8.

The notation AA & O 3 indicates that the

Topics

patient is awake, alert, and oriented to person

Topics included are:

(knows who he is), place (knows where he is), and

time (knows the date and time).

Nursing Assessment

Diets

9. Fluid intake includes all fluids taken by mouth,

Various topics about Fundamentals of

including

Nursing

temperature, such as gelatin, custard, and ice

foods

that

are

liquid

at

room

cream; I.V. fluids; and fluids administered in

Bullets

feeding

tubes.

vomitus,

and

Fluid

output

drainage

includes

(such

as

urine,

from

1. After turning a patient, the nurse should

nasogastric tube or from a wound) as well as

document the position used, the time that the

blood loss, diarrhea or feces, and perspiration.

patient was turned, and the findings of skin

assessment.

10. After administering an intradermal injection,

the nurse shouldnt massage the area because

2. PERRLA is an abbreviation for normal pupil

massage can irritate the site and interfere with

assessment findings: pupils equal, round, and

results.

reactive to light with accommodation.

11. When administering an intradermal injection,
3. When percussing a patients chest for postural

the nurse should hold the syringe almost flat

drainage, the nurses hands should be cupped.

against the patients skin (at about a 15-degree

angle), with the bevel up.

4. When measuring a patients pulse, the nurse

should assess its rate, rhythm, quality, and

12. To obtain an accurate blood pressure, the

strength.

nurse should inflate the manometer to 20 to 30

mm Hg above the disappearance of the radial

5. Before transferring a patient from a bed to a

pulse before releasing the cuff pressure.

wheelchair, the nurse should push the wheelchair

footrests to the sides and lock its wheels.

13. The nurse should count an irregular pulse for

1 full minute.

6. When assessing respirations, the nurse should

document their rate, rhythm, depth, and quality.

14. A patient who is vomiting while lying down

should be placed in a lateral position to prevent

7. For a subcutaneous injection, the nurse should

aspiration of vomitus.

use a 5/8 to 1 25G needle.

15. Prophylaxis is disease prevention.

16. Body alignment is achieved when body parts

25. Although a patients health record, or chart, is

are in proper relation to their natural position.

the health care facilitys physical property, its

contents belong to the patient.

17. Trust is the foundation of a nurse-patient

relationship.

26. Before a patients health record can be

released to a third party, the patient or the

18. Blood pressure is the force exerted by the

patients

circulating volume of blood on the arterial walls.

consent.

19.

wrongful

27. Under the Controlled Substances Act, every

conduct, improper discharge of duties, or failure

dose of a controlled drug thats dispensed by the

to meet standards of care that causes harm to

pharmacy must be accounted for, whether the

another.

dose was administered to a patient or discarded

Malpractice

is

professionals

legal

guardian

must

give

written

accidentally.
20. As a general rule, nurses cant refuse a
patient care assignment; however, in most states,

28. A nurse cant perform duties that violate a

they may refuse to participate in abortions.

rule or regulation established by a state licensing

board, even if they are authorized by a health

21. A nurse can be found negligent if a patient is

care facility or physician.

injured because the nurse failed to perform a

duty that a reasonable and prudent person would

29. To minimize interruptions during a patient

perform or because the nurse performed an act

interview, the nurse should select a private room,

that a reasonable and prudent person wouldnt

preferably one with a door that can be closed.

perform.
30. In categorizing nursing diagnoses, the nurse
22. States have enacted Good Samaritan laws to

addresses life-threatening problems first, followed

encourage

by potentially life-threatening concerns.

professionals

to

provide

medical

assistance at the scene of an accident without

fear of a lawsuit arising from the assistance.

31. The major components of a nursing care plan

These laws dont apply to care provided in a

are outcome criteria (patient goals) and nursing

health care facility.

interventions.

23. A physician should sign verbal and telephone

32.

orders within the time established by facility

guidelines for treating a specific disease or set of

policy, usually 24 hours.

symptoms.

24. A competent adult has the right to refuse

33. In assessing a patients heart, the nurse

lifesaving

medical

the

normally finds the point of maximal impulse at

individual

should

the

the fifth intercostal space, near the apex.

treatment;
be

fully

consequences of his refusal.

however,

informed

of

Standing

orders,

or

protocols,

establish

34. The S1 heard on auscultation is caused by

42. Schedule IV drugs, such as chloral hydrate,

closure of the mitral and tricuspid valves.

have a low abuse potential compared with

Schedule III drugs.

35. To maintain package sterility, the nurse

should open a wrappers top flap away from the

43. Schedule V drugs, such as cough syrups that

body, open each side flap by touching only the

contain codeine, have the lowest abuse potential

outer part of the wrapper, and open the final flap

of the controlled substances.

by grasping the turned-down corner and pulling it

toward the body.

44. Activities of daily living are actions that the

patient must perform every day to provide self-

36. The nurse shouldnt dry a patients ear canal

care and to interact with society.

or remove wax with a cotton-tipped applicator

because it may force cerumen against the

45. Testing of the six cardinal fields of gaze

tympanic membrane.

evaluates the function of all extraocular muscles

and cranial nerves III, IV, and VI.

37. A patients identification bracelet should

remain in place until the patient has been

46. The six types of heart murmurs are graded

discharged from the health care facility and has

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

left the premises.

heard with the stethoscope slightly raised from

the chest.

38. The Controlled Substances Act designated

five

categories,

controlled

drugs

or

schedules,

according

to

that
their

classify
abuse

47. The most important goal to include in a care

plan is the patients goal.

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

48. Fruits are high in fiber and low in protein, and

abuse potential and have no currently accepted

should be omitted from a low-residue diet.

medical use in the United States.

49. The nurse should use an objective scale to
40. Schedule II drugs, such as morphine, opium,

assess and quantify pain. Postoperative pain

and meperidine (Demerol), have a high abuse

varies greatly among individuals.

potential, but currently have accepted medical

uses.

Their

use

may

lead

to

physical

or

psychological dependence.

50.

Postmortem

preparing

the

care

includes

deceased

cleaning

patient

for

and

family

viewing, arranging transportation to the morgue

41. Schedule III drugs, such as paregoric and

or funeral home, and determining the disposition

butabarbital

of belongings.

(Butisol),

have

lower

abuse

potential than Schedule I or II drugs. Abuse of

Schedule III drugs may lead to moderate or low

51. The nurse should provide honest answers to

physical or psychological dependence, or both.

the patients questions.

52. Milk shouldnt be included in a clear liquid

63. To clean the skin before an injection, the

diet.

nurse uses a sterile alcohol swab to wipe from the

center of the site outward in a circular motion.

53. When caring for an infant, a child, or a

confused

patient,

consistency

in

nursing

personnel is paramount.

64. The nurse should inject heparin deep into

subcutaneous

tissue

at

90-degree

angle

(perpendicular to the skin) to prevent skin

54. The hypothalamus secretes vasopressin and

irritation.

oxytocin, which are stored in the pituitary gland.

65. If blood is aspirated into the syringe before an
55. The three membranes that enclose the brain

I.M. injection, the nurse should withdraw the

and spinal cord are the dura mater, pia mater,

needle, prepare another syringe, and repeat the

and arachnoid.

procedure.

56. A nasogastric tube is used to remove fluid

66. The nurse shouldnt cut the patients hair

and gas from the small intestine preoperatively or

without written consent from the patient or an

postoperatively.

appropriate relative.

57.

Psychologists,

chiropractors

physical

arent

therapists,

authorized

to

and

67. If bleeding occurs after an injection, the nurse

write

should apply pressure until the bleeding stops. If

prescriptions for drugs.

bruising occurs, the nurse should monitor the site

for an enlarging hematoma.

58. The area around a stoma is cleaned with mild

soap and water.

68. When providing hair and scalp care, the nurse

should begin combing at the end of the hair and

59. Vegetables have a high fiber content.

work toward the head.

60. The nurse should use a tuberculin syringe to

69. The frequency of patient hair care depends on

administer a subcutaneous injection of less than

the length and texture of the hair, the duration of

1 ml.

hospitalization, and the patients condition.

61. For adults, subcutaneous injections require a

70. Proper function of a hearing aid requires

25G 5/8 to 1 needle; for infants, children,

careful handling during insertion and removal,

elderly, or very thin patients, they require a 25G

regular cleaning of the ear piece to prevent wax

to 27G needle.

buildup,

and

prompt

replacement

of

dead

batteries.
62. Before administering a drug, the nurse should
identify the patient by checking the identification

71. The hearing aid thats marked with a blue dot

band and asking the patient to state his name.

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

72. A hearing aid shouldnt be exposed to heat or

82. A folded towel (scrotal bridge) can provide

humidity and shouldnt be immersed in water.

scrotal support for the patient with scrotal edema

caused by vasectomy, epididymitis, or orchitis.

73. The nurse should instruct the patient to avoid

using hair spray while wearing a hearing aid.

83. When giving an injection to a patient who has

a bleeding disorder, the nurse should use a small-

74. The five branches of pharmacology are

gauge needle and apply pressure to the site for 5

pharmacokinetics,

minutes after the injection.

pharmacodynamics,

pharmacotherapeutics,

toxicology,

and

pharmacognosy.

84. Platelets are the smallest and most fragile

75. The nurse should remove heel protectors

formed element of the blood and are essential for

every 8 hours to inspect the foot for signs of skin

coagulation.

breakdown.
85. To insert a nasogastric tube, the nurse
76. Heat is applied to promote vasodilation, which

instructs the patient to tilt the head back slightly

reduces pain caused by inflammation.

and then inserts the tube. When the nurse feels

the tube curving at the pharynx, the nurse should

77. A sutured surgical incision is an example of

tell the patient to tilt the head forward to close

healing by first intention (healing directly, without

the

granulation).

swallowing. (Sips of water can facilitate this

trachea

and

open

the

esophagus

by

action.)
78. Healing by secondary intention (healing by
granulation)

is

closure

when

86. Families with loved ones in intensive care

granulation tissue fills the defect and allows

units report that their four most important needs

reepithelialization to occur, beginning at the

are to have their questions answered honestly, to

wound edges and continuing to the center, until

be assured that the best possible care is being

the

provided, to know the patients prognosis, and to

entire

of

wound

the

wound

is

covered.

79. Keloid formation is an abnormality in healing

feel that there is hope of recovery.

thats characterized by overgrowth of scar tissue

at the wound site.

87. Double-bind communication occurs when the

verbal

80.

The

nurse

should

administer

procaine

penicillin by deep I.M. injection in the upper outer

message

contradicts

the

nonverbal

message and the receiver is unsure of which

message to respond to.

portion of the buttocks in the adult or in the

midlateral thigh in the child. The nurse shouldnt

88. A nonjudgmental attitude displayed by a

massage the injection site.

nurse shows that she neither approves nor

disapproves of the patient.

81. An ascending colostomy drains fluid feces. A

descending colostomy drains solid fecal matter.

89. Target symptoms are those that the patient

finds most distressing.

90. A patient should be advised to take aspirin on

house document thats used for the purpose of

an empty stomach, with a full glass of water, and

correcting the problem.

should avoid acidic foods such as coffee, citrus

fruits, and cola.

99. Critical pathways are a multidisciplinary

guideline for patient care.

91. For every patient problem, there is a nursing

diagnosis; for every nursing diagnosis, there is a

100. When prioritizing nursing diagnoses, the

goal; and for every goal, there are interventions

following hierarchy should be used: Problems

designed to make the goal a reality. The keys to

associated with the airway, those concerning

answering examination questions correctly are

breathing, and those related to circulation.

identifying the problem presented, formulating a

goal

for

the

problem,

and

selecting

the

101. The two nursing diagnoses that have the

intervention from the choices provided that will

highest priority that the nurse can assign are

enable the patient to reach that goal.

