160 NURSING BULLETS: Medical-Surgical Nursing Reviewer

160 NURSING BULLETS: Medical-Surgical Nursing Reviewer

1. Bone scan is done by injecting radioisotope per IV and then x-rays are taken.

2. To prevent edema on the site of sprain, apply cold compress on the area for the first 24 hours.

3. To turn the client after lumbar Laminectomy, use the logrolling technique.

4. Carpal tunnel syndrome occurs due to the injury of median nerve.

5. Massaging the back of the head is specifically important for the client with Crutchfield tong.

6. A one-year-old child has a fracture of the left femur. He is placed in Bryant’s traction. The reason for elevation of his both legs at 90º angle is his weight isn’t adequate to provide sufficient countertraction, so his entire body must be used.

7. Swing-through crutch gait is done by advancing both crutches together and the client moves both legs past the level of the crutches.

8. The appropriate nursing measure to prevent displacement of the prosthesis after a right total hip replacement for arthritis is to place the patient in the position of right leg abducted.

9. Pain on non-use of joints, subcutaneous nodules and elevated ESR are characteristic manifestations of rheumatoid arthritis.

10. Teaching program of a patient with SLE should include emphasis on walking in shaded area.

11. Otosclerosis is characterized by replacement of normal bones by spongy and highly vascularized bones.

12. Use of high-pitched voice is inappropriate for the client with hearing impairment.

13. Rinne’s test compares air conduction with bone conduction.

14. Vertigo is the most characteristic manifestation of Meniere’s disease.

15. Low sodium is the diet for a client with Meniere’s disease.

16. A client who had cataract surgery should taught to call his MD if he has eye pain.

17. Risk for Injury takes priority for a client with Meniere’s disease.

18. Irrigate the eye with sterile saline is the priority nursing intervention when the client has a foreign body protruding from the eye.

19. Snellen’s Test assesses visual acuity.

20. Presbyopia is an eye disorder characterized by lessening of the effective powers of accommodation.

21. The primary problem in cataract is blurring of vision.

22. The primary reason for performing iridectomy after cataract extraction is to prevent secondary glaucoma.

23. In acute glaucoma, the obstruction of the flow of aqueous humor is caused by displacement of the iris.

24. Glaucoma is characterized by irreversible blindness.

25. Hyperopia is corrected by convex lens.

26. Pterygium is caused primarily by exposure to dust.

27. A sterile chronic granulomatous inflammation of the meibomian gland is chalazion.

28. The surgical procedure which involves removal of the eyeball is enucleation.

29. Romberg’s test is a test for balance or gait.

30. If the client with increased ICP demonstrates decorticate posturing, observe for flexion of elbows, extension of the knees, plantar flexion of the feet.

31. The nursing diagnosis that would have the highest priority in the care of the client who has become comatose following cerebral hemorrhage is Ineffective Airway Clearance.

32. The initial nursing action—for a client who is in the clonic phase of a tonic-clonic seizure—is to obtain equipment for orotracheal suctioning.

33. The first nursing intervention in a quadriplegic client who is experiencing autonomic dysreflexia is to elevate his head as high as possible.

34. Following surgery for a brain tumor near the hypothalamus, the nursing assessment should include observing for inability to regulate body temp.

35.Post-myelography (using metrizamide (Omnipaque) care includes keeping head elevated for at least 8 hours.

36. Homonymous hemianopsia is described by a client had CVA and can only see the nasal visual field on one side and the temporal portion on the opposite side.

37. Ticlopidine may be prescribed to prevent thromboembolic CVA.

38. To maintain airway patency during a stroke in evolution, have orotracheal suction available at all times.

39. For a client with CVA, the gag reflex must return before the client is fed.

40. Clear fluids draining from the nose of a client who had a head trauma 3 hours ago may indicate basilar skull fracture.

41. An adverse effect of gingival hyperplasia may occur during Phenytoin (DIlantin) therapy.

42. Urine output increased: best shows that the mannitol is effective in a client with increased ICP.

43. A client with C6 spinal injury would most likely have the symptom of quadriplegia.

44. Falls are the leading cause of injury in elderly people.

45. The client is for EEG this morning. Prepare him for the procedure by rendering hair shampoo, excluding caffeine from his meal and instructing the client to remain still during the procedure.

46. Primary prevention is true prevention. Examples are immunizations, weight control, and smoking cessation.

47. Secondary prevention is early detection. Examples include purified protein derivative (PPD), breast self-examination, testicular self-examination, and chest X-ray.

48. Tertiary prevention is treatment to prevent long-term complications.

49. On noticing religious artifacts and literature on a patient’s night stand, a culturally aware nurse would ask the patient the meaning of the items.

