1. After turning a patient, the nurse should document the position used, the time that the patient was turned, and the findings of skin assessment.
2. PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation.
3. When percussing a patient’s chest for postural drainage, the nurse’s hands should be cupped.
4. When measuring a patient’s pulse, the nurse should assess its rate, rhythm, quality, and strength.
5. Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair footrests to the sides and lock its wheels.
6. When assessing respirations, the nurse should document their rate, rhythm, depth, and quality.
7. For a subcutaneous injection, the nurse should use a 5/8″ to 1″ 25G needle.
8. The notation “AA & O × 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time).
9. Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or feces, and perspiration.
10. After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results.
11. When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle), with the bevel up.
12. To obtain an accurate blood pressure, the nurse should inflate the manometer to 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure.
13. The nurse should count an irregular pulse for 1 full minute.
14. A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus.
15. Prophylaxis is disease prevention.
16. Body alignment is achieved when body parts are in proper relation to their natural position.
17. Trust is the foundation of a nurse-patient relationship.
18. Blood pressure is the force exerted by the circulating volume of blood on the arterial walls.
19. Malpractice is a professional’s wrongful conduct, improper discharge of duties, or failure to meet standards of care that causes harm to another.
20. As a general rule, nurses can’t refuse a patient care assignment; however, in most states, they may refuse to participate in abortions.
21. A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform.
22. States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from the assistance. These laws don’t apply to care provided in a health care facility.
23. A physician should sign verbal and telephone orders within the time established by facility policy, usually 24 hours.
24. A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of his refusal.
25. Although a patient’s health record, or chart, is the health care facility’s physical property, its contents belong to the patient.
26. Before a patient’s health record can be released to a third party, the patient or the patient’s legal guardian must give written consent.
27. Under the Controlled Substances Act, every dose of a controlled drug that’s dispensed by the pharmacy must be accounted for, whether the dose was administered to a patient or discarded accidentally.
28. A nurse can’t perform duties that violate a rule or regulation established by a state licensing board, even if they are authorized by a health care facility or physician.
29. To minimize interruptions during a patient interview, the nurse should select a private room, preferably one with a door that can be closed.
30. In categorizing nursing diagnoses, the nurse addresses life-threatening problems first, followed by potentially life-threatening concerns.
31. The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions.
32. Standing orders, or protocols, establish guidelines for treating a specific disease or set of symptoms.
33. In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostal space, near the apex.
34. The S1 heard on auscultation is caused by closure of the mitral and tricuspid valves.
35. To maintain package sterility, the nurse should open a wrapper’s top flap away from the body, open each side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body.
36. The nurse shouldn’t dry a patient’s ear canal or remove wax with a cotton-tipped applicator because it may force cerumen against the tympanic membrane.
37. A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises.
38. The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse potential.
39. Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States.
40. Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential, but currently have accepted medical uses. Their use may lead to physical or psychological dependence.
41. Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both.
42. Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs.
43. Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances.
44. Activities of daily living are actions that the patient must perform every day to provide self-care and to interact with society.
45. Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI.
46. The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with the stethoscope slightly raised from the chest.
47. The most important goal to include in a care plan is the patient’s goal.
48. Fruits are high in fiber and low in protein, and should be omitted from a low-residue diet.
49. The nurse should use an objective scale to assess and quantify pain. Postoperative pain varies greatly among individuals.
50. Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings.