501 Nursing Bullets: Fundamentals of Nursing Reviewer

Welcome to your comprehensive study guide for the Fundamentals of Nursing!

Dive into 501 bite-sized nursing bullets packed with essential facts and tips, perfect for quick learning and easy comprehension. Whether you’re a nursing student gearing up for exams or a practicing nurse looking to refresh your knowledge, this fun and engaging guide will enhance your understanding and application of nursing fundamentals. Get ready to breeze through these nuggets of wisdom and elevate your nursing practice with confidence and ease. Happy studying!

Assessment
Patient Safety
Medication Administration
Infection Control and Sterile Technique
Pain Management
Communication and Documentation
Patient Mobility and Rehabilitation
Legal and Ethical Considerations
Cultural Competence
Nursing Process
Nursing Procedures and Skills
Diet and Nutrition
End-of-life Care
Exam Tips
Miscellaneous

Assessment

Accurate patient monitoring and thorough assessments are vital for effective care and early detection of complications.

A thready pulse is very fine and scarcely perceptible.
The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication.
Ptosis is drooping of the eyelid.
Gastric lavage is flushing of the stomach and removal of ingested substances through a nasogastric tube. It’s used to treat poisoning or drug overdose.
After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions.
After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment.
On a drug prescription, the abbreviation p.c. means that the drug should be administered after meals.
To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as a thumbnail. A positive Babinski’s reflex is shown by dorsiflexion of the great toe and fanning out of the other toes.
O.U. means each eye. O.D. is the right eye, and O.S. is the left eye.
To remove a patient’s artificial eye, the nurse depresses the lower lid.
First-morning urine provides the best sample to measure glucose, ketone, pH, and specific gravity values.
Fluid oscillation in the tubing of a chest drainage system indicates that the system is working properly.
Understanding the basic anatomical and physiological aspects is crucial for accurate assessments and interventions.
The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland.
The three membranes that enclose the brain and spinal cord are the dura mater, pia mater, and arachnoid.
Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation.
When measuring a patient’s pulse, the nurse should assess its rate, rhythm, quality, and strength
The nurse should count an irregular pulse for 1 full minute
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
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
Before taking an adult’s temperature orally, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the previous 15 minutes
The nurse shouldn’t take an adult’s temperature rectally if the patient has a cardiac disorder, anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery
In a patient who has a cardiac disorder, measuring temperature rectally may stimulate a vagal response and lead to vasodilation and decreased cardiac output
When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3, bounding pulse (readily palpable and forceful); +2, normal pulse (easily palpable); +1, thready or weak pulse (difficult to detect); and 0, absent pulse (not detectable)
A slight difference in blood pressure (5 to 10 mm Hg) between the right and the left arms is normal
The nurse should place the blood pressure cuff 1″ (2.5 cm) above the antecubital fossa
The nurse should use a leg cuff to measure blood pressure in an obese patient
If a blood pressure cuff is applied too loosely, the reading will be falsely lowered
The nurse shouldn’t use their thumb to take a patient’s pulse rate because the thumb has a pulse that may be confused with the patient’s pulse
An inspiration and an expiration count as one respiration
Eupnea is normal respiration
During blood pressure measurement, the patient should rest the arm against a surface. Using muscle strength to hold up the arm may raise the blood pressure
The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery. To take the pulse rate, the artery is compressed against the radius
In a resting adult, the normal pulse rate is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults
Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidomastoid muscle use during respiration
Pulsus alternans is a regular pulse rhythm with alternating weak and strong beats. It occurs in ventricular enlargement because the stroke volume varies with each heartbeat
The S1 heard on auscultation is caused by closure of the mitral and tricuspid valves
In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostal space, near the apex
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
Bradycardia is a heart rate of fewer than 60 beats/minute
Bruits commonly indicate life- or limb-threatening vascular disease
In an infant, the normal hemoglobin value is 12 g/dl.
People with type O blood are considered universal donors.
People with type AB blood are considered universal recipients.
Prothrombin, a clotting factor, is produced in the liver.
Hyperpyrexia is an extreme elevation in temperature above 106° F (41.1° C).
Ptosis is drooping of the eyelid.
When assessing respirations, the nurse should document their rate, rhythm, depth, and quality
When percussing a patient’s chest for postural drainage, the nurse’s hands should be cupped
Rhonchi are the rumbling sounds heard on lung auscultation. They are more pronounced during expiration than during inspiration
Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidomastoid muscle use during respiration
The autonomic nervous system regulates the cardiovascular and respiratory systems
Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia.
Wheezing is an abnormal, high-pitched breath sound that’s accentuated on expiration.
PERRLA is an abbreviation for normal pupilassessment findings: pupils equal, round, and reactive to light with accommodation
Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI
The notation “AA & O × 3” indicates that the patient is awake, alert, and oriented to person (knows who they are), place (knows where they are), and time (knows the date and time)
The nurse should assess for petechiae in a dark-skinned patient by examining the oral mucosa
To test visual acuity, the nurse should ask the patient to cover each eye separately and to read the eye chart with glasses and without, as appropriate
During assessment of distance vision, the patient should stand 20′ (6.1 m) from the chart
The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers)
The optic disk is yellowish pink and circular, with a distinct border
The autonomic nervous system regulates the cardiovascular and respiratory systems.
To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object. A positive Babinski’s reflex is shown by dorsiflexion of the great toe and fanning out of the other toes.
The fight-or-flight response is a sympathetic nervous system response.
The nurse should grade hyperactive biceps and triceps reflexes as +4.
Abdominal assessment is performed in the following order: inspection, auscultation, percussion & palpation
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
When assessing a patient’s eating habits, the nurse should ask, “What have you eaten in the last 24 hours?”
Residual urine is urine that remains in the bladder after voiding. The amount of residual urine is normally 50 to 100 ml
Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent is the number of milligrams per 100 milliliters of a solution
Metabolism occurs in two phases: anabolism (the constructive phase) and catabolism (the destructive phase)
The basal metabolic rate is the amount of energy needed to maintain essential body functions. It’s measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment. The basal metabolic rate is expressed in calories consumed per hour per kilogram of body weight
The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1° C.
As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion.
The following foods can alter the color of the feces: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown).
After turning a patient, the nurse should document the position used, the time that the patient was turned, and the findings of skin assessment
When providing oral care for an unconscious patient, to minimize the risk of aspiration, the nurse should position the patient on the side
A positive Homan’s sign may indicate thrombophlebitis
Petechiae are tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage
Purpura is a purple discoloration of the skin that’s caused by blood extravasation
The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery. Hand and finger spasms that occur during occlusion indicate Trousseau’s sign and suggest hypocalcemia
To insert a catheter from the nose through the trachea for suction, the nurse should ask the patient to swallow
Percussion involves tapping to assess underlying organ/tissue size, shape, position, density, tenderness, or reflexes.

Patient Safety

Ensuring patient safety during various procedures is essential. The following points highlight key safety measures and best practices in patient care.

Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair footrests to the sides and lock its wheels.
A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus.
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.
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.
A patient’s identification bracelet should remain in place until the patient has been discharged from the healthcare facility and has left the premises.
To minimize interruptions during a patient interview, the nurse should select a private room, preferably one with a door that can be closed.
Activities of daily living are actions that the patient must perform every day to provide self-care and to interact with society.
The nurse should place a patient who has a Sengstaken-Blakemore tube in semi-Fowler position.
A registered nurse should assign a licensed vocational nurse or licensed practical nurse to perform bedside care, such as suctioning and drug administration.
A filter is always used for blood transfusions.
A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide.
Fluid oscillation in the tubing of a chest drainage system indicates that the system is working properly.
In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma.
To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if needed; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet.
For a sigmoidoscopy, the nurse should place the patient in the knee-chest position or Sims’ position, depending on the physician’s preference.
To prevent injury when lifting and moving a patient, the nurse should primarily use the upper leg muscles.
When caring for a patient who has a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness.
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.
A patient who is completely immobile should be lifted on a sheet to avoid shearing force injury.
When preparing for a skull X-ray, the patient should remove all jewelry and dentures.
Wax or a foreign body in the ear should be flushed out gently by irrigation with warm saline solution.
Dentures should be cleaned in a sink that’s lined with a washcloth.
A rectal tube shouldn’t be inserted for longer than 20 minutes because it can irritate the rectal mucosa and cause loss of sphincter control.
A patient should void within 8 hours after surgery.
A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum.
While an occupied bed is being changed, the patient should be covered with a bath blanket to promote warmth and prevent exposure.
If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first.
Before administering preoperative medication, the nurse should ensure that an informed consent form has been signed and attached to the patient’s record.
The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia care unit.
On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water), has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have been taken and recorded. Artificial limbs and other prostheses are usually removed.
Prophylaxis is disease prevention.
Body alignment is achieved when body parts are in proper relation to their natural position.
Blood pressure is the force exerted by the circulating volume of blood on the arterial walls.

Medication Administration

Accurate and safe medication administration is a key component of nursing care. These guidelines ensure the correct administration of medications and patient safety.

For a subcutaneous injection, the nurse should use a 5/8″ to 1″ 25G needle.
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.
After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results.
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.
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.
The nurse should use a tuberculin syringe to administer a subcutaneous injection of less than 1 ml.
For adults, subcutaneous injections require a 25G 5/8″ to 1″ needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½” needle.
Before administering a drug, the nurse should identify the patient by checking the identification band and asking the patient to state their name.
To clean the skin before an injection, the nurse uses a sterile alcohol swab to wipe from the center of the site outward in a circular motion.
The nurse should inject heparin deep into subcutaneous tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation.
If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure.
The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate significant other.
If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops. If bruising occurs, the nurse should monitor the site for an enlarging hematoma.
The nurse should administer procainepenicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site.
When giving an injection to a patient who has a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection.
To prevent injury to the cornea when administering eyedrops, the nurse should waste the first drop and instill the drug in the lower conjunctival sac.
After administering eye ointment, the nurse should twist the medication tube to detach the ointment.
When the nurse removes gloves and a mask, they should remove the gloves first. They are soiled and are likely to contain pathogens.
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. Sites for intradermal injection include the inner arm, the upper chest, and on the back, under the scapula.
The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon).
A blood pressure cuff that’s too narrow can cause a falsely elevated blood pressure reading.
To increase patient comfort, the nurse should let the alcohol dry before giving an intramuscular injection.
The appropriate needle size for insulin injection is 25G and 5/8″ long.
To administer heparin subcutaneously, the nurse should follow these steps: Clean, but don’t rub, the site with alcohol. Stretch the skin taut or pick up a well-defined skin fold. Hold the shaft of the needle in a dart position. Insert the needle into the skin at a right (90-degree) angle. Firmly depress the plunger, but don’t aspirate. Leave the needle in place for 10 seconds. Withdraw the needle gently at the angle of insertion. Apply pressure to the injection site with an alcohol pad.
If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention.
Intrathecal injection is administering a drug through the spine.
To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle.
If a patient can’t cough to provide a sputum sample for culture, a heated aerosol treatment can be used to help obtain a sample.
When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion.
If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart.
When recording drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage.
The steps of the trajectory-nursing model are as follows:
Identifying the trajectory phase
Identifying the problems and establishing goals
Establishing a plan to meet the goals
Identifying factors that facilitate or hinder attainment of the goals
Implementing interventions
Evaluating the effectiveness of the interventions
The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use. Delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction.
Drugs aren’t routinely injected intramuscularly into edematous tissue because they may not be absorbed.
Forcing fluids helps prevent constipation in a postoperative patient.
If a patient complains of hearing issues with their hearing aid, the nurse should first check the switch to ensure it’s turned on and then check the batteries.
The body metabolizes alcohol at a fixed rate, regardless of serum concentration.
In an alcoholic beverage, proof reflects the percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol.

Infection Control and Sterile Technique

Maintaining sterility and proper infection control procedures are essential to prevent complications and ensure patient safety.

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.
Diseases that require strict isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease.
A nurse should spend no more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant.
A nurse shouldn’t be assigned to care for more than one patient who has a radiation implant.
Long-handled forceps and a lead-lined container should be available in the room of a patient who has a radiation implant.
Usually, patients who have the same infection and are in strict isolation can share a room.
An organism may enter the body through the nose,
mouth, rectum, urinary or reproductive tract, or skin.
When instilling ophthalmic ointments, the nurse should waste the first bead of ointment and then apply the ointment from the inner canthus to the outer canthus.
When leaving an isolation room, the nurse should remove their gloves before their mask because fewer pathogens are on the mask.
Understanding the different types of healing and proper wound care techniques is essential for effective patient recovery.
A sutured surgical incision is an example of healing by first intention (healing directly, without granulation).
Healing by secondary intention (healing by granulation) is closure of the wound when granulation tissue fills the defect and allows reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered.
Keloid formation is an abnormality in healing that’s characterized by overgrowth of scar tissue at the wound site.
The area around a stoma is cleaned with mild soap and water.

Pain Management

Effective pain management techniques improve patient comfort and recovery. Understanding different theories and types of pain is essential for appropriate interventions.

Only the patient can describe their pain accurately.
Cutaneous stimulation creates the release of endorphins that block the transmission of pain stimuli.
Patient-controlled analgesia is a safe method to relieve acute pain caused by surgical incision, traumatic injury, labor and delivery, or cancer.
Before administering any “as needed” pain medication, the nurse should ask the patient to indicate the location of the pain.
To induce sleep, the first step is to minimize environmental stimuli.
The nurse should use an objective scale to assess and quantify pain. Postoperative pain varies greatly among individuals.
When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis.
When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present.
To minimize omission and distortion of facts, the nurse should record information as soon as it’s gathered.
A back rub is an example of the gate-control theory of pain.
A subjective sign that a sitz bath has been effective is the patient’s expression of decreased pain or discomfort.
Pain threshold, or pain sensation, is the initial point at which a patient feels pain.
The difference between acute pain and chronic pain is its duration.
Referred pain is pain that’s felt at a site other than its origin.
Pain seems more intense at night because the patient isn’t distracted by daily activities.
Older patients commonly don’t report pain because of fear of treatment, lifestyle changes, or dependency.
Comfort measures, such as positioning the patient, rubbing the patient’s back, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness.
Alleviating pain by performing a back massage is consistent with the gate control theory.

Communication and Documentation

Effective communication and thorough documentation are fundamental aspects of nursing practice, ensuring clarity, continuity, and quality of patient care.

When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign each entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines
Laboratory test results are an objective form of assessment data
The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs
A community nurse is serving as a patient’s advocate if they tell a malnourished patient to go to a meal program at a local park.
If a patient isn’t following their treatment plan, the nurse should first ask why.
When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice.
Outside of the hospital setting, only the sublingual and translingual forms of nitroglycerin should be used to relieve acute anginal attacks.
A living will is a witnessed document that states a patient’s desire for certain types of care and treatment. These decisions are based on the patient’s wishes and views on quality of life.
Anticipatory grief is mourning that occurs for an extended time when the patient realizes that death is inevitable.
The nurse should provide honest answers to the patient’s questions.
Families with loved ones in intensive care units report that their four most important needs are to have their questions answered honestly, to be assured that the best possible care is being provided, to know the patient’s prognosis, and to feel that there is hope of recovery.
Double-bind communication occurs when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to.
A nonjudgmental attitude displayed by a nurse shows that they neither approve nor disapprove of the patient.
The best method to determine a patient’s cultural or spiritual needs is to ask them.
Listening is the most effective communication technique.
The family of a patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to them.
Before teaching any procedure to a patient, the nurse must assess the patient’s current knowledge and willingness to learn.
Process recording is a method of evaluating one’s communication effectiveness.
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.
The nurse can assess a patient’s general knowledge by asking questions such as “Who is the current president of the United States?”
During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy.
Before signing an informed consent form, the patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phases; the risks involved; and the possible complications. The patient should also have a general idea of the time required from surgery to recovery. In addition, they should have an opportunity to ask questions.
A patient must sign a separate informed consent form for each procedure.
When obtaining a health history from an acutely ill or agitated patient, the nurse should limit questions to those that provide necessary information.

Patient Mobility and Rehabilitation

Proper techniques for patient mobility and rehabilitation help prevent injury and promote recovery.

Passive range of motion maintains joint mobility. Resistive exercises increase muscle mass.
Isometric exercises are performed on an extremity that’s in a cast.
Falls are the leading cause of injury in elderly people.
In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch simultaneously.
When being measured for crutches, a patient should wear shoes.
To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2″ (5 cm) to that measurement.
The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity.
To move a patient to the edge of the bed for transfer, the nurse should follow these steps: Move the patient’s head and shoulders toward the edge of the bed. Move the patient’s feet and legs to the edge of the bed (crescent position). Place both arms well under the patient’s hips, and straighten the back while moving the patient toward the edge of the bed.
When patients use axillary crutches, their palms should bear the brunt of the weight.
Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially.
Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in which the patient’s foot moves forward.

Legal and Ethical Considerations

Navigating the complex landscape of legal and ethical principles is crucial for nursing practice, ensuring the protection of patient rights, adherence to professional standards, and the delivery of safe and effective care.

Malpractice is a professional’s wrongful conduct, improper discharge of duties, or failure to meet standards of care that causes harm to another.
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.
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 healthcare facility.
A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of their refusal.
Although a patient’s health record, or chart, is the healthcare facility’s physical property, its contents belong to the patient.
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.
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 healthcare facility or physician.
A physician should sign verbal and telephone orders within the time established by facility policy, usually 24 hours.
As a general rule, nurses can’t refuse a patient care assignment; however, in most states, they may refuse to participate in abortions.
Trust is the foundation of a nurse-patient relationship.
Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for drugs.
Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient.
Administering an I.M. injection against the patient’s will and without legal authority is battery.
An example of a third-party payer is an insurance company.
An incident report or unusual occurrence report isn’t part of a patient’s record, but is an in-house document that’s used for the purpose of correcting the problem.
Critical pathways are a multidisciplinary guideline for patient care.
The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy.
For the patient who abides by Jewish custom, milk and meat shouldn’t be served at the same meal.
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).
When communicating with a hearing-impaired patient, the nurse should face them.
An appropriate nursing intervention for the spouse of a patient who has a serious incapacitating disease is to help them to mobilize a support system.
Hyperpyrexia is extreme elevation in temperature above 106° F (41.1° C).
When a patient expresses concern about a health-related issue, before addressing the concern, the nurse should assess the patient’s level of knowledge.
The most effective way to reduce a fever is to administer an antipyretic, which lowers the temperature set point.
When a patient is ill, it’s essential for the members of their family to maintain communication about their health needs.
Ethnocentrism is the universal belief that one’s way of life is superior to others.
When a nurse is communicating with a patient through an interpreter, the nurse should speak to the patient and the interpreter.
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.”
Prejudice is a hostile attitude toward individuals of a particular group.
Discrimination is preferential treatment of individuals of a particular group. It’s usually discussed in a negative sense.
Increased gastric motility interferes with the absorption of oral drugs.
The three phases of the therapeutic relationship are orientation, working, and termination.
Patients often exhibit resistive and challenging behaviors in the orientation phase of the therapeutic relationship.
Abandonment is premature termination of treatment without the patient’s permission and without appropriate relief of symptoms.
The patients’ bill of rights was introduced by the American Hospital Association.
Values clarification is a process that individuals use to prioritize their personal values.
Distributive justice is a principle that promotes equal treatment for all.
Endorphins are morphine-like substances that produce a feeling of well-being.
Pain tolerance is the maximum amount and duration of pain that an individual is willing to endure.
Decibel is the unit of measurement of sound.
Collaboration is joint communication and decision making between nurses and physicians. It’s designed to meet patients’ needs by integrating the care regimens of both professions into one comprehensive approach.
Nurses are commonly held liable for failing to keep an accurate count of sponges and other devices during surgery.
Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which they work.
Veracity is truth and is an essential component of a therapeutic relationship between a healthcare provider and the patient.
Beneficence is the duty to do no harm and the duty to do good.
Nonmaleficence is the duty to do no harm.
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 an incident report and completing the patient chart. When evaluating needs, this category is never the highest priority.
Understanding insurance and utilization review processes ensures appropriate and cost-effective care for patients.
A third-party payer is an insurance company.
Utilization review is performed to determine whether the care provided to a patient was appropriate and cost-effective.

Cultural Competence

Cultural competence involves understanding and respecting different cultural practices and beliefs in patient care.

A value cohort is a group of people who experienced an out-of-the-ordinary event that shaped their values.
Bananas, citrus fruits, and potatoes are good sources of potassium.
Good sources of magnesium include fish, nuts, and grains.
Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron.
A Hindu patient is likely to request a vegetarian diet.
No pork or pork products are allowed in a Muslim diet.
On noticing religious artifacts and literature on a patient’s nightstand, a culturally aware nurse would ask the patient the meaning of the items.
A Mexican patient may request the intervention of a curandero, or faith healer, who involves the family in healing the patient.
An Asian American or European American typically places distance between themselves and others when communicating.
The patient who believes in a scientific, or biomedical, approach to health is likely to expect a drug, treatment, or surgery to cure illness.
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.”
Seventh-Day Adventists are usually vegetarians.
Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people.
When communicating with a patient through an interpreter, the nurse should speak to the patient and the interpreter.

Nursing Process

The nursing process is a systematic method for providing patient care and includes several stages.

The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation.
Assessment is the stage of the nursing process in which the nurse continuously collects data to identify a patient’s actual and potential health needs.
Nursing diagnosis is the stage of the nursing process in which the nurse makes a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes.
Planning is the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan.
Implementation is the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions.
Evaluation is the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan.
A nursing diagnosis is a statement of a patient’s actual or potential health problem that can be resolved, diminished, or otherwise changed by nursing interventions.
During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data.
The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities.
The evaluation phase of the nursing process is to determine whether nursing interventions have enabled the patient to meet the desired goals.
The patient’s health history consists primarily of subjective data, information that’s supplied by the patient.
The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation.
A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It’s developed in collaboration with the patient.
Effective care planning involves prioritizing nursing diagnoses and setting appropriate patient goals and interventions.
In categorizing nursing diagnoses, the nurse addresses life-threatening problems first, followed by potentially life-threatening concerns.
The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions.
Standing orders, or protocols, establish guidelines for treating a specific disease or set of symptoms.
The most important goal to include in a care plan is the patient’s goal.
For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for the problem, and selecting the intervention from the choices provided that will enable the patient to reach that goal.
When prioritizing nursing diagnoses, the following hierarchy should be used: Problems associated with the airway, those concerning breathing, and those related to circulation.
The two nursing diagnoses that have the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern.
For the nursing diagnosis Deficient diversional activity to be valid, the patient must state that they are “bored,” that they have “nothing to do,” or words to that effect.
The most appropriate nursing diagnosis for an individual who doesn’t speak English is Impaired verbal communication related to inability to speak dominant language (English).

Nursing Procedures and Skills

Helpful nursing tips regarding nursing procedures and skills.

The formula for calculating the drops per minute for an I.V. infusion is as follows: (volume to be infused × drip factor) ÷ time in minutes = drops/minute.
On-call medication should be given within 5 minutes of the call.
To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet.
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.
Crutches should be placed 6″ (15.2 cm) in front of the patient and 6″ to the side to form a tripod arrangement.
The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity.
To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2″ (5 cm) to that measurement.
The safest and surest way to verify a patient’s identity is to check the identification band on their wrist.
In the therapeutic environment, the patient’s safety is the primary concern.
The nurse should place a patient who has a Sengstaken-Blakemore tube in semi-Fowler position.
The best way to prevent falls at night in an oriented, but restless, elderly patient is to raise the side rails.
Falls in the elderly are likely to be caused by poor vision.
By the end of the orientation phase, the patient should begin to trust the nurse.
Informed consent is required for any invasive procedure.
In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic means.
A patient who can’t write their name to give consent for treatment must make an X in the presence of two witnesses, such as a nurse, priest, or physician.
Treatment for a stage 1 ulcer on the heels includes heel protectors.
To put on a sterile glove, the nurse should pick up the first glove at the folded border and adjust the fingers when both gloves are on.
When the nurse removes gloves and a mask, they should remove the gloves first. They are soiled and are likely to contain pathogens.
Hand washing is the single best method of limiting the spread of microorganisms. Once gloves are removed after routine contact with a patient, hands should be washed for 10 to 15 seconds.
A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively.
The area around a stoma is cleaned with mild soap and water.
Proper function of a hearing aid requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries.
The hearing aid that’s marked with a blue dot is for the left ear; the one with a red dot is for the right ear.
A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water.
The nurse should instruct the patient to avoid using hair spray while wearing a hearing aid.
The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown.
Heat is applied to promote vasodilation, which reduces pain caused by inflammation.
A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide.
Fluid oscillation in the tubing of a chest drainage system indicates that the system is working properly.
The diaphragm of the stethoscope is used to hear high-pitched sounds, such as breath sounds.
A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position.
Antiembolism stockings decompress the superficial blood vessels, reducing the risk of thrombus formation.
In adults, the most convenient veins for venipuncture are the basilic and median cubital veins in the antecubital space.
An EEG identifies normal and abnormal brain waves.
Samples of feces for ova and parasite tests should be delivered to the laboratory without delay and without refrigeration.
If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory request.
During lumbar puncture, the nurse must note the initial intracranial pressure and the color of the cerebrospinal fluid.

Diet and Nutrition

Proper dietary guidelines are essential for patient health and recovery. This involves understanding the nutritional content of various foods, dietary restrictions, and appropriate dietary interventions to support patient well-being.

Milk shouldn’t be included in a clear liquid diet.
Vegetables have a high fiber content.
A patient should be advised to take aspirin on an empty stomach, with a full glass of water, and should avoid acidic foods such as coffee, citrus fruits, and cola.
Bananas, citrus fruits, and potatoes are good sources of potassium.
Good sources of magnesium include fish, nuts, and grains.
Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron.
Milk is high in sodium and low in iron.
Most nutrients are absorbed in the small intestine.
A vegan diet should include an abundant supply of fiber.
When assessing a patient’s eating habits, the nurse should ask, “What have you eaten in the last 24 hours?”
Milk and milk products, poultry, grains, and fish are good sources of phosphate.
Vitamin C is needed for collagen production.
Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains intestinal motility, and helps to establish regular bowel habits.
The vitamin B complex, the water-soluble vitamins that are essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12).
When being weighed, an adult patient should be lightly dressed and shoeless.
To avoid staining the teeth, the patient should take a liquid iron preparation through a straw.
The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals.
Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, green leafy vegetables, eggs, and whole grains, commonly have a low water content.
Fruits are high in fiber and low in protein and should be omitted from a low-residue diet.
A low-residue diet includes such foods as roasted chicken, rice, and pasta.
The nitrogen balance estimates the difference between the intake and use of protein.
Most of the absorption of water occurs in the large intestine.
Two to three hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify that gastric emptying is adequate.

End-of-life Care

Understanding different aspects of end-of-life care ensures that patients are treated with dignity and respect.

Active euthanasia is actively helping a person to die.
Brain death is irreversible cessation of all brain function.
Passive euthanasia is stopping the therapy that’s sustaining life.
Voluntary euthanasia is actively helping a patient to die at the patient’s request.
Postmortem care ensures the deceased patient is treated with respect and dignity, and it also supports the family during a difficult time.
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.
A patient indicates that they are coming to terms with having a chronic disease when they say, “I’m never going to get any better.”

Exam Tips

Effective examination strategies help nurses understand and address patient needs accurately.

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.
When answering a question on the NCLEX examination, the student should consider the cue (the stimulus for a thought) and the inference (the thought) to determine whether the inference is correct. When in doubt, the nurse should select an answer that indicates the need for further information to eliminate ambiguity.
For example, the patient complains of chest pain (the stimulus for the thought) and the nurse infers that the patient is having cardiac pain (the thought). In this case, the nurse hasn’t confirmed whether the pain is cardiac. It would be more appropriate to make further assessments.
When answering a question on an NCLEX examination, the basic rule is “assess before action.” The student should evaluate each possible answer carefully. Usually, several answers reflect the implementation phase of nursing and one or two reflect the assessment phase. In this case, the best choice is an assessment response unless a specific course of action is clearly indicated.
Rule utilitarianism is known as the “greatest good for the greatest number of people” theory.
For more exam tips, please visit 75 NCLEX Tips and Strategies

Miscellaneous

Other nursing bullets:

To induce sleep, the first step is to minimize environmental stimuli
The phases of mitosis are prophase, metaphase, anaphase, and telophase
The autonomic nervous system controls the smooth muscles
Various aspects of patient care and management are essential for holistic nursing practice.
A nurse must provide care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy.
The five rights of medication administration are the right patient, right drug, right dose, right route of administration, and right time.
The Patient’s Bill of Rights offers patients guidance and protection by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization.
Quality assurance is a method of determining whether nursing actions and practices meet established standards.
A nurse shouldn’t give false assurance to a patient.
After receiving preoperative medication, a patient isn’t competent to sign an informed consent form.
A nurse may clarify a physician’s explanation about an operation or a procedure to a patient, but must refer questions about informed consent to the physician.
When lifting a patient, a nurse uses the weight of their body instead of the strength in their arms.
The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours.
To prevent injury when lifting and moving a patient, the nurse should primarily use the upper leg muscles.
Chronic illnesses occur in very young as well as middle-aged and very old people.
The trajectory framework for chronic illness states that preferences about daily life activities affect treatment decisions.
Exacerbations of chronic disease usually cause the patient to seek treatment and may lead to hospitalization.
Primary prevention is true prevention. Examples are immunizations, weight control, and smoking cessation.
Secondary prevention is early detection. Examples include purified protein derivative (PPD), breast self-examination, testicular self-examination, and chest X-ray.
Tertiary prevention is treatment to prevent long-term complications.
Major, unalterable risk factors for coronary artery disease include heredity, sex, race, and age
A primary disability is caused by a pathologic process. A secondary disability is caused by inactivity
An ascending colostomy drains fluid feces. A descending colostomy drains solid fecal matter.
A folded towel (scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis.
To insert a nasogastric tube, the nurse instructs the patient to tilt the head back slightly and then inserts the tube. When the nurse feels the tube curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.)
Primary prevention is true prevention. Examples are immunizations, weight control, and smoking cessation.
Secondary prevention is early detection. Examples include purified protein derivative (PPD), breast self-examination, testicular self-examination, and chest X-ray.
Tertiary prevention is treatment to prevent long-term complications.
If a chest drainage system line is broken or interrupted, the nurse should clamp the tube immediately.
Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a comfortable atmosphere.
Comfort measures, such as positioning the patient, rubbing the patient’s back, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness.
A foot cradle keeps bed linen off the patient’s feet to prevent skin irritation and breakdown, especially in a patient who has peripheral vascular disease or neuropathy.
Hertz (Hz) is the unit of measurement of sound frequency.
Hearing protection is required when the sound intensity exceeds 84 dB. Double hearing protection is required if it exceeds 104 dB.
If a patient complains that their hearing aid is “not working,” the nurse should check the switch first to see if it’s turned on and then check the batteries.
Consistency and appropriate care techniques are critical when dealing with vulnerable patient groups.
When caring for an infant, a child, or a confused patient, consistency in nursing personnel is paramount.
When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head.
The frequency of patient hair care depends on the length and texture of the hair, the duration of hospitalization, and the patient’s condition.
Before instilling medication into the ear of a patient who is up to age 3, the nurse should pull the pinna down and back to straighten the eustachian tube.
Hand hygiene is the most effective way to prevent the spread of infections.
Vital signs should be measured regularly to monitor the patient’s condition and detect any changes.
Use personal protective equipment (PPE) appropriately to protect yourself and your patients from infections.
Always verify the patient’s identity before administering medications or performing procedures.
Use the five rights of medication administration: right patient, right drug, right dose, right route, and right time.
Position the patient properly to ensure comfort and prevent pressure ulcers.
Regularly assess the patient’s pain level and provide appropriate pain management interventions.
Educate patients about their medications, including potential side effects and how to take them properly.
Use the SBAR (Situation, Background, Assessment, Recommendation) technique for effective communication with other healthcare professionals.
Document all patient care activities accurately and promptly in the patient’s medical record.
Assess the patient’s hydration status by monitoring intake and output, skin turgor, and mucous membranes.
Perform a thorough head-to-toe assessment during each shift to detect any changes in the patient’s condition.
Implement fall prevention strategies for patients at risk, such as using bed alarms and ensuring a clutter-free environment.
Encourage patients to perform deep breathing and coughing exercises to prevent respiratory complications.
Administer oxygen therapy as prescribed and monitor the patient’s oxygen saturation levels.
Provide oral care to maintain oral hygiene and prevent infections, especially in patients who are NPO (nothing by mouth) or on ventilators.
Follow proper techniques for inserting and managing urinary catheters to prevent urinary tract infections.
Assist patients with mobility and range-of-motion exercises to prevent muscle atrophy and improve circulation.
Educate patients and families about signs and symptoms of infection and when to seek medical attention.
Maintain a clean and organized work environment to ensure safety and efficiency.
Use proper body mechanics when lifting and transferring patients to prevent injury.
Assess the patient’s skin regularly for signs of pressure ulcers, especially in immobile patients.
Implement turning and repositioning schedules for bedridden patients to prevent pressure ulcers.
Monitor the patient’s nutritional status and collaborate with a dietitian if necessary.
Provide education on the importance of hand hygiene to patients and their families.
Use closed suction systems when suctioning patients to reduce the risk of infection.
Perform regular mouth care for intubated patients to prevent ventilator-associated pneumonia.
Apply anti-embolism stockings or sequential compression devices to prevent deep vein thrombosis.
Encourage fluid intake unless contraindicated to maintain hydration and support renal function.
Educate patients on the signs and symptoms of hypoglycemia and hyperglycemia if they have diabetes.
Use aseptic technique during wound care to prevent infection.
Assess the patient’s mental status regularly and report any changes to the healthcare team.
Implement measures to reduce the risk of medication errors, such as using barcoded medication administration systems.
Provide emotional support to patients and their families, especially during difficult times.
Encourage patients to verbalize their concerns and fears, and provide appropriate reassurance.
Ensure that all equipment is functioning properly before use to prevent accidents.
Follow standard precautions for all patients to prevent the spread of infection.
Educate patients on the importance of adherence to their treatment plan for optimal health outcomes.
Monitor the patient’s response to medications and report any adverse reactions.
Use pain scales appropriate for the patient’s age and cognitive ability to assess pain accurately.
Provide culturally competent care by respecting the patient’s cultural beliefs and practices.
Educate patients on proper wound care techniques to promote healing and prevent infection.
Use distraction techniques or non-pharmacological interventions to help manage pain.
Administer blood products according to protocol and monitor the patient for transfusion reactions.
Ensure that consent forms are signed and understood by the patient before procedures.
Encourage patients to participate in their care plan to promote independence and self-management.
Provide care that preserves the patient’s dignity and privacy at all times.
Educate patients on the importance of lifestyle changes, such as smoking cessation and regular exercise.
Perform thorough handoffs during shift changes to ensure continuity of care.
Monitor the patient’s intake and output accurately to assess fluid balance.
Use therapeutic communication techniques to build rapport with patients.
Assess the patient’s risk for aspiration and implement precautions if necessary.
Collaborate with interdisciplinary team members to provide comprehensive patient care.
Ensure that emergency equipment, such as defibrillators, is readily accessible and functional.
Educate patients on the safe use of medical equipment, such as walkers and oxygen tanks.
Provide post-operative care, including pain management, wound care, and monitoring for complications.
Monitor patients on anticoagulant therapy for signs of bleeding.
Perform respiratory assessments and provide interventions, such as incentive spirometry, to promote lung expansion.
Assess the patient’s understanding of discharge instructions and provide clarification as needed.
Use clinical decision support tools to aid in making evidence-based care decisions.
Implement infection control measures, such as isolation protocols, for patients with contagious diseases.

Matt Vera, a registered nurse since 2009, leverages his experiences as a former student struggling with complex nursing topics to help aspiring nurses as a full-time writer and editor for Nurseslabs, simplifying the learning process, breaking down complicated subjects, and finding innovative ways to assist students in reaching their full potential as future healthcare providers.