
f
pr
essur
e.

 Thenur
seshoul
dcountani
rr
egul
arpul
sef
or1f
ull
minut
e.

 Apati
entwhoisvomit
ingwhil
ely
ingdownshoul
dbepl
acedi
nal
ater
alposi
ti
ont
o
pr
eventaspi
rat
ionofv
omitus.

 Pr
ophy
laxi
sisdi
seasepr
event
ion.

 Bodyali
gnmenti
sachi
evedwhenbodypar
tsar
einpr
operr
elat
iont
othei
rnat
ural
posi
ti
on.

 Tr
usti
sthef
oundat
ionofanur
se-
pat
ientr
elat
ionshi
p.

 Bl
oodpressur
eist
hef
orceexer
tedbyt
heci
rcul
ati
ngv
olumeofbl
oodont
hear
ter
ial
wal
ls.

 Mal
pract
iceisaprof
essi
onal
’swrongful
conduct
,improperdi
schar
geofdut
ies,
orf
ail
ure
t
omeetst andar
dsofcar
ethatcausesharmtoanother
.

 Asagener
alrul
e,nur
sescan’tr
efuseapati
entcar
eassi
gnment
;howev
er,
inmostst
ates,
theymayr
efusetopar
ti
cipat
einabort
ions.

 Anursecanbefoundnegli
gentifapatienti
sinj
uredbecausethenursefai
ledt
oper
for
m
adutythatar
easonabl
eandpr udentpersonwouldperfor
m orbecausethenur
se
per
formedanactthatareasonabl
eandpr udentpersonwouldn’
tperf
orm.

 Stat
eshav eenactedGoodSamar i
tanl
awstoencourageprof
essi
onalstopr ovi
de
medicalassi
stanceatthesceneofanacci
dentwit
houtfearofalawsuitari
singfr
om t
he
assi
[Link]’tappl
ytocar
eprovi
dedinahealthcarefacil
i
ty.

 Aphysi
cianshouldsignv
erbalandt
elephoneor
der
swi
thi
nthet
imeest
abl
i
shedby
f
aci
li
typoli
cy,usual
ly24hours.

 Acompet
entadul
thasther
ightt
oref
useli
fesavi
ngmedicalt
reat
ment;howev
er,
the
i
ndi
vi
dual
shouldbeful
l
yinf
ormedoftheconsequencesofhi
sref
usal
.

 Al
thoughapati
ent
’sheal
threcord,orchar
t,i
stheheal
thcar
efaci
l
ity
’sphy
sical
proper
ty,
i
tscontent
sbel
ongtothepatient
.

 Bef
oreapati
ent’sheal
thr
ecor
dcanberel
easedtoat
hir
dpar
ty,
thepat
ientort
he
pat
ient
’sl
egalguardi
anmustgi
vewr
it
tenconsent
.

 Undert
heContr
oll
edSubst
ancesAct
,ev
erydoseofacontr
oll
eddr
ugthat’
sdi
spensed
bythephar
macymustbeaccount
edfor
,whethert
hedosewasadmini
ster
edt
oapat i
ent
 ordi
scar
dedacci
dent
all
y.

 Anur secan’
tper
form duti
esthatv
iol
atearul
eorregulat
ionest
abli
shedbyast at
e
l
icensingboar
d,eveniftheyar
eauthor
izedbyahealt
hcar ef
aci
li
tyorphysi
cian.

 Tomini
mizeint
err
upt
ionsdur
ingapati
enti
nter
view,
thenur
seshoul
dsel
ectapr
ivat
e
room,
pref
erabl
yonewithadoort
hatcanbeclosed.

 I
ncategor
izi
ngnur
singdi
agnoses,t
henurseaddressesl
i
fe-
thr
eat
eni
ngpr
obl
emsf
ir
st,
f
oll
owedbypotent
ial
lyl
if
e-t
hreat
eni
ngconcerns.

 Themajorcomponent
sofanur
singcar
epl
anar
eout
comecr
it
eri
a(pat
ientgoal
s)and
nur
singi
nter
vent
ions.

 Standi
ngorder
s,orpr
otocol
s,est
abl
i
shgui
del
i
nesf
ort
reat
ingaspeci
fi
cdi
seaseorset
ofsymptoms.

 I
nassessingapati
ent’
sheart
,thenursenor
mal
l
yfi
ndst
hepoi
ntofmaxi
mal
impul
seat
t
hefi
fthinter
cost
alspace,
neartheapex.

 TheS1hear
donauscul
tat
ioni
scausedbycl
osur
eoft
hemi
tr
alandt
ri
cuspi
dval
ves.

 Tomai nt
ainpackagesteri
l
ity,t
henurseshoul
dopenawr apper’
stopfl
apawayfrom t
he
body
,openeachsi deflapbytouchingonl
ytheout
erpartofthewrapper
,andopenthe
fi
nal
flapbygraspingtheturned-downcor
nerandpul
li
ngittowardthebody.

 Thenur
seshoul
dn’tdr
yapati
ent’
searcanalorremovewaxwit
hacot
ton-t
ipped
appl
i
cat
orbecauseitmayf
orcecerumenagainstthet
ympani
cmembrane.

 Apati
ent’
sident
if
icat
ionbracel
etshouldremai
ninplaceunt
ilthepat
ienthasbeen
di
schar
gedf r
om theheal
thcarefaci
li
tyandhaslef
tthepremises.

 TheContr
oll
edSubst
ancesActdesignat
edfi
vecategor
ies,
orschedul
es,
thatcl
assi
fy
cont
rol
l
eddrugsaccor
dingt
otheirabusepot
enti
al.

 Schedul
eIdr
ugs,suchasher
oin,hav
eahighabusepot
ent
ial
andhav
enocur
rent
ly
accept
edmedicalusei
ntheUnit
edStat
es.

 Schedul
eIIdrugs,suchasmor phi
ne,opium,andmeperi
dine(Demerol
),haveahigh
abusepotent
ial,
butcurrent
lyhaveacceptedmedi
[Link]
physi
calorpsychologi
caldependence.

 ScheduleI
IIdrugs,suchasparegoricandbutabarbi
tal
(Buti
sol)
,hav
ealowerabuse
potent
ialt
hanSchedul eIorI
[Link]
ugsmayleadtomoderat
e
orlowphysicalorpsychol
ogi
cal dependence,orbot
h.
 Schedul
eIVdr
ugs,suchaschl
oral
hydr
ate,
hav
eal
owabusepot
ent
ial
compar
edwi
th
Schedul
eII
Idr
ugs.

 ScheduleVdrugs,
suchascoughsyrupst
hatcont
aincodei
ne,
hav
ethel
owestabuse
potent
ialoft
hecontr
oll
edsubst
ances.

 Act
ivi
ti
esofdail
yli
vingareact
ionsthatt
hepat
ientmustper
for
m ev
erydayt
opr
ovi
de
sel
f-
careandtoint
eractwit
hsociet
y.

 Test
ingofthesixcar
dinalfi
eldsofgazeeval
uat
est
hef
unct
ionofal
lext
raocul
ar
musclesandcrani
alnervesII
I,I
V,andVI.

 Thesixt
ypesofheartmurmursar
egradedf
rom 1t
o6.Agrade6hear
tmur
murcanbe
hear
dwiththest
ethoscopesl
i
ghtl
yrai
sedfr
om t
hechest
.

 Themosti
mpor
tantgoal
toi
ncl
udei
nacar
epl
ani
sthepat
ient
’sgoal
.

 Fr
uit
sar
ehi
ghi
nfi
berandl
owi
npr
otei
n,andshoul
dbeomi
tt
edf
rom al
ow-
resi
duedi
et.

 Thenurseshoul
duseanobj
ect
ivescal
etoassessandquant
if
ypai
[Link]
oper
ati
vepai
n
var
iesgreat
lyamongi
ndi
vi
dual
s.

 Post
mor tem careincl
udescleani
ngandpr
eparingt
hedeceasedpati
entf
orfamil
y
vi
ewing,arr
angingt r
anspor
tati
ontothemorgueorfuner
alhome,anddet
ermini
ngthe
di
sposit
ionofbel ongi
ngs.

 Thenur
seshoul
dpr
ovi
dehonestanswer
stot
hepat
ient
’squest
ions.

 Mi
l
kshoul
dn’
tbei
ncl
udedi
nacl
earl
i
qui
ddi
et.

 Whencari
ngforaninf
ant,achi
l
d,oraconf
usedpat
ient
,consi
stencyi
nnur
sing
per
sonnel
isparamount.

 Thehypot
hal
amussecr
etesv
asopr
essi
nandoxy
toci
n,whi
char
est
oredi
nthepi
tui
tar
y
gl
and.

 Thethreemembranest
hatencl
oset
hebr
ainandspi
nal
cor
dar
ethedur
amat
er,
pia
mater,
andarachnoi
d.

 Anasogastri
ctubei
susedt oremovef
lui
dandgasf
rom t
hesmal
li
ntest
ine
pr
eoperat
ivel
yorpostoper
ativ
ely.

 Psychologi
sts,
physi
cal
ther
api
sts,
andchi
ropr
act
orsar
en’
taut
hor
izedt
owr
it
e
prescr
ipti
onsfordr
ugs.

 Thear
eaar
oundast
omai
scl
eanedwi
thmi
l
dsoapandwat
er.
 Veget
abl
eshav
eahi
ghf
ibercont
ent
.

 Thenur
seshoul
duseat
uber
cul
i
nsy
ringet
oadmi
nist
erasubcut
aneousi
nject
ionofl
ess
than1ml.

 Foradul
ts,
subcut
aneousi
njecti
onsrequi
rea25G5/8″t
o1″needl
e;f
ori
nfant
s,chi
l
dren,
el
derl
y,orver
ythi
npati
ent
s,theyrequi
rea25Gto27G½”needl
e.

 Bef
oreadmini
ster
ingadrug,t
henurseshouldi
denti
fyt
hepat
ientbychecki
ngt
he
i
denti
fi
cat
ionbandandaskingthepat
ientt
ostatehi
sname.

 Tocleantheski
nbefor
eaninject
ion,t
henurseusesast
eri
l
eal
cohol
swabt
owi
pef
rom
thecent
erofthesi
teoutwar
dinaci r
cularmot
ion.

 Thenurseshoul
dinj
ecthepar
indeepi
ntosubcut
aneoust
issueata90-
degr
eeangl
e
(per
pendi
culart
otheski
n)toprev
entski
nir
ri
tati
on.

 I
fbl
oodisaspi
rat
edintothesyringebefor
eanI .
M.i
nject
ion,
thenur
seshoul
dwi
thdr
aw
t
heneedl
e,pr
epareanothersy
ringe,andrepeatt
heprocedur
e.

 Thenur
seshoul
dn’tcutt
hepat
ient
’shai
rwi
thoutwr
it
tenconsentf
rom t
hepat
ientoran
appr
opr
iat
erel
ati
ve.

 Ifbl
eedingoccursaft
eraninj
ect
ion,
thenur
seshoul
dappl
ypressur
eunti
lthebl
eedi
ng
stops.I
fbrui
singoccurs,
thenur
seshoul
dmonitort
hesi
teforanenl
argi
nghematoma.

 Whenprov
idi
nghairandscalpcar
e,t
henur
seshoul
dbegi
ncombi
ngatt
heendoft
he
hai
randworktowardthehead.

 Thefr
equencyofpati
enthaircar
edependsonthelengt
handt
ext
ureoft
hehai
r,t
he
dur
ati
onofhospit
ali
zati
on,andthepat
ient
’scondi
ti
on.

 Properf
uncti
onofaheari
ngaidr
equi
rescar
eful
handli
ngduringinser
ti
onandremoval
,
regul
arcl
eani
ngoftheearpi
ecetopr
eventwaxbui
ldup,andpromptrepl
acementof
deadbatt
eri
es.

 Thehear
ingaidthat
’smar
kedwi
thabl
uedoti
sfort
hel
eftear
;theonewi
thar
eddoti
s
fort
heri
ghtear.

 Ahear
ingai
dshoul
dn’
tbeexposedt
oheatorhumi
dit
yandshoul
dn’
tbei
mmer
sedi
n
wat
er.

 Thenur
seshoul
dinst
ructt
hepat
ientt
oav
oidusi
nghai
rspr
aywhi
l
ewear
ingahear
ing
ai
d.

 Thef
ivebr
anchesofphar
macol
ogyar
ephar
macoki
net
ics,
phar
macody
nami
cs,
 phar
macot
her
apeut
ics,
toxi
col
ogy
,andphar
macognosy
.

 Thenurseshoul
dremov
eheel
prot
ect
orsev
ery8hour
stoi
nspectt
hef
ootf
orsi
gnsof
ski
nbreakdown.

 Heati
sappl
i
edt
opr
omot
evasodi
l
ati
on,
whi
chr
educespai
ncausedbyi
nfl
ammat
ion.

 Asutur
edsurgicali
nci
sioni
sanexampl
eofheal
i
ngbyf
ir
sti
ntent
ion(
heal
i
ngdi
rect
ly,
wi
thoutgr
anulati
on).

 Heal
ingbysecondar
yintent
ion(heal
ingbygranulati
on)iscl
osur
eofthewoundwhen
gr
anulat
iont
issuefi
l
lsthedefectandall
owsreepitheli
ali
zat
iont
ooccur,begi
nni
ngatt
he
woundedgesandcontinui
ngtothecenter,
until
theent i
rewoundiscov
er ed.

 Keloi
dfor
mat
ionisanabnor
mal
i
tyi
nheal
i
ngt
hat
’schar
act
eri
zedbyov
ergr
owt
hofscar
ti
ssueatt
hewoundsit
e.

 Thenur seshouldadministerprocai
nepeni
cil
l
inbydeepI.
M.i
nject
ioni
ntheupperout
er
port
ionoft hebutt
ocksint headultori
nthemidl
ater
alt
highi
nthechil
[Link]
se
shouldn’tmassagetheinjecti
onsite.

 Anascendi
ngcol
ost
omydr
ainsf
lui
[Link]
ngcol
ost
omydr
ainssol
i
dfecal
matt
er.

 Afoldedt
owel(
scr
otalbri
dge)canprov
idescr
otalsuppor
tfort
hepat
ientwi
thscr
otal
edemacausedbyvasect
omy ,
epidi
dymit
is,
ororchi
ti
s.

 Whengiv
inganinj
ect
iont
oapat
ientwhohasableedi
ngdi
sorder
,thenur
seshouldusea
smal
l-
gaugeneedl
eandappl
ypr
essuret
othesi
tefor5minut
esaftert
heinj
ect
ion.

 Plat
elet
sarethesmall
estandmostf
ragi
l
efor
medel
ementoft
hebl
oodandar
e
essenti
alf
orcoagul
ati
on.

 Toinsertanasogastr
ictube,t
henurseinst
ructsthepatientt
otil
ttheheadbacksl
ight
ly
andtheninser
[Link] henur
sefeelsthet ubecurv
ingatthephar
ynx,t
he
nurseshouldt
ellt
hepat i
enttoti
l
ttheheadf or
war dtoclosethetr
acheaandopenthe
esophagusbyswallowing.(Si
psofwatercanfacili
tatethi
sacti
on.)

 Famil
ieswithlov
edonesinint
ensiv
ecareunit
sreportthatt
hei
rfourmostimport
ant
needsaretohavethei
rquesti
onsanswer
edhonestly,t
obeassuredthatthebest
possi
blecareisbei
ngprovi
ded,t
oknowt hepati
ent
’sprognosi
s,andtofeelt
hatt
her
eis
hopeofrecovery
.

 Doubl
e-bi
ndcommunicationoccur
swhenthev
erbal
messagecont
radi
ctst
henonv
erbal
messageandther
eceiverisunsur
eofwhi
chmessaget
orespondt
o.
 Anonjudgmentalat
ti
tudedispl
ayedbyanur
seshowst
hatshenei
therappr
ovesnor
di
sapprovesofthepati
ent
.

 Tar
getsy
mpt
omsar
ethoset
hatt
hepat
ientf
indsmostdi
str
essi
ng.

 Apati
entshoul
dbeadvi
sedtot
akeaspi
ri
nonanempt ystomach,wi
thaf
ull
glassof
wat
er,andshoul
davoi
daci
dicf
oodssuchascof
fee,
citr
usfrui
ts,
andcol
a.

 Forev er
ypatientproblem,thereisanursingdi agnosis;foreverynursi
ngdi agnosis,
there
i
sagoal ;
andf oreverygoal,therear
einterventionsdesi gnedtomaket hegoal ar
ealit
y.
Thekey stoanswer ingexami nati
onquestionscor rect
lyar ei
denti
fyingt hepr obl
em
presented,f
ormulatingagoal f
ortheproblem, andsel ecti
ngtheinterventionf r
om the
choicesprovi
dedt hatwillenablethepati
entt or eachthatgoal.

 Fi
del
i
tymeansloy
alt
yandcanbeshownasacommi
tmentt
othepr
ofessi
onofnur
sing
andt
othepat
ient
.

 Admini
ster
inganI
.M.i
nject
ionagai
nstt
hepat
ient
’swi
l
landwi
thoutl
egal
aut
hor
it
yis
bat
tery
.

 Anexampl
eofat
hir
d-par
typay
eri
sani
nsur
ancecompany
.

 Thefor
mulaforcalcul
ati
ngthedropspermi
nut
eforanI
.[Link]
usi
onisasf
oll
ows:
(v
olumetobeinfused×dripfact
or)÷ti
meinmi
nutes=drops/mi
nut
e

 On-
cal
lmedi
cat
ionshoul
dbegi
venwi
thi
n5mi
nut
esoft
hecal
l
.

 Usual
l
y,t
hebestmet
hodt
odet
ermi
neapat
ient
’scul
tur
alorspi
ri
tual
needsi
stoaskhi
m.

 Anincidentr
epor
torunusualoccur
rencer
eporti
sn’
tpartofapat
ient’
srecor
d,buti
san
i
n-housedocumentthat
’susedforthepur
poseofcorr
ecti
ngtheprobl
em.

 Cr
it
ical
pat
hway
sar
eamul
ti
disci
pli
nar
ygui
del
i
nef
orpat
ientcar
e.

 Whenpr i
ori
ti
zi
ngnursi
ngdi
agnoses,
thefoll
owi
nghi
erar
chyshouldbeused:Pr
oblems
associ
atedwitht
heair
way,
thoseconcer
ningbr
eat
hing,
andthoserel
atedtoci
rcul
ati
on.

 Thetwonursi
ngdi
agnosesthathavethehighestpr
ior
it
ythatt
henur
secanassi
gnar
e
I
neff
ecti
veair
waycl
earanceandIneff
ecti
vebreathi
ngpatt
ern.

 Asubject
ivesi
gnthatasit
zbathhasbeenef
fect
ivei
sthepat
ient
’sexpr
essi
onof
decr
easedpainordiscomfor
t.

 Forthenursi
ngdiagnosisDef
ici
entdi
versi
onalact
ivi
tyt
obev al
i
d,thepat
ientmustst
ate
thathe’
s“bored,
”thathehas“not
hingtodo,”orwordst
othateff
ect.
 Themostappropri
atenur
singdi
agnosi
sforani
ndiv
idual
whodoesn’
tspeakEngl
ishi
s
I
mpair
edverbalcommunicati
onrel
atedtoi
nabi
l
ityt
ospeakdomi
nantlanguage(
Engl
ish)
.

 Thefamil
yofapat
ientwhohasbeendi
agnosedashear
ingi
mpai
redshoul
dbe
i
nstr
uctedtof
acet
hei ndi
vi
dual
whentheyspeakt
ohim.

 Bef
oreinsti
ll
i
ngmedicat
ioni
ntotheearofapati
entwhoi suptoage3,
thenur
seshoul
d
pul
lthepinnadownandbacktostr
aight
entheeustachi
antube.

 Topr eventi
njuryt
ot hecorneawhenadmini
ster
ingey
edrops,
thenur
seshoul
dwast
ethe
fi
rstdropandi nst
il
lthedrugint
helowerconj
uncti
val
sac.

 Afteradmini
ster
ingey
eoi
ntment
,thenur
seshoul
dtwi
stt
hemedi
cat
iont
ubet
odet
ach
theointment
.

 Whent
henur
seremovesglov
esandamask, sheshoul
dremov
ethegl
ovesf
ir
[Link]
ar
esoi
l
edandar
elikel
ytocontai
npat
hogens.

 Cr
utchesshoul
dbeplaced6″(
15.
2cm)i
nfr
ontoft
hepat
ientand6″t
othesi
det
ofor
m
at
ripodarr
angement
.

 Li
steni
ngi
sthemostef
fect
ivecommuni
cat
iont
echni
que.

 Befor
et eachi
nganypr
oceduretoapat
ient
,thenur
semustassesst
hepat
ient
’scur
rent
knowledgeandwill
i
ngnesstolear
n.

 Pr
ocessr
ecor
dingi
samet
hodofev
aluat
ingone’
scommuni
cat
ionef
fect
iveness.

 Whenf
eedinganelder
lypat
ient,t
henur
seshoul
dli
mithi
gh-
car
bohy
drat
efoodsbecause
oft
her
iskofglucosei
ntol
erance.

 Whenf
eedi
nganel
der
lypat
ient
,essent
ial
foodsshoul
dbegi
venf
ir
st.

 Passi
ver
angeofmot
ionmai
ntai
nsj
ointmobi
l
ity
.Resi
sti
veexer
cisesi
ncr
easemuscl
e
mass.

 I
somet
ri
cexer
cisesar
eper
for
medonanext
remi
tyt
hat
’si
nacast
.

 Abackr
ubi
sanexampl
eoft
hegat
e-cont
rol
theor
yofpai
n.

 Anyt
hingthat
’sl
ocatedbelowthewaisti
sconsideredunst
eri
le;asteri
lefi
eldbecomes
unst
eri
lewhenitcomesi ncont
actwi
t hanyunster
il
eit
em; asteri
l
ef i
eldmustbe
monit
oredconti
nuously
;andaborderof1″(2.5cm)aroundast eri
l
ef i
eldi
sconsider
ed
unst
eri
le.

 A“
shi
ftt
othel
eft
”isev
identwhent
henumberofi
mmat
urecel
l
s(bands)i
nthebl
ood
 i
ncr
easest
ofi
ghtani
nfect
ion.

 A“shi
ftt
otheri
ght”i
sevidentwhenthenumberofmatur
ecel
l
sint
hebl
oodi
ncr
eases,
asseeni
nadvancedli
verdiseaseandper
nici
ousanemi
a.

 Befor
eadminister
ingpr
eoperat
ivemedicat
ion,t
henurseshoul
densur
ethatani
nfor
med
consentf
orm hasbeensignedandatt
achedt othepat
ient
’sr
ecor
d.

 Anurseshoul
dspendnomoret
han30mi
nut
esper8-
hourshi
ftpr
ovi
dingcar
etoa
pat
ientwhohasaradi
ati
oni
mpl
ant
.

 Anurseshoul
dn’
tbeassi
gnedt
ocar
eformor
ethanonepat
ientwhohasar
adi
ati
on
i
mplant.

 Long-handl
edf
orcepsandalead-
li
nedcont
ainershoul
dbeav
ail
abl
eint
her
oom ofa
pati
entwhohasar adi
ati
oni
mplant.

 Usual
l
y,pat
ient
swhohav
ethesamei
nfect
ionandar
einst
ri
cti
sol
ati
oncanshar
ea
room.

 Diseasesthatrequir
estr
icti
sol
ati
onincludechi
ckenpox,
dipht
her
ia,
andv
iral
hemor r
hagicfeverssuchasMarburgdisease.

 Fort
hepat
ientwhoabi
desbyJewi
shcust
om,
mil
kandmeatshoul
dn’
tbeser
vedatt
he
samemeal
.

 Whetherthepati
entcanperform aprocedure(psy chomotordomainofl
ear
ning)isa
bet
teri
ndicat
oroft heeff
ecti
venessofpatientteachingthanwhethert
hepatientcan
si
mplystatethestepsinvol
vedintheprocedure( cognit
ivedomai
noflear
ning).

 Accordi
ngt oErikEri
kson,devel
opment alstagesaretr
ustv ersusmistr
ust(bi
rt
hto18
months),autonomyv er
susshameanddoubt( 18mont hstoage3) ,i
nit
iat
ivever
susguilt
(ages3to5) ,i
ndustr
yv er
susinferi
orit
y(ages5t o12),i
dent i
tyver
susidenti
tydi
ffusi
on
(ages12to18) ,i
nti
macyv ersusisol
ation(ages18t o25),generat
ivi
tyver
susstagnati
on
(ages25to60) ,andegointegri
tyversusdespair(ol
derthanage60) .

 Whencommuni
cat
ingwi
thahear
ingi
mpai
redpat
ient
,thenur
seshoul
dfacehi
m.

 Anappropr
iat
enursi
ngi
nter
venti
onfort
hespouseofapati
entwhohasaser
ious
i
ncapaci
tat
ingdi
seasei
stohelphimtomobi
li
zeasupportsyst
em.

 Hy
per
pyr
exi
aisext
remeel
evat
ioni
ntemper
atur
eabov
e106°F(
41.
1°C)
.

 Mi
l
kishi
ghi
nsodi
um andl
owi
nir
on.

 Whenapat
ientexpr
essesconcer
naboutaheal
th-
rel
atedi
ssue,
bef
oreaddr
essi
ngt
he
 concer
n,t
henur
seshoul
dassesst
hepat
ient
’sl
evel
ofknowl
edge.

 Themosteff
ecti
vewaytoreduceaf
everi
stoadmi
nist
eranant
ipy
ret
ic,
whi
chl
ower
s
thet
emperat
uresetpoi
nt.

 Whenapati
enti
sil
l,
it’
sessent
ialf
orthemember
sofhi
sfami
l
ytomai
ntai
n
communi
cati
onabouthisheal
thneeds.

 Et
hnocent
ri
sm i
stheuni
ver
sal
bel
i
eft
hatone’
swayofl
i
fei
ssuper
iort
oot
her
s.

 Whenanursei
scommuni cat
ingwithapat
ientt
hroughani
nter
pret
er,
thenur
seshoul
d
speakt
othepat
ientandt
heinter
preter
.

 I
naccor dancewit
ht he“hot
-col
d”syst
em usedbysomeMexicans,
Puer
toRi
cans,
and
otherHispani
candLat i
nogroups,mostf
oods,bev
erages,
her
bs,anddr
ugsar
e
descri
bedas“ col
d.”

 Pr
ejudi
cei
sahost
il
eat
ti
tudet
owar
dindi
vi
dual
sofapar
ti
cul
argr
oup.

 Di
scri
minat
ioni
spref
erent
ialt
reat
mentofi
ndi
vi
dual
sofapar
ti
cul
argr
oup.I
t’
susual
l
y
di
scussedi
nanegati
vesense.

 I
ncr
easedgast
ri
cmot
il
it
yint
erf
ereswi
tht
heabsor
pti
onofor
aldr
ugs.

 Thethreephasesoft
het
her
apeut
icr
elat
ionshi
par
eor
ient
ati
on,
wor
king,
and
ter
minati
on.

 Pati
entsoft
enexhibi
tresi
sti
veandchal
l
engi
ngbehav
ior
sint
heor
ient
ati
onphaseoft
he
ther
apeuti
crel
ati
onship.

 Abdominalassessmenti
sper
for
medi
nthef
oll
owi
ngor
der
:inspect
ion,
auscul
tat
ion,
per
cussion&palpati
on.

 Whenmeasuri
ngbloodpr
essur
einaneonate,
thenurseshoul
dselectacuf
fthat’
sno
l
essthanone-
hal
fandnomorethant
wo-thi
rdsthel
engthoftheextr
emit
ythat’
sused.

 Whenadmini
ster
ingadr
ugbyZ-
tr
ack,thenurseshoul
dn’
tusethesameneedl
ethatwas
usedt
odrawthedrugi
ntot
hesy
ringebecausedoingsocoul
dstai
ntheski
n.

 Sit
esforint
rader
mali
nject
ioni
ncl
udet
hei
nnerar
m,t
heupperchest
,andont
heback,
underthescapul
a.

 Whenev al
uati
ngwhetheranansweronanexaminat
ioni
scorrect
,thenurseshoul
d
considerwhethert
heactiont
hat’
sdescr
ibedpr
omotesautonomy( i
ndependence)
,saf
ety
,
sel
f-esteem,andasenseofbelongi
ng.

 Whenanswer
ingaquest
ionont
heNCLEXex
ami
nat
ion,
thest
udentshoul
dconsi
dert
he
 cue(thestimulusforat hought)andtheinference( t
het hought)todeterminewhet her
thei
nf er
[Link] ndoubt,thenur seshoul dsel
ectananswert hatindi
cates
theneedf orf
urtheri
nfor mationtoel
iminateambi [Link] e,
thepat ient
complainsofchestpai n( t
hestimul
usforthet hought )andthenur seinf
erst hatthe
pati
entishavingcardiacpai n(t
hethought).Inthiscase, t
henur sehasn’tconf i
rmed
whetherthepainiscar diac.I
twouldbemor eappr opri
atetomakef ur
therassessment s.

 Veraci
tyi
struthandisanessenti
alcomponentofat
her
apeut
icr
elat
ionshi
pbet
weena
healt
hcareprovi
derandhi
spat i
ent.

 Benefi
cencei
sthedut
ytodonoharm andthedutyt
[Link]
e’sanobl
i
gat
ioni
n
pati
entcaret
odonoharm andanequalobl
i
gati
ontoassi
stt
hepati
ent.

 Nonmal
efi
cencei
sthedut
ytodonohar
m.

 Fr
ye’
sABCDEcascadepr ov
idesaf
ramewor
kforpr
ior
it
izi
ngcar
ebyi
dent
if
yingt
hemost
i
mportantt
reat
mentconcerns.

 A=Ai r
way .Thi
scat egor
yincl
udesever
ythi
ngthataffect
sapatentai
rway
,incl
udi
nga
for
eignobject,
flui
df r
om anupperr
espir
ator
yinfect
ion,andedemafr
om tr
aumaoran
all
ergi
creacti
on.

 B=Breathi
[Link] scategor
yincl
udesever
ythi
ngthataf
fect
sthebreathi
ngpatter
n,
i
ncl
udinghyperventil
ati
onorhypovent
il
ati
onandabnormalbreat
hingpatt
erns,
suchas
Kor
sakoff’
s,Bi
ot’s,orCheyne-
Stokesr
espir
ati
on.

 C=Cir
cul
ati
[Link]
egoryincl
udeseveryt
hingthataf
fectstheci
rcul
ati
on,i
ncludi
ng
f
lui
dandel
ectr
olyt
edist
urbancesanddiseaseprocessesthataff
ectcar
diacoutput.

 D=Di seasepr [Link]

hepati
enthasnopr obl
em withtheair
way ,breat
hing,or
circul
ation,thenthenur seshoul
dev aluat
ethediseaseprocesses,givi
ngpriori
tytothe
diseasepr ocesst hatposesthegreatesti
mmedi ateri
[Link] e,i
fapat i
enthas
terminal cancerandhy pogly
cemia,hypoglycemiaisamor eimmedi ateconcern.

 E=Ev er
ythi
[Link]
scategor
yincl
udessuchissuesaswrit
ingani
nci
dentrepor
tand
completi
ngthepati
entchar
[Link]
ingneeds,t
hiscat
egoryi
snevert
hehighest
pri
ori
ty.

 Whenanswer ingaquestiononanNCLEXexami nati

on,thebasicruleis“assessbef or
e
acti
on.”Thestudentshouldeval
uateeachpossi
bleanswercarefull
[Link]
y, sever
al
answersrefl
ecttheimplementat
ionphaseofnursi
ngandoneort worefl
ectt he
[Link],
thebestchoi
ceisanassessmentr esponseunl essa
specif
iccour
seofact i
oni scl
ear
lyi
ndicat
ed.

 Rul
eut
il
it
ari
ani
sm i
sknownast
he“
great
estgoodf
ort
hegr
eat
estnumberofpeopl
e”
 t
heor
y.

 Egal
itar
iant
heor
yemphasi
zest
hatequalaccesstogoodsandser
vicesmustbe
prov
idedtothel
essf
ort
unat
ebyanaffl
uentsociet
y.

 Act
iveeut
hanasi
aisact
ivel
yhel
pingaper
sont
odi
e.

 Br
aindeat
hisi
rr
ever
sibl
ecessat
ionofal
lbr
ainf
unct
ion.

 Passi
veeut
hanasi
aisst
oppi
ngt
het
her
apyt
hat
’ssust
aini
ngl
i
fe.

 At
hir
d-par
typay
eri
sani
nsur
ancecompany
.

 Uti
li
zati
onrev
iewi
sperformedtodet
ermi
newhet
hert
hecar
epr
ovi
dedt
oapat
ientwas
appropr
iat
eandcost
-ef
fecti
ve.

 Av al
uecohorti
sagroupofpeopl
ewhoexper
iencedanout
-of
-t
he-
ordi
nar
yev
entt
hat
shapedthei
rval
ues.

 Vol
unt
aryeut
hanasi
aisact
ivel
yhel
pingapat
ientt
odi
eatt
hepat
ient
’sr
equest
.

 Bananas,
cit
rusf
rui
ts,
andpot
atoesar
egoodsour
cesofpot
assi
um.

 Goodsour
cesofmagnesi
um i
ncl
udef
ish,
nut
s,andgr
ains.

 Beef
,oy
ster
s,shr
imp,
scal
l
ops,
spi
nach,
beet
s,andgr
eensar
egoodsour
cesofi
ron.

 I
ntr
athecal
inj
ect
ioni
sadmi
nist
eri
ngadr
ugt
hrought
hespi
ne.

 Whenapatientasksaquestionormakesast
atementt
hat
’semotional
l
ycharged,t
he
nur
seshoul
dr espondtotheemotionbehi
ndt
hestat
ementorquesti
onrat
herthanto
what’
sbei
ngsai dorasked.

 Thest
epsoft
het
raj
ect
ory
-nur
singmodel
areasf
oll
ows:

 St
ep1:
Ident
if
yingt
het
raj
ect
oryphase

 St
ep2:
Ident
if
yingt
hepr
obl
emsandest
abl
i
shi
nggoal
s

 St
ep3:
Est
abl
i
shi
ngapl
ant
omeett
hegoal
s

 St
ep4:
Ident
if
yingf
act
orst
hatf
aci
l
itat
eorhi
nderat
tai
nmentoft
hegoal
s

 St
ep5:
Impl
ement
ingi
nter
vent
ions

 St
ep6:
Eval
uat
ingt
heef
fect
ivenessoft
hei
nter
vent
ions

 AHi
ndupat
ienti
sli
kel
ytor
equestav
eget
ari
andi
et.
 Pai
nthr
eshol
d,orpai
nsensat
ion,
ist
hei
nit
ial
poi
ntatwhi
chapat
ientf
eel
spai
n.

 Thedi
ff
erencebet
weenacut
epai
nandchr
oni
cpai
nisi
tsdur
ati
on.

 Ref
err
edpai
nispai
nthat
’sf
eltatasi
teot
hert
hani
tsor
igi
n.

 Al
l
evi
ati
ngpai
nbyper
for
mingabackmassagei
sconsi
stentwi
tht
hegat
econt
rol
theor
y.

 Romber
g’st
esti
sat
estf
orbal
anceorgai
t.

 Pai
nseemsmor
eint
enseatni
ghtbecauset
hepat
ienti
sn’
tdi
str
act
edbydai
l
yact
ivi
ti
es.

 Olderpat
ientscommonlydon’
trepor
tpai
nbecauseoff
earoft
reat
ment
,li
fest
yle
changes,ordependency
.

 Nopor
korpor
kpr
oduct
sar
eal
l
owedi
naMusl
i
m di
et.

 Twogoal
sofHeal
thyPeopl
e2010ar
e:

 Hel
pindi
vidualsofal
lagest
oincr
easet
hequal
i
tyofl
i
feandt
henumberofy
ear
sof
opt
imalhealt
h

 El
i
minat
eheal
thdi
spar
it
iesamongdi
ff
erentsegment
soft
hepopul
ati
on.

 Acommuni
tynur
seisserv
ingasapati
ent
’sadv
ocat
eifshet
ell
samal
nour
ishedpat
ient
t
ogotoamealprogr
am atalocal
par
k.

 I
fapat
ienti
sn’
tfol
l
owi
nghi
str
eat
mentpl
an,
thenur
seshoul
dfi
rstaskwhy
.

 Fal
l
sar
ethel
eadi
ngcauseofi
njur
yinel
der
lypeopl
e.

 Pri
mar
yprevent
ioni
str
uepr
event
[Link]
esar
eimmuni
zat
ions,
wei
ghtcont
rol
,and
smoki
ngcessat
ion.

 Secondarypr
eventi
onisear
lydetect
[Link]
ncl
udepur
if
iedpr
otei
nderi
vat
ive
(PPD),br
eastsel
f-
examinat
ion,
testi
cularsel
f-
exami
nati
on,
andchestX-r
ay.

 Ter
ti
arypr
event
ioni
str
eat
mentt
opr
eventl
ong-
ter
m compl
i
cat
ions.

 Apati
enti
ndi
cat
esthathe’
scomingtoter
mswi
thhav
ingachr
oni
cdi
seasewhenhe
say
s,“I
’
m nev
ergoi
ngtogetanybett
er.
”

 Onnot
ici
ngrel
igi
ousart
ifact
sandli
ter
atur
eonapati
ent’
sni
ghtst
and,
acul
tur
all
yawar
e
nur
sewouldaskthepat
ientthemeani
ngofthei
tems.

 AMexicanpati
entmayrequestthei
nter
vent
ionofacur
ander
o,orf
ait
hheal
er,
who
i
nvol
vesthefamil
yinheal
ingthepat
ient
.
 I
nani
nfant
,thenor
mal
hemogl
obi
nval
uei
s12g/
dl.

 Theni
tr
ogenbal
anceest
imat
est
hedi
ff
erencebet
weent
hei
ntakeanduseofpr
otei
n.

 Mostoft
heabsor
pti
onofwat
eroccur
sint
hel
argei
ntest
ine.

 ADVERTI
SEMENTS

 Mostnut
ri
ent
sar
eabsor
bedi
nthesmal
li
ntest
ine.

 Whenassessi
ngapat
ient
’seat
inghabi
ts,
thenur
seshoul
dask,
“Whathav
eyoueat
eni
n
t
helast24hour
s?”

 Av
egandi
etshoul
dincl
udeanabundantsuppl
yoff
iber
.

 Ahy
pot
oni
cenemasof
tenst
hef
eces,
dist
endst
hecol
on,
andst
imul
atesper
ist
alsi
s.

 Fi
rst-
morni
nguri
nepr ov
idest
hebestsampl
etomeasur
egl
ucose,
ket
one,
pH,
and
speci
fi
cgravi
tyv
alues.

 Toi
nducesl
eep,
thef
ir
stst
epi
stomi
nimi
zeenv
ironment
alst
imul
i
.

 Bef
oremovi
ngapat i
ent,
thenurseshoul
dassesst
hepati
ent
’sphysi
calabi
li
ti
esand
abi
l
ityt
ounder
standinst
ruct
ionsaswellast
heamountofst
rengt
hrequir
edtomovethe
pat
ient
.

 Tolose1lb(0.5kg)i
n1week,thepatientmustdecr
easehisweekl
yintakeby3,500
cal
ori
es(approxi
matel
y500calor
iesdaily)
.Tolose2lb(1kg)i
n1week, thepat
ient
mustdecreasehisweekl
ycal
ori
cintakeby7,000cal
ories(
appr
oximately1,
000calor
ies
dai
ly)
.

 Toav
oidshear
ingf
orcei
njur
y,apat
ientwhoi
scompl
etel
yimmobi
l
eisl
i
ftedonasheet
.

 Toinsertacat
heterfr
om t
henoset
hrought
het
racheaf
orsuct
ion,
thenur
seshoul
dask
thepati
enttoswall
ow.

 Vi
tami
nCi
sneededf
orcol
l
agenpr
oduct
ion.

 Onl
ythepat
ientcandescr
ibehi
spai
naccur
atel
y.

 Cut
aneousst
imul
ati
oncr
eat
est
her
eleaseofendor
phi
nst
hatbl
ockt
het
ransmi
ssi
onof
pai
nsti
muli
.

 Pat
ient
-cont
rol
l
edanal
gesi
aisasaf
emet
hodt
orel
i
eveacut
epai
ncausedbysur
gical
 i
nci
sion,
traumat
ici
njur
y,l
aboranddel
i
ver
y,orcancer
.

 AnAsi
anAmeri
canorEur
opeanAmer
icant
ypi
cal
l
ypl
acesdi
stancebet
weenhi
msel
fand
ot
her
swhencommunicat
ing.

 Thepati
entwhobeli
evesi
nascienti
fi
c,orbi
omedical
,appr
oacht
oheal
thi
sli
kel
yto
expectadr
ug,t
reat
ment,orsur
gerytocurei
ll
ness.

 Chr
oni
cil
l
nessesoccuri
nver
yyoungaswel
lasmi
ddl
e-agedandv
eryol
dpeopl
e.

 Thetr
aject
oryframewor
kforchronici
ll
nessst
atest
hatpr
efer
encesaboutdai
l
yli
fe
act
ivi
ti
esaffecttr
eat
mentdeci
sions.

 Exacerbat
ionsofchroni
cdi
seaseusual
l
ycauset
hepat
ientt
oseekt
reat
mentandmay
l
eadt ohospit
ali
zat
ion.

 Schoolheal
thpr
ogr
amsprovi
decost
-ef
fect
iveheal
thcar
eforl
ow-
incomef
ami
l
iesand
thosewhohavenoheal
thi
nsur
ance.

 Col
l
egi
ali
tyi
sthepromoti
onofcol
l
abor
ati
on,
dev
elopment
,andi
nter
dependenceamong
member
sofaprofessi
on.

 Achangeagenti
sanindi
vidual
whorecogni
zesaneedforchangeori
ssel
ect
edt
omake
achangewit
hinanest
abl
ishedent
it
y,suchasahospi
tal
.

 Thepat
ient
s’bi
l
lofr
ight
swasi
ntr
oducedbyt
heAmer
icanHospi
tal
Associ
ati
on.

 Abandonmentisprematureter
minati
onoftr
eat
mentwi
thoutt
hepat
ient
’sper
missi
on
andwithoutappr
opri
aterel
iefofsy
mpt oms.

 Val
uescl
ari
fi
cat
ioni
sapr
ocesst
hati
ndi
vi
dual
suset
opr
ior
it
izet
hei
rper
sonal
val
ues.

 Di
str
ibut
ivej
ust
icei
sapr
inci
plet
hatpr
omot
esequal
treat
mentf
oral
l
.

 Mi
l
kandmi
l
kpr
oduct
s,poul
tr
y,gr
ains,
andf
ishar
egoodsour
cesofphosphat
e.

 Thebestwayt
opreventf
all
satni
ghti
nanor
ient
ed,
butr
est
less,
elder
lypat
ienti
sto
rai
set
hesider
ail
s.

 Byt
heendoft
heor
ient
ati
onphase,
thepat
ientshoul
dbegi
ntot
rustt
henur
se.

 Fal
l
sint
heel
der
lyar
eli
kel
ytobecausedbypoorv
isi
on.

 Bar
ri
erst
ocommunicat
ioni
ncludel
anguagedefi
cit
s,sensor
ydef
ici
ts,
cogni
ti
ve
i
mpair
ments,
str
uct
ural
defi
cit
s,andpar
alysi
s.

 Thet
hreeel
ement
sthatar
enecessar
yforaf
ir
ear
eheat
,oxy
gen,
andcombust
ibl
e
 mat
eri
al.

 Sebaceousgl
andsl
ubr
icat
etheski
n.

 Tocheckforpet
echi
aei
nadar
k-ski
nnedpat
ient
,thenur
seshoul
dassesst
heor
al
mucosa.

 Toputonaster
il
eglov
e,t
henurseshoul
dpickupt
hef
ir
stgl
oveatt
hef
oldedbor
derand
adj
ustt
hefi
ngerswhenbothgl
ovesareon.

 Toincr
easepat
ientcomfor
t,t
henur
seshoul
dlett
heal
cohol
drybef
oregi
vi
ngan
i
ntr
amusculari
nject
ion.

 Tr
eat
mentf
orast
age1ul
ceront
heheel
sincl
udesheel
prot
ect
ors.

 Sev
ent
h-DayAdv
ent
ist
sar
eusual
l
yveget
ari
ans.

 Endor
phi
nsar
emor
phi
ne-
li
kesubst
ancest
hatpr
oduceaf
eel
i
ngofwel
l
-bei
ng.

 Pai
nt ol
erancei
sthemaxi
mum amountanddur
ati
onofpai
nthatani
ndi
vi
dual
iswi
l
li
ng
toendure.

 Abloodpressur
ecuf
fthat
’st
oonar
rowcancauseaf
alsel
yel
evat
edbl
oodpr
essur
e
r
eading.

 Whenprepari
ngasi ngl
einj
ect i
onf orapati
entwhotakesregul
arandneutral
protei
n
Hagedor
ninsuli
n,thenurseshoul ddrawtheregul
ari
nsuli
nintothesy
ringefi
rstsothati
t
doesnotcont
ami natet
her egularinsul
i
n.

 Rhonchiar
etherumbli
ngsoundsheardonl
ungauscul
tat
[Link]
emor
epr
onounced
dur
ingexpi
rat
ionthandur
ingi
nspi
rati
on.

 Gavagei
sfor
cedfeedi
ng,
usual
l
ythr
oughagast
ri
ctube(
atubepassedi
ntot
hest
omach
t
hrought
hemouth).

 Accordi
ngtoMaslow’
shi
erar
chyofneeds,phy
siol
ogicneeds(
air
,wat
er,
food,
shel
ter
,
sex,act
ivi
ty,
andcomf
ort
)havethehi
ghestpri
ori
ty.

 Thesaf
estandsur
estwayt
over
if
yapat
ient
’si
dent
it
yist
ocheckt
hei
dent
if
icat
ionband
onhi
swr i
st.

 I
nthet
her
apeut
icenv
ironment
,thepat
ient
’ssaf
etyi
sthepr
imar
yconcer
n.

 Fl
uidosci
l
lati
oninthet
ubi
ngofachestdr
ainagesy
stem i
ndi
cat
est
hatt
hesy
stem i
s
worki
ngproperl
y.

 Thenur
seshoul
dpl
aceapat
ientwhohasaSengst
aken-
Blakemor
etubei
nsemi
-Fowl
er
 posi
ti
on.

 Thenursecaneli
citTr
ousseau’
ssignbyoccl
udi
ngthebrachi
alorradi
alar
ter
[Link]
fi
ngerspasmsthatoccurduri
ngoccl
usi
onindi
cat
eTrousseau’
ssignandsuggest
hypocal
cemia.

 Forbl
oodt
ransf
usi
oni
nanadul
t,t
heappr
opr
iat
eneedl
esi
zei
s16t
o20G.

 I
ntr
act
abl
epai
nispai
nthati
ncapaci
tat
esapat
ientandcan’
tber
eli
evedbydr
ugs.

 I
nanemer gency
,consentf
ort
reat
mentcanbeobt
ainedbyf
ax,
tel
ephone,
orot
her
t
elegr
aphi
cmeans.

 Deci
bel
ist
heuni
tofmeasur
ementofsound.

 I
nfor
medconsenti
srequi
redf
oranyi
nvasi
vepr
ocedur
e.

 Apati
entwhocan’
twrit
ehisnametogi
veconsentfort
reat
mentmustmakeanXi
nthe
pr
esenceoft
wowitnesses,
suchasanurse,
pri
est,
orphysi
cian.

 TheZ-t
rackI.
[Link]
ecti
ontechni
quesealsthedrugdeepi
ntothemuscl
e,t
her
eby
mini
mizingski
nirr
it
ati
onandstai
ning.I
trequi
resaneedl
ethat’
s1″(
2.5cm)orl
onger
.

 I
nt heev entoffi
re,
theacrony
m mostoft
enusedisRACE.(
R)Removethepatient
.(A)
Activ
at ethealar
m.(C)Attemptt
ocontai
nthefi
rebycl
osi
ngthedoor
.(E)Ext
ingui
shthe
fi
reifitcanbedonesaf el
y.

 Aregi
ster
ednur seshouldassi
gnali
censedvocat
ional
nur
seorlicensedpr
act
ical
nur
se
t
operform bedsidecar
e,suchassuct
ioni
nganddrugadmini
str
ation.

 I
fapatientcan’
tvoi
d,t
hef
ir
stnur
singact
ionshoul
dbebl
adderpal
pat
iont
oassessf
or
bl
adderdist
enti
on.

 Thepat
ientwhousesacaneshoul
dcar
ryi
tont
heunaf
fect
edsi
deandadv
ancei
tatt
he
sameti
meast heaff
ect
edextr
emit
y.

 Tofi
tasupi
nepat
ientf
orcr
utches,t
henur
seshoul
dmeasur
efr
om t
heaxi
l
lat
othesol
e
andadd2″(
5cm)tothatmeasurement
.

 Assessmentbegi nswi
ththenurse’
sfi
rstencounterwit
hthepati
entandconti
nues
throughoutthepati
ent
’sst
[Link]
nsassessmentdatathroughtheheal
th
histor
y,physical
exami
nati
on,andrevi
ewofdi agnost
icstudi
es.

 Theappr
opr
iat
eneedl
esi
zef
ori
nsul
i
ninj
ect
ioni
s25Gand5/
8″l
ong.

 Residual
uri
nei
sur
inet
hatr
emainsi
nthebl
adderaf
terv
oidi
[Link]
esi
dual
uri
neisnormal
l
y50to100ml.
 Thefi
vest
agesofthenur
singpr
ocessar
eassessment
,nur
singdi
agnosi
s,pl
anni
ng,
i
mplement
ati
on,andeval
uati
on.

 Assessmenti
sthestageofthenursi
ngprocessinwhi
cht henur
secont
inuousl
ycol
l
ect
s
datatoi
denti
fyapat
ient
’sactual
andpotenti
alheal
thneeds.

 Nursi
ngdiagnosi
sisthestageofthenur
singpr
ocessi
nwhichthenursemakesa
cl
ini
calj
udgmentaboutindivi
dual,
fami
ly
,orcommunit
yresponsest
oactual
orpotent
ial
heal
thprobl
emsorlif
epr ocesses.

 Planningisthestageofthenursingprocessi
nwhichthenur
seassi
gnspr
ior
it
iest
o
nursingdiagnoses,def
inesshort-
ter
m andlong-
ter
m goal
sandexpect
edout
comes,and
establi
shesthenursingcareplan.

 Implement
ationisthestageofthenursi
ngprocessinwhichthenur
seput
sthenur
sing
careplani
ntoaction,
delegatesspeci
fi
cnursi
nginter
venti
onstomembersoft
henursi
ng
team,andchartspati
entresponsestonursi
ngint
ervent
ions.

 Eval
uat
ioni
sthestageofthenursi
ngpr
ocessinwhichthenursecomparesobj
ect
ive
andsubj
ect
ivedat
awiththeoutcomecri
ter
iaand,
ifneeded,
modi f
iest
henursi
ngcare
pl
an.

 Bef
oreadmini
ster
ingany“
asneeded”pai
nmedi
cat
ion,
thenur
seshoul
daskt
hepat
ient
toi
ndi
catet
helocati
onofthepai
n.

 Jehovah’sWit
nessesbel
i
evet
hatt
heyshoul
dn’
trecei
vebl
oodcomponent
sdonat
edby
otherpeopl
e.

 Totestv
isual
acui
ty,
thenur
seshouldaskthepati
entt
ocovereachey
esepar
atel
yand
tor
eadtheeyechar
twithgl
assesandwit
hout,asappr
opr
iat
e.

 Whenprovi
dingoralcaref
oranunconsci
ouspat
ient
,tomi
nimi
zet
her
iskofaspi
rat
ion,
t
henurseshouldpositi
onthepat
ientont
hesi
de.

 Duri
ngassessmentofdi
stancev
isi
on,
thepat
ientshoul
dst
and20′
(6.
1m)f
rom t
he
char
t.

 Forageri
atr
icpat
ientoronewhoi
sext
remel
yil
l
,thei
deal
room t
emper
atur
eis66°t
o
76°F(18.
8°to24.
4°C) .

 Nor
mal
room humi
dit
yis30%t
o60%.

 Handwashingisthesi
ngl
ebestmet hodofl
imi
ti
ngthespreadofmicr
oor
gani
[Link]
glov
esareremovedaft
errout
inecontactwi
thapat
ient
,handsshoul
dbewashedf
or10
to15seconds.
 Toperf
orm cat
het
eri
zat
ion,
thenur
seshoul
dpl
aceawomani
nthedor
sal
recumbent
posi
ti
on.

 Aposi
ti
veHoman’
ssi
gnmayi
ndi
cat
ethr
ombophl
ebi
ti
s.

 El
ectr
oly
tesi
nasolut
ionar
emeasuredi
nmil
li
equi
val
entsperl
i
ter(
mEq/L)
.A
mil
li
equi
val
enti
sthenumberofmi
ll
i
gramsper100mil
li
l
iter
sofasol
uti
on.

 Metabol
i
sm occursi
ntwophases:
anabol
i
sm (
theconst
ruct
ivephase)andcat
abol
i
sm
(
thedestr
uct
ivephase)
.

 Thebasal metabol
i
crateist
heamountofenergyneededtomaint
ainessent
ial
body
functi
ons.I
t’
smeasuredwhenthepati
entisawakeandresti
ng,
hasn’teat
enfor14t
o18
hours,andisi
nacomf ort
abl
e,war
m envi
ronment.

 Thebasalmetabol
i
crat
eisex
pressedi
ncal
ori
esconsumedperhourperki
l
ogr
am of
bodyweight
.

 Di
etar
yf i
ber(
roughage)
,whichisderi
vedfr
om cel
lul
ose,
suppli
esbul
k,mai
ntai
ns
i
ntest
inalmot
il
it
y,andhelpstoestabl
i
shregul
arbowelhabi
ts.

 Al
coholi
smetabol
izedpr
imar
il
yint
hel
i
ver
.Smal
l
eramount
sar
emet
abol
i
zedbyt
he
ki
dneysandl
ungs.

 Pet
echi
aeareti
ny,r
ound,pur
pli
shredspot
sthatappearont
heskinandmucous
membranesasaresul
tofint
rader
malorsubmucosalhemor
rhage.

 Pur
pur
aisapur
pledi
scol
orat
ionoft
heski
nthat
’scausedbybl
oodext
rav
asat
ion.

 Accor
dingtothestandardprecaut
ionsrecommendedbytheCent
ersforDi
seaseControl
andPrevent
ion,
thenurseshouldn’
trecapneedl
esaft
[Link]
esti
cksresul
t
fr
om missedneedl
er ecappi
ng.

 Thenur
seadminist
[Link]
nganeedl
eandsy
ringet
odel
i
vert
he
dosedi
rect
lyi
ntoavein,
I.
[Link]
ng,oracathet
er.

 Whenchangi
ngthet
iesonatracheost
omyt
ube,
thenur
seshoul
dleav
etheol
dti
esi
n
pl
aceunt
ilt
henewonesareappli
ed.

 Anur
seshoul
dhav
eassi
stancewhenchangi
ngt
het
iesonat
racheost
omyt
ube.

 Af
il
teri
sal
way
susedf
orbl
oodt
ransf
usi
ons.

 Afour-
poi
nt(quad)canei
sindi
cat
edwhenapat
ientneedsmor
est
abi
l
ityt
hanar
egul
ar
canecanprovi
de.
 Agoodwayt
obegi
napat
ienti
nter
viewi
stoask,
“Whatmadey
ouseekmedi
cal
hel
p?”

 Whencar
ingforanypati
ent
,thenur
seshoul
dfol
l
owst
andar
dpr
ecaut
ionsf
orhandl
i
ng
bl
oodandbodyflui
ds.