Ineffective

airway

clearance

and

Ineffective

breathing pattern.
92. Fidelity means loyalty and can be shown as a
commitment to the profession of nursing and to

102. A subjective sign that a sitz bath has been

the patient.

effective is the patients expression of decreased

pain or discomfort.

93. Administering an I.M. injection against the

patients will and without legal authority is

103.

For

the

nursing

diagnosis

Deficient

battery.

diversional activity to be valid, the patient must

state that hes bored, that he has nothing to

94. An example of a third-party payer is an

do, or words to that effect.

insurance company.
104. The most appropriate nursing diagnosis for
95. The formula for calculating the drops per

an individual who doesnt speak English is

minute for an I.V. infusion is as follows: (volume

Impaired

to be infused drip factor) time in minutes =

inability to speak dominant language (English).

verbal

communication

related

to

drops/minute
105. The family of a patient who has been
96. On-call medication should be given within 5

diagnosed

as

hearing

impaired

should

be

minutes of the call.

instructed to face the individual when they speak

to him.

97. Usually, the best method to determine a

patients cultural or spiritual needs is to ask him.

106. Before instilling medication into the ear of a

patient who is up to age 3, the nurse should pull

98. An incident report or unusual occurrence

the pinna down and back to straighten the

report isnt part of a patients record, but is an in-

eustachian tube.

107. To prevent injury to the cornea when

118. A back rub is an example of the gate-control

administering eyedrops, the nurse should waste

theory of pain.

the first drop and instill the drug in the lower

conjunctival sac.

119. Anything thats located below the waist is

considered unsterile; a sterile field becomes

108. After administering eye ointment, the nurse

unsterile when it comes in contact with any

should twist the medication tube to detach the

unsterile item; a sterile field must be monitored

ointment.

continuously; and a border of 1 (2.5 cm) around

a sterile field is considered unsterile.

109. When the nurse removes gloves and a mask,

she should remove the gloves first. They are

120. A shift to the left is evident when the

soiled and are likely to contain pathogens.

number of immature cells (bands) in the blood

increases to fight an infection.

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

front of the patient and 6 to the side to form a

121. A shift to the right is evident when the

tripod arrangement.

number of mature cells in the blood increases, as

seen in advanced liver disease and pernicious

111.

Listening

is

the

most

effective

anemia.

communication technique.
122.

Before

administering

preoperative

112. Before teaching any procedure to a patient,

medication, the nurse should ensure that an

the nurse must assess the patients current

informed consent form has been signed and

knowledge and willingness to learn.

attached to the patients record.

113. Process recording is a method of evaluating

123. A nurse should spend no more than 30

ones communication effectiveness.

minutes per 8-hour shift providing care to a

patient who has a radiation implant.

114. When feeding an elderly patient, the nurse

should limit high-carbohydrate foods because of

124. A nurse shouldnt be assigned to care for

the risk of glucose intolerance.

more than one patient who has a radiation

implant.

115. When feeding an elderly patient, essential

foods should be given first.

125.

Long-handled

forceps

and

lead-lined

container should be available in the room of a

116. Passive range of motion maintains joint
mobility.

Resistive

exercises

increase

patient who has a radiation implant.

muscle

mass.

126.

Usually,

patients

who

have

the

same

infection and are in strict isolation can share a

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

room.

127. Diseases that require strict isolation include

135. When a patient expresses concern about a

chickenpox, diphtheria, and viral hemorrhagic

health-related

fevers such as Marburg disease.

concern, the nurse should assess the patients

issue,

before

addressing

the

level of knowledge.
128. For the patient who abides by Jewish
custom, milk and meat shouldnt be served at the

136. The most effective way to reduce a fever is

same meal.

to administer an antipyretic, which lowers the

temperature set point.

129.

Whether

the

patient

can

perform

procedure (psychomotor domain of learning) is a

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

better indicator of the effectiveness of patient

members

teaching than whether the patient can simply

communication about his health needs.

state

the

steps

involved

in

the

of

his

family

to

maintain

procedure

(cognitive domain of learning).

138. Ethnocentrism is the universal belief that

ones way of life is superior to others.

130. According to Erik Erikson, developmental

stages are trust versus mistrust (birth to 18

139. When a nurse is communicating with a

months), autonomy versus shame and doubt (18

patient through an interpreter, the nurse should

months to age 3), initiative versus guilt (ages 3 to

speak to the patient and the interpreter.

5), industry versus inferiority (ages 5 to 12),

identity versus identity diffusion (ages 12 to 18),

140. In accordance with the hot-cold system

intimacy

used by some Mexicans, Puerto Ricans, and other

versus

isolation

(ages

18

to

25),

generativity versus stagnation (ages 25 to 60),

Hispanic

and ego integrity versus despair (older than age

beverages, herbs, and drugs are described as

60).

cold.

131.

When

communicating

with

hearing

141.

and

Prejudice

Latino

is

groups,

hostile

most

attitude

foods,

toward

impaired patient, the nurse should face him.

individuals of a particular group.

132. An appropriate nursing intervention for the

142. Discrimination is preferential treatment of

spouse

individuals of a particular group. Its usually

of

patient

who

has

serious

incapacitating disease is to help him to mobilize a

discussed in a negative sense.

support system.
143. Increased gastric motility interferes with the
133.

Hyperpyrexia

is

extreme

elevation

in

absorption of oral drugs.

temperature above 106 F (41.1 C).

144.
134. Milk is high in sodium and low in iron.

The

relationship
termination.

three
are

phases

of

orientation,

the

therapeutic

working,

and

145.

Patients

often

exhibit

resistive

and

challenging behaviors in the orientation phase of

pain is cardiac. It would be more appropriate to

make further assessments.

the therapeutic relationship.

152.

Veracity

is

truth

and

is

an

essential

146. Abdominal assessment is performed in the

component of a therapeutic relationship between

following

a health care provider and his patient.

order:

inspection,

auscultation,

percussion & palpation.

153. Beneficence is the duty to do no harm and
147.

When

measuring

blood

pressure

in

the duty to do good. Theres an obligation in

neonate, the nurse should select a cuff thats no

patient care to do no harm and an equal

less than one-half and no more than two-thirds

obligation to assist the patient.

the length of the extremity thats used.

154. Nonmaleficence is the duty to do no harm.
148. When administering a drug by Z-track, the
nurse shouldnt use the same needle that was

155. Fryes ABCDE cascade provides a framework

used to draw the drug into the syringe because

for prioritizing care by identifying the most

doing so could stain the skin.

important treatment concerns.

149. Sites for intradermal injection include the

156.

inner arm, the upper chest, and on the back,

everything that affects a patent airway, including

under the scapula.

a foreign object, fluid from an upper respiratory

Airway.

This

category

includes

infection, and edema from trauma or an allergic

150. When evaluating whether an answer on an

reaction.

examination is correct, the nurse should consider

whether the action thats described promotes

157. B = Breathing. This category includes

autonomy (independence), safety, self-esteem,

everything that affects the breathing pattern,

and a sense of belonging.

including hyperventilation or hypoventilation and

abnormal breathing patterns, such as Korsakoffs,

151. When answering a question on the NCLEX

Biots, or Cheyne-Stokes respiration.

examination, the student should consider the cue

(the stimulus for a thought) and the inference

158. C = Circulation. This category includes

(the thought) to determine whether the inference

everything that affects the circulation, including

is correct. When in doubt, the nurse should select

fluid and electrolyte disturbances and disease

an answer that indicates the need for further

processes that affect cardiac output.

information to eliminate ambiguity. For example,

the patient complains of chest pain (the stimulus

159. D = Disease processes. If the patient has no

for the thought) and the nurse infers that the

problem with the airway, breathing, or circulation,

patient is having cardiac pain (the thought). In

then the nurse should evaluate the disease

this case, the nurse hasnt confirmed whether the

processes, giving priority to the disease process

that poses the greatest immediate risk. For

example, if a patient has terminal cancer and

169. A value cohort is a group of people who

hypoglycemia,

experienced an out-of-the-ordinary event that

hypoglycemia

is

more

immediate concern.

shaped their values.

160. E = Everything else. This category includes

170. Voluntary euthanasia is actively helping a

such issues as writing an incident report and

patient to die at the patients request.

completing the patient chart. When evaluating

needs, this category is never the highest priority.

171. Bananas, citrus fruits, and potatoes are good

sources of potassium.

161. When answering a question on an NCLEX

examination, the basic rule is assess before

172. Good sources of magnesium include fish,

action.

nuts, and grains.

possible

The

student

answer

should

carefully.

evaluate
Usually,

each

several

answers reflect the implementation phase of

173. Beef, oysters, shrimp, scallops, spinach,

nursing and one or two reflect the assessment

beets, and greens are good sources of iron.

phase. In this case, the best choice is an

assessment response unless a specific course of

174. Intrathecal injection is administering a drug

action is clearly indicated.

through the spine.

162. Rule utilitarianism is known as the greatest

175. When a patient asks a question or makes a

good for the greatest number of people theory.

statement thats emotionally charged, the nurse

should

respond

to

the

emotion

behind the

163. Egalitarian theory emphasizes that equal

statement or question rather than to whats being

access to goods and services must be provided to

said or asked.

the less fortunate by an affluent society.

176. The steps of the trajectory-nursing model
164. Active euthanasia is actively helping a

are

person to die.

177. Step 1: Identifying the trajectory phase

178.

as
Step

2:

Identifying

follows:
the

problems

and

165. Brain death is irreversible cessation of all

establishing

goals

brain function.

179. Step 3: Establishing a plan to meet the goals

180. Step 4: Identifying factors that facilitate or

166. Passive euthanasia is stopping the therapy

hinder

thats sustaining life.

181.

attainment
Step

5:

of

Implementing

the

goals

interventions

182. Step 6: Evaluating the effectiveness of the

167. A third-party payer is an insurance company.

interventions

168. Utilization review is performed to determine

183. A Hindu patient is likely to request a

whether the care provided to a patient was

vegetarian diet.

appropriate

and

cost-effective.

184. Pain threshold, or pain sensation, is the

197. Falls are the leading cause of injury in

initial point at which a patient feels pain.

elderly people.

185. The difference between acute pain and

198.

chronic pain is its duration.

Examples are immunizations, weight control, and

Primary

prevention

is

true

prevention.

smoking cessation.
186. Referred pain is pain thats felt at a site
other than its origin.

199. Secondary prevention is early detection.

Examples

include

purified

protein

derivative

187. Alleviating pain by performing a back

(PPD), breast self-examination, testicular self-

massage is consistent with the gate control

examination, and chest X-ray.

theory.
200. Tertiary prevention is treatment to prevent
188. Rombergs test is a test for balance or gait.

long-term complications.

189. Pain seems more intense at night because

201. A patient indicates that hes coming to

the patient isnt distracted by daily activities.

terms with having a chronic disease when he

says, Im never going to get any better.

190. Older patients commonly dont report pain

because of fear of treatment, lifestyle changes, or

202. On noticing religious artifacts and literature

dependency.

on a patients night stand, a culturally aware

nurse would ask the patient the meaning of the

191. No pork or pork products are allowed in a

items.

Muslim diet.
203.

Mexican

patient

may

request

the

192. Two goals of Healthy People 2010 are:

intervention of a curandero, or faith healer, who

193. Help individuals of all ages to increase the

involves the family in healing the patient.

quality of life and the number of years of optimal

health

204. In an infant, the normal hemoglobin value is

194. Eliminate health disparities among different

12 g/dl.

segments of the population.

205.
195. A community nurse is serving as a patients

The

nitrogen

balance

estimates

the

difference between the intake and use of protein.

advocate if she tells a malnourished patient to go

to a meal program at a local park.

206. Most of the absorption of water occurs in the

large intestine.

196. If a patient isnt following his treatment plan,

the nurse should first ask why.

207. Most nutrients are absorbed in the small

intestine.

208. When assessing a patients eating habits,

219. Cutaneous stimulation creates the release of

the nurse should ask, What have you eaten in

endorphins that block the transmission of pain

the last 24 hours?

stimuli.

209. A vegan diet should include an abundant

220. Patient-controlled analgesia is a safe method

supply of fiber.

to relieve acute pain caused by surgical incision,

traumatic injury, labor and delivery, or cancer.

210. A hypotonic enema softens the feces,

distends the colon, and stimulates peristalsis.

221. An Asian American or European American

typically places distance between himself and

211. First-morning urine provides the best sample

others when communicating.

to measure glucose, ketone, pH, and specific

gravity values.

222. The patient who believes in a scientific, or

biomedical, approach to health is likely to expect

212. To induce sleep, the first step is to minimize

a drug, treatment, or surgery to cure illness.

environmental stimuli.
223. Chronic illnesses occur in very young as well
213. Before moving a patient, the nurse should

as middle-aged and very old people.

assess the patients physical abilities and ability

to understand instructions as well as the amount

224. The trajectory framework for chronic illness

of strength required to move the patient.

states that preferences about daily life activities

affect treatment decisions.

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

must

decrease

his

weekly intake

by

3,500

225. Exacerbations of chronic disease usually

calories (approximately 500 calories daily). To

cause the patient to seek treatment and may

lose 2 lb (1 kg) in 1 week, the patient must

lead to hospitalization.

decrease his weekly caloric intake by 7,000

calories (approximately 1,000 calories daily).

226.

School

health

programs

provide

cost-

effective health care for low-income families and

215. To avoid shearing force injury, a patient who

those who have no health insurance.

is completely immobile is lifted on a sheet.

227. Collegiality is the promotion of collaboration,
216. To insert a catheter from the nose through

development,

and

interdependence

the trachea for suction, the nurse should ask the

members of a profession.

among

patient to swallow.
228. A change agent is an individual who
217. Vitamin C is needed for collagen production.

recognizes a need for change or is selected to

make a change within an established entity, such

218. Only the patient can describe his pain

accurately.

as a hospital.

229. The patients bill of rights was introduced by

238. The three elements that are necessary for a

the American Hospital Association.

fire are heat, oxygen, and combustible material.

230. Abandonment is premature termination of

239. Sebaceous glands lubricate the skin.

treatment without the patients permission and

without appropriate relief of symptoms.

240. To check for petechiae in a dark-skinned

patient, the nurse should assess the oral mucosa.

231.

Values

clarification

is

process

that

individuals use to prioritize their personal values.

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

pick up the first glove at the folded border and

232.

Distributive

justice

is

principle

that

adjust the fingers when both gloves are on.

promotes equal treatment for all.

242. To increase patient comfort, the nurse
233. Milk and milk products, poultry, grains, and

should let the alcohol dry before giving an

fish are good sources of phosphate.

intramuscular injection.

234. The best way to prevent falls at night in an

243. Treatment for a stage 1 ulcer on the heels

oriented, but restless, elderly patient is to raise

includes heel protectors.

the side rails.

244.
235. By the end of the orientation phase, the

Seventh-Day

Adventists

are

usually

vegetarians.

patient should begin to trust the nurse.

245. Endorphins are morphine-like substances
236. Falls in the elderly are likely to be caused by

that produce a feeling of well-being.

poor vision.
246. Pain tolerance is the maximum amount and
237. Barriers to communication include language

duration of pain that an individual is willing to

deficits, sensory deficits, cognitive impairments,

endure.

structural deficits, and paralysis.