50. A Mexican patient may request the intervention of a curandero, or faith healer, who involves the family in healing the patient.

51. In an infant, the normal hemoglobin value is 12 g/dl.

52. A patient indicates that he’s coming to terms with having a chronic disease when he says something like: “I’m never going to get any better,” or when he exhibits hopelessness.

53. Most of the absorption of water occurs in the large intestine.

54. Most nutrients are absorbed in the small intestine.

55. When assessing a patient’s eating habits, the nurse should ask, “What have you eaten in the last 24 hours?”

56. A vegan diet should include an abundant supply of fiber.

57. A hypotonic enema softens the feces, distends the colon, and stimulates peristalsis.

58. First-morning urine provides the best sample to measure glucose, ketone, pH, and specific gravity values.

59. To induce sleep, the first step is to minimize environmental stimuli.

60. Before moving a patient, the nurse should assess the patient’s physical abilities and ability to understand instructions as well as the amount of strength required to move the patient.

61. To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his weekly intake by 3,500 calories (approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly caloric intake by 7,000 calories (approximately 1,000 calories daily).

62. To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet.

63. To insert a catheter from the nose through the trachea for suction, the nurse should ask the patient to swallow.

64. Vitamin C is needed for collagen production.

65. Bananas, citrus fruits, and potatoes are good sources of potassium.

66. Good sources of magnesium include fish, nuts, and grains.

67. Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron.

68. The nitrogen balance estimates the difference between the intake and use of protein.

69. A Hindu patient is likely to request a vegetarian diet.

70. No pork or pork products are allowed in a Muslim diet.

71. In accordance with the “hot-cold” system used by some Mexicans, Puerto Ricans, and other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are described as “cold.”

72. Milk is high in sodium and low in iron.

73. Discrimination is preferential treatment of individuals of a particular group. It’s usually discussed in a negative sense.

74. Increased gastric motility interferes with the absorption of oral drugs.

75. When feeding an elderly patient, the nurse should limit high-carbohydrate foods because of the risk of glucose intolerance.

76. When feeding an elderly patient, essential foods should be given first.

78. For the patient who abides by Jewish custom, milk and meat shouldn’t be served at the same meal.

79. Only the patient can describe his pain accurately.

80. Cutaneous stimulation creates the release of endorphins that block the transmission of pain stimuli.

81. Patient-controlled analgesia (PCA) is a safe method to relieve acute pain caused by surgical incision, traumatic injury, labor and delivery, or cancer.

82. An Asian-American or European-American typically places distance between himself and others when communicating.

83. Active euthanasia is actively helping a person to die.

84. Brain death is irreversible cessation of all brain function.

85. Passive euthanasia is stopping the therapy that’s sustaining life.

86. Voluntary euthanasia is actively helping a patient to die at the patient’s request.

87. A back rub is an example of the gate-control theory of pain.

88. Pain threshold, or pain sensation, is the initial point at which a patient feels pain.

89. The difference between acute pain and chronic pain is its duration.

90. Referred pain is pain that’s felt at a site other than its origin.

91. Alleviating pain by performing a back massage is consistent with the gate control theory.

92. Pain seems more intense at night because the patient isn’t distracted by daily activities.

93. Older patients commonly don’t report pain because of fear of treatment, lifestyle changes, or dependency.

94. Utilization review is performed to determine whether the care provided to a patient was appropriate and cost-effective.

95. A value cohort is a group of people who experienced an out-of-the-ordinary event that shaped their values.

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

97. Intrathecal injection is administering a drug through the spine.

98. When a patient asks a question or makes a statement that’s emotionally charged, the nurse should respond to the emotion behind the statement or question rather than to what’s being said or asked.

99–105. The steps of the trajectory-nursing model are as follows:

Step 1: Identifying the trajectory phase

Step 2: Identifying the problems and establishing goals

Step 3: Establishing a plan to meet the goals

Step 4: Identifying factors that facilitate or hinder attainment of the goals

Step 5: Implementing interventions

Step 6: Evaluating the effectiveness of the interventions

106–107. Two goals of Healthy People 2010 are:

▪️Help individuals of all ages to increase the quality of life and the number of years of optimal health

▪️Eliminate health disparities among different segments of the population.

108. A community nurse is serving as a patient’s advocate if she tells a malnourished patient to go to a meal program at a local park.

109. If a patient isn’t following his treatment plan, the nurse should first ask why.

110. When a patient is ill, it’s essential for the members of his family to maintain communication about his health needs.

110. Ethnocentrism is the universal belief that one’s way of life is superior to others’.

111. When a nurse is communicating with a patient through an interpreter, the nurse should speak to the patient and the interpreter.