 Pot
assi
um (
K+)i
sthemostabundantcat
ioni
nint
racel
l
ularf
lui
d.

 I
nthefour
-poi
nt,
oralt
ernat
ing,
gait
,thepati
entf
irstmov estheri
ghtcr
utchf
oll
owedby
t
helef
tfootandthent
heleftcr
utchfol
lowedbytherightfoot.

 Inthethr
ee-pointgai
t,t
hepat
ientmov est
wocrutchesandt
heaf
fect
edl
eg
simult
aneouslyandthenmovest heunaff
ect
edleg.

 ADVERTI
SEMENTS

 Int
het wo-
poi
ntgai
t,t
hepat
ientmov
est heri
ghtl
egandtheleftcr
utchsi
mul
taneousl
y
andthenmovesthel
eftl
egandther
ightcrut
chsimul
taneousl
y.

 Thev i
tami
nBcomplex,thewater
-sol
ublevi
taminst
hatareessent
ialf
ormetaboli
sm,
i
ncludethi
ami
ne(B1),r
ibofl
avi
n(B2),
niaci
n( B3)
,py
ridox
ine(
B6),andcyanocobal
ami
n
(B12).

 Whenbei
ngwei
ghed,
anadul
tpat
ientshoul
dbel
i
ght
lydr
essedandshoel
ess.

 Befor
etaki
nganadult
’st
emperat
ureoral
l
y,t
henur seshoul
densur
ethatt
hepat
ient
hasn’
tsmokedorconsumedhotorcol
dsubstancesinthepr
evi
ous15minut
es.

 Thenurseshoul
dn’
ttakeanadul
t’
stemper
aturer
ectal
l
yi ft
hepati
enthasacardi
ac
di
sorder,
anall
esi
ons,orbl
eedi
nghemorr
hoidsorhasrecentl
yunder
gonerect
alsur
ger
y.

 I
napati
entwhohasacar
diacdisorder
,measur
ingtemperat
urerectal
l
ymayst
imul
atea
v
agal
responseandl
eadt
ov asodi
lati
onanddecreasedcar
diacoutput
.

 Whenr ecordingpulseampli
tudeandr hyt
hm, t
henurseshoul
duset hesedescr
ipt
ive
measures: +3,boundingpul
se(readi
l
ypal pabl
eandforcef
ul)
;+2,normalpul
se(easi
ly
pal
pable);+1, t
hreadyorweakpulse(dif
fi
cultt
odetect
);and0,absentpul
se(not
det
ectable).

 Theint
raoper
ati
veper
iodbeginswhenapat
ienti
stransferr
edt
otheoper
ati
ngr
oom bed
andendswhenthepatienti
sadmit
tedt
othepostanesthesi
acar
euni
t.

 Onthemorni
ngofsur
gery,t
henurseshouldensuret
hatt
heinf
ormedconsentfor
m has
beensi
gned;
thatt
hepat
ienthasn’
ttakenanyt
hingbymouthsi
ncemidni
ght,hast
akena
 showerwi t
hanti
micr
obialsoap,
hashadmout hcare(withoutswallowingthewater)
,has
removedcommonj ewelry
,andhasreceiv
edpr eoperati
vemedi cat
ionaspr escr
ibed;
and
thatv
italsi
[Link]
if
iciall
imbsandot herpr
osthesesare
usual
lyremoved.

 Comf ortmeasures,suchasposi
ti
oni
ngthepati
ent
,rubbingthepati
ent’
sback,and
provi
dingarestf
ul envi
ronment
,maydecreaset
hepatient’
sneedforanal
gesicsormay
enhancetheiref
fectiv
eness.

 Adr ughasthr
eenames:generi
cname,whichi susedinof
fi
cial
publ
icati
ons;
trade,
or
brand,name(suchasTy
lenol)
,whichi
sselectedbythedrugcompany;andchemical
name, whi
chdescri
best
hedrug’schemicalcompositi
on.

 Toavoi
dst
aini
ngt
het
eet
h,t
hepat
ientshoul
dtakeal
i
qui
dir
onpr
epar
ati
ont
hrougha
st
raw.

 Thenurseshoul
duset
heZ-
tr
ackmet
hodt
oadmi
nist
eranI
.M.i
nject
ionofi
rondex
tran
(I
mfer
on).

 Anorgani
sm mayentert
hebodyt
hrought
henose,
mout
h,r
ect
um,
uri
nar
yor
repr
oduct
ivet
ract
,orski
n.

 Indescendi
ngorder
,thel
evel
sofconsci
ousnessar
eal
ert
ness,
let
har
gy,
stupor
,li
ght
coma, anddeepcoma.

 Tot ur
napatientbylogrol
li
ng,t
henursef
oldsthepati
ent
’sar
msacr ossthechest;
extendsthepati
ent’
slegsandinser
tsapil
lowbetweenthem,i
fneeded;placesadraw
sheetunderthepati
ent;andtur
nsthepat
ientbysl
owlyandgentl
ypulli
ngont hedr
aw
sheet.

 Thediaphr
agm oft
hest
ethoscopei
susedt
ohearhi
gh-
pit
chedsounds,
suchasbr
eat
h
sounds.

 Asli
ghtdif
fer
encei
nbl
oodpr
essur
e(5t
o10mm Hg)bet
weent
her
ightandt
hel
eft
ar
msi snormal.

 Thenur
seshoul
dpl
acet
hebl
oodpr
essur
ecuf
f1″(
2.5cm)abov
etheant
ecubi
tal
fossa.

 Wheninst
il
li
ngophthal
micoi
ntments,
thenurseshouldwastethefir
stbeadofoi
ntment
andt
henapplytheoint
mentf
rom thei
nnercanthustotheoutercanthus.

 Thenur
seshoul
duseal
egcuf
ftomeasur
ebl
oodpr
essur
einanobesepat
ient
.

 I
fabl
oodpr
essur
ecuf
fisappl
i
edt
ool
oosel
y,t
her
eadi
ngwi
l
lbef
alsel
ylower
ed.

 Pt
osi
sisdr
oopi
ngoft
heey
eli
d.
 At i
l
ttableisusef
ulf
orapat
ientwit
haspinalcor
dinj
ury,
orthost
ati
chy pot
ensi
on,
or
brai
ndamagebecauseitcanmov ethepat
ientgr
adual
lyfr
om ahorizontal
toaver
ti
cal
(upri
ght)posi
ti
on.

 Toperfor
mv eni
punctur
ewi t
hthel easti
njur
ytothev essel
,thenur
seshoul
dtur
nthe
bevel
upwardwhent hevessel’
slumeni slar
gerthantheneedleandtur
nitdownwar
d
whenthelumenisonlysli
ghtl
ylargerthantheneedle.

 Tomov eapat i
enttotheedgeofthebedf ortr
ansfer,t
henurseshouldf ol
l
owt hese
steps:Mov ethepati
ent’
sheadandshoul derstowardtheedgeoft [Link] ethe
patient
’sfeetandlegstotheedgeofthebed( crescentposi
ti
on).Placebotharmswel l
underthepat i
ent’
ships,andst
rai
ghtenthebackwhi lemov i
ngthepat i
enttowardthe
edgeoft hebed.

 Whenbei
ngmeasur
edf
orcr
utches,
apat
ientshoul
dwearshoes.

 Thenurseshoul
dat
tacharest
rai
nttot
hepar
toft
hebedf
ramet
hatmov
eswi
tht
he
head,
nottothemat
tressorsi
derai
l
s.

 Themisti
namistt
entshoul
dneverbecomesodenset
hati
tobscur
escl
ear
vi
sual
i
zati
onoft
hepati
ent’
srespi
rat
orypat
ter
n.

 Toadmi ni
sterhepari
nsubcutaneousl y,t
henurseshouldfoll
owt hesesteps:Clean,but
don’trub,thesitewit
[Link]
ckupawel l
-defi
nedskinfold.
Holdt heshaf toft
heneedleinadar tposi
ti
[Link]
heneedleintotheskinatar i
ght
(90-degree)[Link]
rml
ydepr esst heplunger,butdon’
taspi
[Link]
placef [Link]
awt heneedlegent l
yattheangl
eofi nsert
[Link]
pressur etotheinj
ect
ionsit
ewi thanal coholpad.

 Forasi
gmoidoscopy,t
henurseshouldplacethepatienti
ntheknee-
chestposi
ti
onor
Si
ms’posi
ti
on,dependingonthephysici
an’spref
erence.

 Maslow’shierar
chyofneedsmustbemeti nthefoll
owingorder
:phy
siol
ogi
c(oxygen,
food,water
,sex,rest
,andcomfort)
,saf
etyandsecuri
ty,l
oveandbel
ongi
ng,sel
f-
esteem
andrecogniti
on,andself
-act
ual
izat
ion.

 Whencari
ngforapati
entwhohasanasogastr
ictube,
thenur
seshoul
dappl
yawat
er-
sol
ubl
elubr
icantt
othenost
ri
ltopr
eventsor
eness.

 Dur
inggast
ri
clavage,anasogast
ri
ctubei
sinserted,
thest
omachi
sfl
ushed,
and
i
ngest
edsubstancesareremovedthr
oughthetube.

 Indocumenti
ngdrai
nageonasur
gicaldr
essing,t
henurseshoul
dincl
udet
hesize,col
or,
andconsi
stencyoft
hedrai
nage(
forexample,“10mm ofbrownmucoiddr
ainagenoted
ondressi
ng”)
.
 Toel
icitBabi
nski
’srefl
ex,thenur
sest
rokest
hesol
eoft
hepat
ient
’sf
ootwi
tha
moderatel
ysharpobject,
suchasathumbnai
l.

 Aposi
ti
veBabi
nski
’
sref
lexi
sshownbydor
sif
lexi
onoft
hegr
eatt
oeandf
anni
ngoutof
t
heothert
oes.

 Whenassessi
ngapat
ientforbladderdi
stent
ion,thenur
seshoul
dcheckt
hecont
ourof
t
helowerabdomenf
orar oundedmassabov et hesymphysi
spubi
s.

 Thebestwaytopr
eventpr
essur
eul
cer
sist
oreposi
ti
ont
hebedr
iddenpat
ientatl
east
ever
y2hours.

 Anti
embol
i
sm st
ocki
ngsdecompr
esst
hesuper
fi
cial
bloodv
essel
s,r
educi
ngt
her
iskof
thr
ombusfor
mati
on.

 I
nadul
ts,t
hemostconveni
entv
einsf
orv
eni
punct
urear
ethebasi
l
icandmedi
ancubi
tal
v
einsi
ntheant
ecubi
tal
space.

 Twot othr
eehoursbef
orebegi
nni
ngat ubefeedi
ng,
thenur
seshouldaspi
rat
ethe
pat
ient’
sstomachcont
entstover
if
ythatgastr
icempty
ingi
sadequate.

 Peopl
ewi
tht
ypeObl
oodar
econsi
der
eduni
ver
sal
donor
s.

 Peopl
ewi
tht
ypeABbl
oodar
econsi
der
eduni
ver
sal
reci
pient
s.

 Her
tz(
Hz)i
stheuni
tofmeasur
ementofsoundf
requency
.

 Heari
ngprotect
ionisr
equir
edwhent hesoundi
ntensi
[Link]
ehear
ing
pr
otecti
onisrequi
redi
fitexceeds104dB.

 Pr
othr
ombi
n,acl
ott
ingf
act
or,
ispr
oducedi
nthel
i
ver
.

 I
fapat
ienti
smenstruati
ngwhenaur
inesampl
eiscol
l
ect
ed,
thenur
seshoul
dnot
ethi
s
ont
helabor
ator
yrequest.

 Dur
inglumbarpunctur
e,t
henursemustnot
ethei
nit
ial
int
racr
ani
alpr
essur
eandt
he
col
orofthecer
ebrospi
nalfl
uid.

 I
fapati
entcan’
tcought
oprovi
deasputum sampl
eforcul
tur
e,aheat
edaer
osol
t
reat
mentcanbeusedtohel
ptoobtai
nasampl e.

 I
feyeoint
mentandey
edr
opsmustbei
nst
il
ledi
nthesameey
e,t
heey
edr
opsshoul
dbe
i
nst
il
ledfi
rst
.

 Whenl eav
inganisolat
ionr
oom, t
henur
seshoul
dremov
ehergl
ovesbef
orehermask
becausefewerpathogensareonthemask.
 Skel
etal
tracti
on,whi
chi
sappl
i
edt
oabonewi
thwi
repi
nsort
ongs,
ist
hemostef
fect
ive
meansoft r
acti
on.

 Thetotalparent
eralnutri
ti
onsoluti
onshouldbestor
edinaref
riger
atorandremoved30
to60mi nutesbefor
[Link]
l
edsoluti
oncancausepain,hypot
her
mia,
venousspasm, andv enousconstri
cti
on.

 Drugsar
en’trout
inel
yinj
ect
edi
ntr
amuscul
arl
yint
oedemat
oust
issuebecauset
heymay
notbeabsorbed.

 Whencar
ingforacomat
osepat
ient
,thenur
seshoul
dexpl
aineachact
iont
othepat
ient
i
nanormalvoice.

 Dent
uresshoul
dbecl
eanedi
nasi
nkt
hat
’sl
i
nedwi
thawashcl
oth.

 Apat
ientshoul
dvoi
dwi
thi
n8hour
saf
tersur
ger
y.

 AnEEGi
dent
if
iesnor
mal
andabnor
mal
brai
nwav
es.

 Samplesoff
ecesf
orovaandparasi
tet
est
sshoul
dbedel
i
ver
edt
othel
abor
ator
y
wit
houtdel
ayandwit
houtr
efr
iger
ati
on.

 Theaut
onomi
cner
voussy
stem r
egul
atest
hecar
diov
ascul
arandr
espi
rat
orysy
stems.

 Whenpr ovi
dingtracheost
omycare,thenur
seshouldinsertthecat
hetergent
lyintothe
tr
acheostomyt [Link]
awingthecat
heter,t
henur seshouldappl
yintermit
tent
suct
ionfornomor ethan15secondsanduseaslighttwist
ingmotion.

 Al
ow-
resi
duedi
eti
ncl
udessuchf
oodsasr
oast
edchi
cken,
rice,
andpast
a.

 Arect
alt
ubeshoul
dn’
tbei
nser
tedforl
ongerthan20mi
nut
esbecausei
tcani
rr
it
atet
he
r
ectal
mucosaandcausel
ossofsphi
nctercont
rol
.

 Apati
ent’
sbedbat hshouldpr
oceedi
nthi
sor
der
:face,
neck,
arms,
hands,
chest
,
abdomen,back,
legs,per
ineum.

 Topreventi
njur
ywhenl
i
fti
ngandmov
ingapat
ient
,thenur
seshoul
dpr
imar
il
yuset
he
upperl
egmuscl es.

 Pat
ientpr
epar
ati
onf
orchol
ecy
stogr
aphyi
ncl
udesi
ngest
ionofacont
rastmedi
um anda
l
ow-fatev
eni
ngmeal
.

 Whil
eanoccupi
edbedi
sbei
ngchanged,t
hepatientshoul
dbecov
eredwi
thabat
h
bl
ankett
opromotewar
mthandpr
eventexposur
e.

 Ant
ici
pat
orygr
iefi
smour
ningt
hatoccur
sforanext
endedt
imewhent
hepat
ientr
eal
i
zes
 t
hatdeat
hisi
nev
itabl
e.

 Thefol
lowingfoodscanalt
erthecol
orofthef
eces:
beets(
red),
cocoa(dar
kredor
brown)
,li
cori
ce(black)
,spi
nach(gr
een)
,andmeatprot
ein(
darkbrown)
.

 Whenpr
epar
ingf
oraskul
lX-
ray
,thepat
ientshoul
dremov
eal
lj
ewel
ryanddent
ures.

 Thef
ight
-or
-f
li
ghtr
esponsei
sasy
mpat
het
icner
voussy
stem r
esponse.

 Bronchov
esicul
arbr
eat
hsoundsi
nper
ipher
all
ungf
iel
dsar
eabnor
mal
andsuggest
pneumonia.

 Wheezi
ngi
sanabnor
mal
,hi
gh-
pit
chedbr
eat
hsoundt
hat
’saccent
uat
edonexpi
rat
ion.

 Waxorafor
eignbodyi
ntheearshoul
dbef
lushedoutgent
lybyi
rr
igat
ionwi
thwar
m
sal
i
nesol
uti
on.

 Ifapat
ientcompl
ainsthathishear
ingaidis“
notworki
ng,
”thenur
seshoul
dcheckt
he
swit
chfir
sttoseei
fit’
sturnedonandt hencheckt
hebatt
eri
es.

 Thenur
seshoul
dgr
adehy
per
act
ivebi
cepsandt
ri
cepsr
efl
exesas+4.

 Ift
woey emedi
cat
ionsarepr
escr
ibedf
ort
wice-
dai
l
yinst
il
lat
ion,
theyshoul
dbe
admini
ster
ed5minutesapar
t.

 I
napost
oper
ati
vepat
ient
,for
cingf
lui
dshel
pspr
eventconst
ipat
ion.

 Anur
semustprov
idecar
einaccor
dancewit
hstandar
dsofcareestabl
i
shedbyt
he
Amer
icanNur
sesAssoci
ati
on,
stat
eregul
ati
ons,
andfaci
l
itypol
icy
.

 Thekil
ocalor
ie(
kcal
)isauni
tofenergymeasur
ementthatr
epresent
stheamountof
heatneededtor
aiset
hetemperat
ureof1kil
ogr
am ofwater1°C.

 Asnutri
entsmovethroughthebody
,theyunder
goi
ngest
ion,
digest
ion,
absor
pti
on,
tr
ansport
,cel
lmetaboli
sm,andexcr
etion.

 Thebodymet
abol
i
zesal
cohol
ataf
ixedr
ate,
regar
dlessofser
um concent
rat
ion.

 Inanal
cohol
icbever
age,
proofr
efl
ectstheper
centageofal
cohol
mul
ti
pli
[Link]
exampl
e,a100-pr
oofbev
eragecont
ains50%alcohol.

 Ali
v i
ngwil
lisawit
nesseddocumentthatst
atesapati
ent
’sdesi
reforcer
tai
nt y
pesof
careandtr
eatment
.Thesedecisi
onsarebasedonthepat
ient
’swishesandviewson
quali
tyofl
i
fe.

 Thenurseshoul
dfl
ushaperi
pheral
hepari
nlockever
y8hours(i
fitwasn’
tusedduri
ng
thepr
evious8hour
s)andasneededwit
hnor malsal
i
nesol
uti
ontomai nt
ainpat
ency.
 Qual
it
yassurancei
samet hodofdet
ermi
ningwhet
hernur
singact
ionsandpr
act
ices
meetest
abli
shedstandar
ds.

 Thefi
ver
ight
sofmedicati
onadmi
nistr
ati
onar
ether
ightpat
ient
,ri
ghtdr
ug,
rightdose,
ri
ghtr
out
eofadmini
strat
ion,
andr
ightti
me.

 Theeval
uati
onphaseofthenur
singprocessi
stodeter
minewhethernur
sing
i
nter
vent
ionshav
eenabledthepati
enttomeetthedesi
redgoal
s.

 Outsi
deoft
hehospit
alset
ti
ng,onl
ythesubl
ingual
andt
ransl
i
ngual
for
msofni
tr
ogl
ycer
in
shoul
dbeusedt
or el
iev
eacuteangi
nalat
tacks.

 Theimplementat
ionphaseofthenur
singpr
ocessinvolv
esr ecordingthepati
ent’
s
responset
othenursi
ngplan,put
ti
ngthenursi
ngplanintoaction,delegat
ingspeci
fi
c
nursi
ngint
erv
enti
ons,andcoordi
nati
ngthepati
ent
’sacti
vit
ies.

 ThePat i
ent
’sBil
lofRi
ght
sofferspat
ient
sguidanceandpr
otect
ionbystat
ingt
he
responsi
bil
i
tiesoft
hehospi
talandit
sstafft
owardpati
ent
sandt hei
rfami
l
iesdur
ing
hospit
ali
zati
on.

 Tomini
mizeomissi
onanddi
stor
ti
onoff
act
s,t
henur
seshoul
drecor
dinf
ormat
ionas
soonasi
t’
sgather
ed.

 Whenassessi
ngapatient’
sheal
thhi
stor
y,t
henur
seshoul
drecor
dthecurr
enti
ll
ness
chr
onol
ogical
l
y,begi
nningwit
htheonsetoft
hepr
obl
em andconti
nui
ngtothepr
esent.

 Whenassessi
ngapatient’
sheal
thhi
stor
y,t
henur
seshoul
drecor
dthecurr
enti
ll
ness
chr
onol
ogical
l
y,begi
nningwit
htheonsetoft
hepr
obl
em andconti
nui
ngtothepr
esent.

 Anur
seshoul
dn’
tgi
vef
alseassur
ancet
oapat
ient
.

 Aft
erreceiv
ingpr
eoper
ati
vemedi
cat
ion,
apat
ienti
sn’
tcompet
entt
osi
gnani
nfor
med
consentfor
m.

 Whenl
i
fti
ngapat
ient
,anur
seusest
hewei
ghtofherbodyi
nst
eadoft
hest
rengt
hinher
ar
ms.

 Anursemayclar
if
yaphy si
cian’
sexpl
anat
ionaboutanoper
ati
onoraprocedur
etoa
pat
ient
,butmustref
erquest
ionsabouti
nfor
medconsenttothephy
sici
an.

 Whenobtai
ningahealt
hhistor
yfr
om anacutelyil
loragi
tat
edpat
ient
,thenur
seshoul
d
l
imi
tquesti
onstothosethatpr
ovi
denecessaryinfor
mati
on.

 I
fachestdrai
nagesy
stem l
i
nei
sbr
okenori
nter
rupt
ed,
thenur
seshoul
dcl
ampt
het
ube
i
mmediatel
y.
 Thenur
seshoul
dn’
tusehert
humbtot
akeapati
ent’
spul
ser
atebecauset
het
humbhas
apul
sethatmaybeconf
usedwi
tht
hepat
ient
’spul
se.

 Ani
nspi
rat
ionandanexpi
rat
ioncountasoner
espi
rat
ion.

 Eupneai
snor
mal
respi
rat
ion.

 Dur
ingbl
oodpr
essur
emeasur
ement,
thepati
entshoul
drestthearm agai
nstasur
face.
Usi
ngmuscl
estr
engtht
ohol
dupthearm mayrai
sethebloodpressure.

 Major
,unal
ter
abl
eri
skf
act
orsf
orcor
onar
yar
ter
ydi
seasei
ncl
udeher
edi
ty,
sex,
race,
and
age.

 I
nspect
ioni
sthemostf
requent
lyusedassessmentt
echni
que.

 Familymember sofanel
derl
ypersoninalong-
ter
m caref
acil
i
tyshouldtr
ansf
ersome
personali
tems(suchasphotogr
aphs,afavor
it
echai
r,andkni
ckknacks)t
otheperson’
s
room toprovi
deacomfort
ableatmosphere.

 Pulsusal
ternansisaregul
arpul
serhythm wit
hal
ternat
ingweakandst
rongbeats.I
t
occursi
nv entr
icul
arenl
argementbecausethest
rokevolumevar
ieswi
theachheart
beat
.

 Theupperr
espi
rator
ytr
actwar
msandhumi
dif
iesi
nspi
redai
randpl
aysar
olei
ntast
e,
smel
l,andmast
icati
on.

 Signsofaccessor
ymuscleuseincludeshoul
derel
evati
on,i
ntercostal
muscl
eret
ract
ion,
andscaleneandster
nocl
eidomastoidmuscleuseduri
ngrespir
ation.

 Whenpat
ient
suseaxi
l
lar
ycr
utches,
thei
rpal
msshoul
dbeart
hebr
untoft
hewei
ght
.

 Acti
vi
ti
esofdai
l
ylivi
ngi
ncl
udeeat
ing,
bat
hing,
dressi
ng,
groomi
ng,
toi
l
eti
ng,
and
i
nter
acti
ngsoci
all
y.

 Normal
gaithastwophases:
thest
ancephase,inwhicht
hepat
ient
’sf
ootr
est
sont
he
gr
ound,andtheswi
ngphase,i
nwhicht
hepatient’
sfootmov
esforwar
d.

 Thephasesofmi
tosi
sar
epr
ophase,
met
aphase,
anaphase,
andt
elophase.

 Thenur
seshoul
dfol
l
owst
andar
dpr
ecaut
ionsi
nther
out
inecar
eofal
lpat
ient
s.

 Thenur
seshoul
duset
hebel
loft
hest
ethoscopet
oli
stenf
orv
enoushumsandcar
diac
murmurs.

 Thenur
secanassessapat
ient
’sgener
alknowledgebyaski
ngquest
ionssuchas“
Who
i
sthecurr
entpr
esi
dentoft
heUnitedSt
ates?”

 Col
dpacksar
eappl
i
edf
ort
hef
ir
st20t
o48hour
saf
terani
njur
y;t
henheati
sappl
i
ed.
 Dur
ingcol
dappl
icati
on,thepackisappli
edfor20minut
esandthenremovedfor10t
o
15minut
estopr
ev entr
eflexdi
lat
ion(r
eboundphenomenon)andfr
ostbi
tei
njur
y.

 Theponsi
slocat
edabovethemedull
aandconsi
stsofwhi
temat
ter(
sensor
yandmot
or
tr
act
s)andgraymat
ter(
ref
lexcent
ers)
.

 Theaut
onomi
cner
voussy
stem cont
rol
sthesmoot
hmuscl
es.

 Acorrect
lywr
it
tenpati
entgoalexpr
essest
hedesir
edpati
entbehav
ior,
crit
eri
afor
measurement,
timefr
amef orachi
evement
,andcondi
ti
onsunderwhichthebehav
iorwi
l
l
occur
.It’
sdev
elopedi
ncollabor
ati
onwitht
hepati
ent.

 Percussioncausesfi
v ebasi
cnot es:tympany(loudintensi
ty,
ashear doveragastr
icair
bubbleorpuf f
edoutcheek),hyperresonance(veryloud,asheardoveran
emphy sematouslung),r
esonance( loud,asheardov eranormal l
ung),
dull
ness(medium
i
ntensity
, ashear
dov erthel
i
v erorot hersol
i
dor gan),andfl
atness(soft
,ashear
dov er
thethi
gh) .

 Theopt
icdi
ski
syel
l
owi
shpi
nkandci
rcul
ar,
wit
hadi
sti
nctbor
der
.

 Apri
marydisabi
l
ityi
scausedbyapat
hol
ogi
cpr
[Link]
ydi
sabi
l
ityi
scaused
byi
nact
ivi
ty.

 Nursesar
ecommonlyheldl
iabl
eforf
ail
i
ngt
okeepanaccur
atecountofspongesand
ot
herdevi
cesdur
ingsur
gery
.

 Thebestdiet
arysour
cesofv
itami
nB6ar
eli
ver
,ki
dney
,por
k,soy
beans,
cor
n,andwhol
e-
grai
ncereal
s.

 Ir
on-r
ichfoods,
suchasorganmeat
s,nut
s,legumes,
dri
edfr
uit
,gr
eenl
eaf
yveget
abl
es,
eggs,andwholegrai
ns,
commonlyhavealowwatercont
ent
.

 Col
laborati
oni sj
ointcommuni
cati
onanddeci sionmakingbetweennur
sesand
phy
[Link]
’sdesignedt
omeetpatient
s’needsbyintegrat
ingt
hecareregi
mensof
bot
hpr ofessi
onsintoonecomprehensiv
eappr oach.

 Br
ady
car
diai
sahear
trat
eoff
ewert
han60beat
s/mi
nut
e.

 Anursi
ngdiagnosi
sisastat
ementofapati
ent’
sactual
orpotent
ial
heal
thprobl
em t
hat
canberesol
ved,di
mini
shed,orot
her
wisechangedbynursi
ngint
erv
enti
ons.

 Dur i
ngtheassessmentphaseofthenursingprocess,t
henursecoll
ectsandanal
yzes
threety
pesofdat a:
heal
thhist
ory
, phy
sicalexaminati
on,andlabor
ator
yanddiagnost
ic
testdata.

 Thepat
ient
’sheal
thhi
stor
yconsi
stspr
imar
il
yofsubj
ect
ivedat
a,i
nfor
mat
iont
hat
’s
 suppl
i
edbyt
hepat
ient
.

 Thephysicalexami
nati
onincl
udesobj
ect
ivedat
aobt
ainedbyi
nspect
ion,
pal
pat
ion,
per
cussion,andauscul
tat
ion.

 Whendocument ingpat
ientcar
e,thenurseshoul
dwrit
elegi
bly
,useonl
ystandar
d
abbr
eviati
ons,andsi
gneachent r
[Link]
dneverdestr
oyorat
temptto
obl
it
eratedocumentati
onorleavevacantli
nes.

 Fact
orsthataf
fectbodytemperat
urei
ncl
udet
imeofday
,age,
phy
sical
act
ivi
ty,
phaseof
menstr
ualcycl
e,andpregnancy
.

 Themostaccessibl
eandcommonl
yusedart
eryformeasuri
ngapat i
ent
’spul
ser
atei
s
ther
adi
alar
[Link]
hepul
ser
ate,
thear
teryiscompressedagai
nstther
adi
us.

 I
naresti
ngadul
t,t
henor
malpul
ser
atei
s60to100beats/mi
nut
[Link]
eissl
i
ght
ly
f
ast
erinwomenthaninmenandmuchf
ast
erinchi
l
drenthani
nadult
s.

 Labor
ator
ytestr
esul
tsar
eanobj
ect
ivef
orm ofassessmentdat
a.

 Themeasurementsy stemsmostcommonl yusedincl

i
nical
pract
icear
ethemet
ri
c
syst
em,apothecar
ies’syst
em,andhouseholdsyst
em.

 Beforesi
gningani nformedconsentf orm,t
hepatientshoul
dknowwhet herother
tr
eatmentoptionsar eavailabl
eandshouldunderstandwhatwilloccurduringthe
preoper
ati
ve,i
ntraoper at
ive,andpostoper
ati
vephases; t
heri
sksinvolved;andthe
possibl
ecompl i
[Link] i
entshoul
dalsohav eagenerali
deaoft het i
merequir
ed
fr
om surger
yt orecov ery
.Inadditi
on,heshoul
dhav eanoppor t
unit
ytoaskquest ions.

 Apat
ientmustsi
gnasepar
atei
nfor
medconsentf
ormf
oreachpr
ocedur
e.

 Duringpercussi
on,
thenurseusesqui ck,
sharptappingofthefingersorhandsagai
nst
[Link]
sdonet odet er
mi net
hesize,
shape,
positi
on,anddensi
tyofunderl
yi
ngor gansandt i
ssues;el
i
cittenderness;
orassess
ref
lexes.

 Ball
ott
ementisafor
m ofli
ghtpalpati
oninv
olv
inggent
le,
repet
it
ivebounci
ngoft
issues
agai
nstthehandandfeel
i
ngtheirrebound.

 Afootcr
adl
ekeepsbedli
nenoffthepat
ient
’sf
eett
oprev
entski
nirri
tat
ionand
br
eakdown,
especi
all
yinapat
ientwhohasperi
pher
alv
ascul
ardiseaseorneur
opat
hy.

 Gastr
iclavageisfl
ushi
ngofthest
omachandremoval
ofi
ngest
edsubst
ancest
hrougha
nasogastr
ictube.I
t’
susedtotr
eatpoi
soni
ngordr
ugover
dose.

 Dur
ingt
heev
aluat
ionst
epoft
henur
singpr
ocess,
thenur
seassessest
hepat
ient
’s
 r
esponset
other
apy
.

 Br
uit
scommonl
yindi
cat
eli
fe-orl
i
mb-
thr
eat
eni
ngv
ascul
ardi
sease.

 O.
[Link]
e.O.
D.i
sther
ightey
e,andO.
S.i
sthel
eftey
e.

 Tor
emov
eapat
ient
’sar
ti
fi
cial
eye,
thenur
sedepr
essest
hel
owerl
i
d.

 Thenur
seshoul
duseawar
m sal
i
nesol
uti
ont
ocl
eananar
ti
fi
cial
eye.

 At
hreadypul
sei
sver
yfi
neandscar
cel
yper
cept
ibl
e.

 Axi
l
lar
ytemper
atur
eisusual
l
y1°Fl
owert
hanor
alt
emper
atur
e.

 Aft
ersuctioni
ngatracheost
omyt ube,t
henur
semustdocumentt
hecol
or,
amount
,
consi
stency,andodorofsecret
ions.

 Onadrugprescr
ipt
ion,
theabbr
evi
ati
onp.
[Link]
hatt
hedr
ugshoul
dbeadmi
nist
ered
af
termeal
s.

 Af
terbl
adderi
rr
igat
ion,
thenur
seshoulddocumentt
heamount
,col
or,
andcl
ari
tyoft
he
ur
ineandthepr
esenceofcl
otsorsedi
ment.

 Af
terbl
adderi
rr
igat
ion,
thenur
seshoulddocumentt
heamount
,col
or,
andcl
ari
tyoft
he
ur
ineandthepr
esenceofcl
otsorsedi
ment.

 Lawsregar
dingpat
ientsel
f-
det
erminat
ionv
aryf
rom st
atet
[Link]
efor
e,t
henur
se
mustbefamili
arwi
ththelawsofthest
atei
nwhichsheworks.

 Gaugei
sthei
nsi
dedi
amet
erofaneedl
e:t
hesmal
l
ert
hegauge,
thel
argert
hedi
amet
er.

 Anadul
tnor
mal
l
yhas32per
manentt
eet
h.

UPDATEDONNOVEMBER5,
2021

BYMATTVERA,
BSN,
R.N.