Foundations
During a lecture on nursing history, the instructor describes a pioneer who dramatically improved sanitation in hospitals during the Crimean War and is considered the founder of modern nursing. Who is she?
Florence Nightingale pg.2
These nine anatomical regions are used to map the abdomen. Name all nine, in any order.
1. Right Hypochondriac Region
2. Epigastric Region
3. Left Hypochondriac Region
4. Right Lumbar Region
5. Umbilical Region
6. Left Lumbar Region
7. Right Iliac Region
8. Hypogastric Region
9. Left Iliac Region pg.9
What are the 5 vital signs
BP: s:90-140 d:50-100
Pulse: 60 - 100
Resp: 12- 20
Temp: 98.6 - 99.6
Pain: 0 - 10
A nurse is caring for two patients: one is receiving a bed bath, and the other is about to have a urinary catheter inserted. For the first patient, the nurse uses hand hygiene and clean gloves, while for the second, she creates a completely sterile field and uses sterile gloves and instruments. These two approaches illustrate which two types of asepsis?
Medical Asepsis and Surgical Asepsis. CHATGPT pg. 118
The heart pumps blood throughout the body, delivering oxygen and nutrients to tissues and organs.
What is the name of the chamber of the heart that receives oxygen-rich blood from the lungs and pumps it out to the body?
Left Ventricle
The nurse health care provider has ordered an aerobic culture from a patient’s leg wound. Where on the wound would the nurse obtain this culture?
From wound secretions NCLEX ch.23
Aerobic microorganisms grow in superficial wounds that are exposed to air, and cultures need to be obtained from wound secretions. Anaerobic organisms tend to grow within the body cavity and this specimen would be anaerobic. Dried drainage grows resident colonies of bacteria, and aerobic and anaerobic cultures would never be taken from dried exudate. Aerobic microorganisms grow in superficial wounds that are exposed to air, and cultures need to be obtained from wound secretions. Anaerobic organisms tend to grow within the body cavity and this specimen would be anaerobic.
A 15-year-old comes into the clinic worried because he hasn’t grown as much as his classmates this year. X-rays show that a specific structure in his long bones has nearly closed, explaining why his height is not increasing as quickly. Name this structure.
Epiphyseal Plate or Epiphyseal Line pg. 183
Name 7 medication rights
Right patient, medication, dose, route, time, reason, documentation pg.66
During surgery, the health care provider requests more sterile water. What action must the nurse perform before pouring the solution into the sterile container?
A. Wipe off the rim of the bottle to make sure it is clean
B. Nothinng, just pour the water into the container
C. "Lipping" of the bottle with its solution
D. Hand the bottle to the sterile nurse to pour
C. Before pouring the solution into the container, the nurse pours a small amount into a waste receptacle, which cleans the lip of the bottle. This is referred to as “lipping” the bottle. Wiping the rim of the bottle introduces the possibility of contamination from the cloth or towel. Pouring the water straight into the container does not take into account that the edge of the bottle may not be clean. Handing the bottle over without making sure it is clean would introduce the possibility of infection to the sterile nurse.
What is the normal range for Calcium in the body? What are 2 tests that can be done on a patient to identify if they have hypocalcemia?
Trousseau’s sign and Chvostek’s sign
8.5 – 10.5 mg/dL or 4.5 – 5.6 mg/dL
A patient has returned from surgery and has a history of smoking. The nurse health care provider has orders for the use of incentive spirometry (IS) every 2 hours. The patient asks why he has to do IS so often. The nurse teaches the patient about the importance of breathing deeply to clear any secretions and prevent pneumonia. What is this teaching an example of?
implementation of a nursing intervention. NCLEX CH.5
Teaching is the implementation of a nursing intervention or provider order. A patient problem is an identified problem. An outcome statement is what you want to see your patient do or how they improve. The nursing process is a 6-step process in which teaching is only one step.
A 3-year-old is brought to the pediatrician with a recurrent ear infection. The doctor explains that the child’s ear infections are more common at this age because a certain structure in the ear is shorter and more horizontal than in adults. Name this structure.
Opening of auditory Tube or Eustachian Tube. pg.476
The physician orders Tylenol for a child weighing 20kg. The order reads: Tylenol 15mg/kg q4-6hr PRN. The bottle contains 160mg/5ml.
How much Tylenol do we give?
9.4 ml
For an infection to develop, a specific cycle or chain of events must occur.What are those six elements?
Infectious Agent: A pathogen
Reservoir: Where the pathogen can grow
Portal of exit: Exit route from the reservoir
Mode of transmission: Method or vehicle of transportation.
Portal of entry: entrance through the skin, mucous lining, or mouth
Host: another person or animal that is susceptible to the pathogen
A nurse is assessing a patient who has been experiencing shortness of breath and fatigue. The patient’s lungs sound clear, but their skin appears slightly bluish, and their oxygen saturation is 88%.
Which physiological process is most likely impaired in this patient?
Gas exchange in the lungs – the process of oxygen entering the blood and carbon dioxide being removed is compromised, leading to hypoxemia and Cyanosis.
A patient has had a wrist safety reminder device on for the last 2 hours. What is the nurse’s highest priority intervention?
Remove the safety reminder device and assess circulation and skin integrity.
When physical safety reminder devices are being used on a patient, it is important to remove them at least every 2 hours and assess the area for proper circulation and for any impairment in skin integrity. The others are not appropriate interventions for a patient who has been in restraints for 2 hours. pg.242
While examining a patient’s skin on a cold day, the nurse notices “goosebumps” forming on their arms. This reaction occurs when tiny muscles attached to hair follicles contract in response to cold or emotional stimuli. Name these muscles.
Arrector Pili Muscles pg. 155
A nurse is preparing to administer a medication to a patient who has never received the drug before. The provider orders a small test dose to check for an allergic reaction.
Before giving the test dose, what is the most important action the nurse must take?
pg. 77
Ensure emergency equipment (such as epinephrine) is immediately available in case of an allergic reaction.
Which signs of a localized inflammatory response would you expect to experience?
When inflammation becomes systemic, what would a patient experience?
redness, warm, swelling, tenderness/pain, loss of function.
fever, increased wbc, malaise, anorexia, nausea, vomiting, and lymph enlargement. pg.126
What is ADH. What glad produces it? What glad secretes it? What does it do?
Antidiuretic Hormone
Hypothalamus produces it
Pituitary Gland secretes it
Kidney reabsorbs urine, prevents dehydration.
You are the only nurse available on the unit when a fire alarm sounds. You enter a patient’s room and find a patient who is unable to walk and must be carried to safety.
What is the safest action for the nurse to take?
pg.250
Universal carry or blanket drag.
These twelve paired nerves emerge directly from the brain. List them in order and include their primary functions.
I: Olfactory : Sense of smell
II: Optic : Vision
III: Oculomotor : eye movement
IV: Trochlear : Eye movement
V: Trigeminal : Senseation of face, scalp,teeth,cheewing
VI: Abducens : Eye movements
VII: Facial : Taste, contraction of muscles of facial expression
VIII: Vestibulocochlear : Hearing, sense of balance
IX: Glossopharyngeal : sensation of throat, taste, swalling, secretion of saliva
X: Vagus : sensation of throat and larynx and thoracic and abdominal organs, swallowing, voice production, slowing of heartbeat, acceleration of peristalsis.
XI: Accessory : Shoulder movements, turning movements of head
XII: Hypoglossal : Tongue movements pg.277
A patient with type 1 diabetes has been self-administering insulin in the same spot on their abdomen for several months. During a routine visit, the nurse notices small lumps and hardened areas at the injection site.( Lipodystrophy)
What should the nurse teach the patient to prevent this complication in the future?
Rotate injection sites regularly within the same body region to prevent tissue damage and ensure proper insulin absorption.
A chemotherapy patient is highly immunocompromised. The nurse follows strict hand hygiene, wears gowns, gloves, and masks, and limits visitors to protect them from bacteria, viruses, and fungi. Identify the type of isolation precautions required, the category of pathogens being guarded against, and the aseptic principle most critical for their care.
protective (neutropenic) isolation precautions; all pathogens (bacteria, viruses, fungi, parasitic); and surgical asepsis (sterile technique)?
A patient asks the nurse why spinal cord injuries often result in permanent loss of function, while peripheral nerve injuries sometimes recover. Give an explanation on how this is possible.
Neurilemma; a structure found in PNS but absent in CNS. It provides the essential pathway needed for damaged axons to regenerate. pg.256