112. Prejudice is a hostile attitude toward individuals of a particular group.

113. The three phases of the therapeutic relationship are orientation, working, and termination.

114. Patients often exhibit resistive and challenging behaviors in the orientation phase of the therapeutic relationship.

115. Abdominal assessment is performed in the following order: inspection, auscultation, palpation, and percussion.

116. When measuring blood pressure in a neonate, the nurse should select a cuff that’s no less than one-half and no more than two-thirds the length of the extremity that’s used.

117. When administering a drug by Z-track, the nurse shouldn’t use the same needle that was used to draw the drug into the syringe because doing so could stain the skin.

118. Sites for intradermal injection include the inner arm, the upper chest, and on the back, under the scapula.

119. When evaluating whether an answer on an examination is correct, the nurse should consider whether the action that’s described promotes autonomy (independence), safety, self-esteem, and a sense of belonging.

120. Veracity is truth and is an essential component of a therapeutic relationship between a health care provider and his patient.

121. Beneficence is the duty to do no harm and the duty to do good. There’s an obligation in patient care to do no harm and an equal obligation to assist the patient.

122. Nonmaleficence is the duty to do no harm.

123–128. Frye’s ABCDE cascade provides a framework for prioritizing care by identifying the most important treatment concerns.

A: Airway. This category includes everything that affects a patent airway, including a foreign object, fluid from an upper respiratory infection, and edema from trauma or an allergic reaction.

B: Breathing. This category includes everything that affects the breathing pattern, including hyperventilation or hypoventilation and abnormal breathing patterns, such as Korsakoff’s, Biot’s, or Cheyne-Stokes respiration.

C: Circulation. This category includes everything that affects the circulation, including fluid and electrolyte disturbances and disease processes that affect cardiac output.

D: Disease processes. If the patient has no problem with the airway, breathing, or circulation, then the nurse should evaluate the disease processes, giving priority to the disease process that poses the greatest immediate risk. For example, if a patient has terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern.

E: Everything else. This category includes such issues as writing any incident report and completing the patient chart. When evaluating needs, this category is never the highest priority.

129. Rule utilitarianism is known as the “greatest good for the greatest number of people” theory.

130. Egalitarian theory emphasizes that equal access to goods and services must be provided to the less fortunate by an affluent society.

131. Before teaching any procedure to a patient, the nurse must assess the patient’s current knowledge and willingness to learn.

132. Process recording is a method of evaluating one’s communication effectiveness.

133. Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps involved in the procedure (cognitive domain of learning).

134. When communicating with a hearing impaired patient, the nurse should face him.

135. When a patient expresses concern about a health-related issue, before addressing the concern, the nurse should assess the patient’s level of knowledge.

136. Passive range of motion maintains joint mobility. Resistive exercises increase muscle mass.

137. Isometric exercises are performed on an extremity that’s in a cast.

138. Anything that’s located below the waist is considered unsterile; a sterile field becomes unsterile when it comes in contact with any unsterile item; a sterile field must be monitored continuously; and a border of 1″ (2.5 cm) around a sterile field is considered unsterile.

139. A “shift to the left” is evident when the number of immature cells (bands) in the blood increases to fight an infection.

140. A “shift to the right” is evident when the number of mature cells in the blood increases, as seen in advanced liver disease and pernicious anemia.

141. Before administering preoperative medication, the nurse should ensure that an informed consent form has been signed and attached to the patient’s record.

142. A nurse should spend no more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant.

143. A nurse shouldn’t be assigned to care for more than one patient who has a radiation implant.

144. Long-handled forceps and a lead-lined container should be available in the room of a patient who has a radiation implant.

145. Usually, patients who have the same infection and are in strict isolation can share a room.

146. Diseases that require strict isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease.

147–155. According to Erik Erikson, developmental stages are:

•Trust versus mistrust (birth to 18 months)

•Autonomy versus shame and doubt (18 months to age 3)

•Initiative versus guilt (ages 3 to 5)

•Industry versus inferiority (ages 5 to 12)

•Identity versus identity diffusion (ages 12 to 18)

•Intimacy versus isolation (ages 18 to 25)

•Generativity versus stagnation (ages 25 to 60), and

•Ego integrity versus despair (older than age 60).

156. An appropriate nursing intervention for the spouse of a patient who has a serious incapacitating disease is to help him to mobilize a support system.

157. The most effective way to reduce a fever is to administer an antipyretic, which lowers the temperature set point.

158–163. The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse potential.

▪️Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States.

▪️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.

▪️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.

▪️Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs.

▪️Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances.

164. During lumbar puncture, the nurse must note the initial intracranial pressure and the color of the cerebrospinal fluid.

165. Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury.