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Fundamentals Midterm Guide
Fundamentals Of Nursing (Florida National University)
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Question 1. Know cranial nerves and how to assess them.
1st Cranial nerve – Olfactory: Smell, a function of the 1st (olfactory) cranial nerve, is usually evaluated
only after head trauma or when lesions of the anterior fossa (eg, meningioma) are suspected or patients report
abnormal smell or taste. The patient is asked to identify odors (eg, soap, coffee, cloves) presented to each nostril while
the other nostril is occluded. Alcohol, ammonia, and other irritants, which test the nociceptive receptors of the 5th
(trigeminal) cranial nerve, are used only when malingering is suspected.
2nd Cranial nerve- Optic. Visual acuity or visual fields.
Visual Acuity:
Distant vision: w/ the Snellen and Rosenbaum charts, eye cover Ishihara test for color blindness.
 If the client can read use the Snellen and Rosenbaum charts
 if client wears glasses or contact lenses have the client wear them during test.
 Materials should be in client’s language
Test: Snellen chart is used to screen for myopia (impaired far vision). The client stands 20 feet from the Snellen
Chart. Evaluate both eyes and then each eye separately with and w/o correction, foe each eye cover the opposite eye.
Ask the client to read the smallest line of print visible. Note the number of that line. Rosenbaun Chart assess
presbyopia (impaired near vision) hold chart 14 inces from client’s face.
Near vission: w/ hand-held card.
Visual fields: evaluate by facing the client at a distance of 60 cm (2 ft.) the client covers 1 eye while you cover the
direct opposite eye (i.e. client’s right eye and your left eye) ask client to look at you and report when she/he can see
your finger coming in from 4 directions (up, down, temporally, nasally)
Cranial nerves 3rd (Oculomotor), 4th (Trochlear), and 6th (Abducens), assess EOMs to
determine coordination of the eye muscles, using 3 different tests:
1. Assess for parallel eye movement, the position of the upper lid and the presence of abnormal eye movements while
the client looks in each direction.
2. Test the corneal light reflex by directing a light onto the eyes and looking to see if the reflection is symmetric on the
corneas (5th Cranial nerve- Trigeminal)
3. Screen for strabismus with the cover/uncover test: cover 1 eye and ask the client to look in another direction.
Remove the cover and expect both eyes to be gazing in the same direction.
4. The 6 cardinal positions of gaze require the client to follow your finger w/ his eyes w/o moving his head. Move
your finger in a wide H pattern 20 – 25 cm from client’s eyes. Expected = smooth and symmetric eye movements w/o
jerky movements (nystagmus)
3rd Cranial nerve – Oculomotor Pupillary light reflex: direct and consensual.
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5th Cranial nerve- Trigeminal; assess the face for strength and sensation. the Sensory division: test light
touch by having the client close their eyes while you touch the face gently with a wisp of cotton, client should be able
to tell you where they feel the touch. Test the corneal light reflex by directing a light onto the eyes and looking to see
if the reflection is symmetric on the corneas. Motor division: test the strength of the muscle contraction by asking the
client to clench their teeth while you palpate the masseter and temporal muscles, and then the TMJ, joint movement
should be smooth. Ask the patient to open the mouth against resistance.
7th Cranial nerve – Facial: Assess the face for symmetrical movement. Sensory division: assess the anterior
2/3 of the tongue for taste – having the client close their eyes and identify foods you place on the tongue, i.e. sweet,
sour, salty, and bitter solutions applied with a cotton swab first on one side of the tongue, then on the other. Motor
division: test facial movement and symmetry by having the client smile, frown, puff out the cheeks, raise the
eyebrows, close their eyes tightly and show their teeth.
8th Cranial nerve – Auditory: assess the ears for hearing.
Auditory screening tests: Whisper Test = occlude one ear and test the other to see if the client can hear whispered
sounds w/o seeing your mouth move. Repeat w/ other ear. Rinne Test = place a vibrating tuning fork firmly against
mastoid bone, have the client state when he can no longer hear the sound. Note the length of time that the client heard
the sound (bone conduction) then move the tuning fork in front of ear canal, when the client cannot longer hear the
tuning fork sound, note the length of the time the sound was heard (air conduction). Air conduction sound longer than
bone conduction, ratio is 2:1. Weber Test = place a vibrating tuning fork on top of the client’s head. Ask whether the
client can hear the sound best in the Right ear, Left ear or both ears equally.
Vestibular function test: ask the client to walk across the room and back and assess the client’s gait; The client
should have upright posture and steady gait and able to maintain balance. Vestibular function can be evaluated by
testing for nystagmus.
9th Cranial nerve – Glossopharyngeal, and 10th Cranial nerve – Vagus: are usually evaluated
together. Motor division: Assess the mouth for movement of the soft palate and the gag reflex. Assess swallowing and
speech quality. Soft palate should appear symmetric and it should move with vocalization. Uvula should appear mid
line. The palate elevates symmetrically when the patient says "ah". If one side is paretic, the uvula is lifted away from
the paretic side. If the patient can swallow with ease and has no hoarseness when talking, cranial nerve X is intact.
Gag Reflex = elicit by using a tongue blade to stimulate the back of the throat.
CN IX sensory division: assess taste of posterior 1/3 of the tongue.
11th Cranial nerve – Spinal accessory: assess the head and shoulder for strength. For the
Sternocleidomastoid mm, the patient is asked to turn the head against resistance supplied by the examiner’s hand
while the examiner palpates the active muscle (opposite the turned head). For the upper trapezius mm, the patient is
asked to elevate the shoulders against resistance supplied by the examiner.
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12th Cranial nerve – hypoglossal: is evaluated by asking the patient to extend the tongue and inspecting it
for atrophy, fasciculations, and weakness (deviation is toward the side of a lesion). Have patient stick tongue out and
move it side to side. Also apply resistance against each cheek while client stick the tongue into the cheek.
Question 2. Know your Vital Signs Normal Ranges:
Vital signs for the average healthy adult while resting are:
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Blood pressure: 90/60 mm Hg to 120/80 mm Hg.
Breathing: 12 to 18 breaths per minute.
Pulse: 60 to 100 beats per minute.
Oral Temperature: 36 to 38 C (96.8 to 100.4 F)
Question 3. Know how to proper use cane, walker, crutches.
Assisting with Ambulation
1. *Provide privacy as needed,
2. *Introduce yourself to the client.
3. *Perform hand hygiene and put on appropriate PPE if indicated.
4. *Verify client identification.
5. *Determine whether the client has allergies.
6. *Provide client education.
7. Place the bed in the lowest position and lock the brake.
8. Instruct the client to report any dizziness, weakness, or shortness of breath.
9. Instruct the client to move to the side of the bed if they are able.
10. Have the client sit on the side of the bed, with feet dangling.
11. Assist the client with any footwear.
12. Place gait belt around client’s waist.
13. Assist the client to stand, using the gait belt and stand-assist device.
Ambulation with Cane
1. Instruct the client to hold the cane on their stronger side, close to the body.
2. Position yourself on the affected side and slightly behind the client.
3. Advise the client to advance the cane 6 to 10 inches, support their weight on the stronger leg and cane, and
then move the weaker leg forward parallel to cane.
4. With weight on their weaker leg and cane, tell the client to move their stronger leg forward, past the cane, to
complete the step (repeat)
Ambulation with Crutches
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Do not alter crutches after fitting.
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Follow the prescribed crutch gait.
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Support body weight at the hand grips w/ elbows flexed at 20 to 30 degrees.
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Hold the crutches in one hand and grasp the arm of the chair/ bed rail w/ the other hand for balance while
sitting or rising from a chair/bed. When pt is standing and stable have client place one crutch underneath each
arm.
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Tripod position is the basic crutch stance. Place the crutches 15 cm (6 in) in front of and 15 cm (6 in) to the
side of each foot to provide a wide base support..
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Crutch gait: client alternates weight from 1 leg to the other as well as on the crutches.
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The client should stand w/ straight back, hips, head and neck and should not place any weight on the axillae
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1. Ambulation with Crutches: After verifying appropriate crutch height for client, instruct the client to stand
erect, face forward, and hold the crutches 12 inches in front of and 12 inches to the side of each foot.
2. Four-point gait: Tell the client to move the right crutch forward 12 inches, followed by the left foot moving
to the level of the right crutch. The client will then move the left crutch 12 inches forward, followed by the
right foot moving to the level of the right crutch.
3. Three-point gait: Instruct the client to move the affected leg and both crutches forward 12 inches, then move
the stronger leg forward to the level of crutches.
4. Two-point gait: Instruct the client to move the left crutch and the right foot forward 12 inches, following by
moving the right crutch and left foot forward
Ambulation with a Walker
Instruct a patient using a walker to do the following:
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Wear nonskid shoes or slippers.
When rising from a seated position, use the chair arms for support if raising from bed client should place one
hand on the bed and one hand on the rails. Once standing, place one hand at a time on the walker and move
forward into it.
Caution the patient to avoid pushing the walker out too far in front and leaning over it. Patients should always
step into the walker, rather than walking behind it, staying upright as they move.
Never attempt to use a walker on stairs.
After the client stands, instruct the client to hold the hand-grips on the walker firmly.
Help the client to turn around slowly and instruct client how to properly walk with the walker.
Position yourself slightly behind the client on one side.
Instruct the client to move the walker forward 6 to 8 inches, setting it down with all four feet on the floor.
While supporting their weight on the walker, tell the client to move one foot forward, following with the
other foot.
6. Tell the client to move the walker forward, repeating the same step.
Sitting Down and Getting Up from a Chair?
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Sitting Down: the patient will back up to the chair/bed with the walker until they feel the chair/bed
with the back of their legs. The patient will then slightly extend the weak leg and bend the strong leg,
while feeling for the chair’s arm rests or the bed and the side rail with the hands. Once the arm rests of
the chair are felt, the patient will continue to bend the strong leg and sit down in the chair.
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Getting Up: the patient will place the walker in front of them while in the chair. Then the patient will
lean forward in the chair, keep the weak leg slightly extended out, and place hands are the arm rests of
the chair. Then the patient will push up with the hands on the arm rests of the chair and with the strong
leg. Once standing, the patient will firmly grip the hand grips of the walker and begin to ambulate with
the walker.
Question 4: Know how to instruct patient with diaphragmatic breathing before surgery.
DIAPHRAGMATIC BREATHING EXERCISE Diaphragmatic (abdominal) breathing exercises are taught to
the client who is at risk for developing pulmonary complications, such as atelectasis or pneumonia. Risk factors for
pulmonary complications include general anesthesia, abdominal or thoracic surgery, history of smoking, chronic lung
disease, obesity, and advanced age. In diaphragmatic breathing, the client inspires deeply while allowing the abdomen
to expand outward. On expiration, the abdomen contracts inward as air from the lungs is expelled.
1. Explain to the client that the diaphragm is a muscle that makes up the floor of the thoracic cavity and assists
in breathing. The purpose of diaphragmatic breathing is to promote lung expansion and ventilation and
enhance blood oxygenation.
2. Position the client in a high or semi-Fowler’s position (see figure below).
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3.
4.
5.
6.
Ask the client to place the hands lightly on the abdomen.
Instruct the client to breathe in deeply through the nose, allowing the chest and abdomen to expand.
Have the client hold the breath for a count of 5.
Tell the client to exhale completely through pursed (puckered) lips, allowing the chest and abdomen to
deflate.
7. Have the client repeat the exercise five times consecutively.
8. Encourage the client to perform diaphragmatic breathing exercises every 1 to 2 waking hours, depending on
the client’s needs and institutional protocol.
Question 5: Know the procedure in applying ice bag to reduce swelling and pain from ankle injury.
The ice bag is a dry cold application.
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Fill the bag with small pieces of ice to about two thirds full. This makes the bag lightweight. Using
ice chips, rather than cubes, makes it easier to mold the bag to the body part.
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Remove air from the ice bag in the same manner as removing air from a hot water bag.
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After securing the cap, test the ice bag for leaks and wipe off excess moisture.
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Place a cover on the ice bag to provide comfort and to absorb moisture that may accumulate on the
outside of the bag.
Nursing actions:
1. Apply to the area.
2. Make sure the call light is within reach, and instruct the client to report any discomfort.
3. Assess the site every 5 to 10 minutes to check for the following: 1. redness or pallor; 2. pain or burning; 3.
numbness; 4. shivering (with cold applications); 5. blisters; 6. decreased sensation; 7. mottling of the skin; 8.
cyanosis (with cold applications)
4. Apply an ice bag for 30 minutes, then remove it for about an hour before reapplying it. This technique
prevents the effects of prolonged exposure to cold.
Question 6. Know the procedure in instructions for the insertion of indwelling urinary catheter for female patient.
Inserting an Indwelling Catheter
1. Confirm prescription for indwelling catheter.
2. Gather all supplies needed for procedure.
3. *Introduce yourself to the client.
4. *Preform hand hygiene.
5. *Verify client identification.
6. *Provide privacy as needed.
7. *Explain procedure to the client.
8. *Determine whether the client has allergies.
9. Place equipment on a stable surface within reach (such as a bedside table).
10. Adjust the environment for convenience, ergonomics, and lighting.
11. Assist the client to a position that accounts for their physical limitations and performing the catheterization.
12. Apply clean gloves and perform perineal care.
13. Perform hand hygiene.
14. Use sterile technique to prepare equipment and apply sterile gloves.
15. Cleanse the meatus using sterile technique – FEMALE CLIENT
 Use non-dominant hand to separate the labia and expose the meatus.
 Cleanse the labia and urinary meatus with sterile antiseptic.
 Use only one cotton swab or cotton ball for each area cleansed.
16. Insert catheter. - FEMALE CLIENT
 With your dominant hand, slowly insert the catheter into the urethra. Advance the catheter until
urine appears in the drainage tube.
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Advance catheter approximately 2 inches after urine appears in the tubing.
17. Hold catheter securely with non-dominant hand, while inflating catheter balloon.
18. Gently pull back on the catheter until resistance is felt.
19. Secure catheter with securement device.
20. Secure collection device below the level of the bladder.
21. Perform perineal care.
22. Dispose of equipment per agency policy.
23. Perform hand hygiene.
24. *Ensure that the client is in a safe position prior to leaving the room and has the call light within reach.
Question 7: Know who is responsible for to explain to patient inform consents.
Informed consent is a legal process by which a client or the client’s legally appointed designee has given written
permission for a procedure or treatment. Consent is informed when a provider explains and the client understands:
1. the reason the client needs the treatment/ procedure. 2. how the treatment/ procedure will benefit the client. 3.
the risks involved. 4. other options. The Nurse’s role in the inform consent is to witness the client’s signature on the
inform consent and to ensure that the provider has obtained the informed consent responsibly.
Question 8: know the procedure how to administer cleansing enema.
Cleansing enema: the height of the bag above rectum determines the depth of cleansing. Clients should retains the
solution for 5 to 15 minutes.
Equipment:
 Gloves – Lubricant – absorbent, water prof pads – bedpan, bedside commode, or toilet – IV pole – enema bag
with tubing or prepacked enema – solutions and additives (see ATI book p. 248)
Procedure:
1. Perform hand hygiene.
2. Prepare and warm the enema solution (to prevent abdominal cramping)
3. Pour the solution into the enema bag, allow it to fill the tubing, and the close the clamp.
4. Provide privacy.
5. Provide quick access to commode or bedpan.
6. Place absorbent pads under client to protect bed linens.
7. Position the client on the left side with right leg flexed forward.
8. Put on gloves.
9. Lubricate the rectal tube or nozzle.
10. Slowly insert the rectal tube 7.5 to 10 cm (3 to 4 in). For a child, insert tube 5 to 7.5 (2 to 3 in)
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11. with the bag level with the client’s hip, open the clamp.
12. Raise the bag 30 to 45 cm (12 to18 in) above the anus, depending on the level of cleansing desired.
13. Slow the flow of the solution by lowering the container if the client reports cramping, or fluid leaks around
the tube at the anus.
14. If using prepackaged solution, insert the lubricated tip into the rectum, and squeezed the container to instill all
of the solution.
15. Ask the client to retain the solution for the prescribed amount of time, or until the client is no longer able to
retain it.
16. Discard the enema bag and tubing.
17. Assist the client to appropriate position to defecate.
18. Remove gloves.
19. Perform hand hygiene.
20. For clients that have little or no sphincter control administer enema on a bedpan.
21. Document the results and client’s tolerance of the procedure.
Question 9: Know what an occupational therapist is and what they do for patients.
Occupational therapists: assesses and plans for clients to regain activities of daily living (ADL) skills, especially
motor skills of the upper extremities.
Occupational Therapist: evaluate the patient’s functional level and teaching activities to promote self-care in
activities of daily living. They assess the home for safety and provide adaptive equipment as necessary.
Question 10: Know what is Respite care, Palliative care and Hospice care.
Respite care is a type of care provided for caregivers of home-bound ill, disabled, or older adults. The main
purpose is to give the primary caregiver some time away from the responsibilities of day-to-day care. Professionals
or volunteers may provide care in an adult daycare center or in the patient’s home. In most instances, the care is
provided by qualified nursing assistants or volunteers. Professional nurses provide information about how to access
respite care and may make referrals. Medicaid and most insurance providers do not cover the costs of respite care.
Palliative care evolved from the hospice experience but also exists outside of hospice programs. It is not restricted to
the end of life and can be used from the point of initial diagnosis. Palliative care, which may be given in conjunction
with medical treatment and in all types of health care settings, is patient- and family-centered care that optimizes the
quality of life by anticipating, preventing, and treating suffering.
 The nurse serve as an advocate for the client’s sense of dignity and self esteem.
 Goal is to learn to live fully with an incurable condition.
 Palliative care improve the quality of life of clients and their families facing end-of-life issues.
 Palliative care interventions are primarily used when caring for clients who are dying and family members
who are grieving; but can be used for any client who has a chronic condition.
 Palliative care interventions focus on the relief of physical manifestations as well as addressing spiritual,
emotional, and psycho social aspects of the client’s life.
Hospice care: is a comprehensive care delivered in a variety of settings, and can be implemented when a client is
not expected to live longer than 6 months. Further medical care aimed toward a cure is stopped, and the focus
becomes enhancing quality of life and supporting the client toward a peaceful and dignified death.
Hospice: is a program of palliative and supportive care services providing physical, psychological, social, and
spiritual care for dying people, their families, and other loved ones. The interdisciplinary hospice team:
 Manages the patient’s pain and symptoms
 Assists the patient with emotional, psycho-social, and spiritual aspects of dying
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Provides needed drugs, medical supplies, and equipment
Instructs the family on how to care for the patient
Delivers special services like speech and physical therapy when needed
Makes short-term inpatient care available when pain or symptoms become too difficult to treat at home, or
the caregiver needs respite
Provides bereavement care and counseling to surviving family and friends.
Question 11: Know what is the TMJ, its S&S and whom take care of this problem in the medical field.
Signs and symptoms of TMJ disorders may include:
 Pain or tenderness of your jaw
 Pain in one or both of the temporo-mandibular joints
 Aching pain in and around your ear
 Difficulty chewing or pain while chewing
 Aching facial pain
 Locking of the joint, making it difficult to open or close your mouth
 Painful clicking, popping or grating in the jaw joint when opening or closing the mouth
Who treats TMJ syndrome:
1. Oral and maxillo facial specialist (OMFS)**
2. ENT specialist
3. Prosthetic dentist (dentist specialized in TMJ)
Question 12: Know about delegation and TAPE as discuss in class.
Delegation is the process of transferring the performance of a task to another member of the healthcare team while
retaining accountability for the outcome.
A licensed nurse is responsible for providing clear directions when delegating a task initially and for periodic
reassessment and evaluation of the outcome of the task.
 RN can delegate to other RNs, PNs, and AP.
 RN must be knowledgeable about their state’s nurse practice act and regulations that guide the use of PN and
AP.
 RN must delegate tasks so that they can complete higher-level tasks that only RN can perform.
 RN can only delegate tasks appropriate for the skill and education level of the individual who is receiving the
assignment (delegatee).
 RN cannot delegate nursing process, client education or tasks that require nursing judgment: TAPE –
Teaching, Assessment, Planning, Evaluation
The Five Rights of Delegation
1. Right task
2. Right circumstance
3. Right person.
4. Right direction and communication.
5. Right supervision and evaluation.
Question 13: Know what EHR= medical record is, and its purpose as a Health Record Documentation.
Electronic Health Records (EHR) are replacing manual formats in many settings. The goal of the EHR is to
enable the interdisciplinary team caring for the patient to more easily view the patient’s risks, health
promotion possibilities, and actual long-term care problems.
*Electronic health record (EHR): The EHR is the patient care record created when facilities under different
ownership share their data. The goal is for this sharing to be nationwide, creating a situation in which a person’s
health care record is accessible by designated health care providers anywhere in the nation. The patient will decide
which portions of a record will be available to whom.
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Advantages include standardization, accuracy, confidentiality, easy access for multiple users, providing ease
in maintaining ongoing health record of the client’s condition, and rapid acquisition and transfer of client’s
information.
Challenges include learning the system, knowing how to correct errors, and maintaining security.
Documentation rules and formats are similar to those for paper charting.
Question 14: Know what to do with a medication you need to administer and falls to the floor.
 Discard medication appropriately in a container from where medication can not be retrieve; do not leave
medication on the floor or is clients room.
 Call for a fellow nurse or a nurse manager to witness medication being discarded.
 Take special care discarding controlled substances.
Question 15: Know the type of room assignment for patients with TB and precautions you need to use.
Standard precautions (tier one):
 Hand hygiene (ATI book p. 55).
 masks, eye protection, and face-shields required when care might cause splashing or spraying of bodily
fluids.
 Clean gloves are worn when touching anything that has the potential to contaminate the hands of the nurse.
 Hand hygiene is required after removal of the gown; bag soiled items and tie the bag at the top.
 Properly clean all equipment for client care; dispose of one-time use items according to facility policy.
 Bag and handle contaminated laundry to prevent leaking or contamination of clothing or skin.
 Enable safety devices on all equipment and supplies after use; dispose of all sharps in a puncture-resistant
container,
 Client does not need private room unless they are unable to maintain appropriate hygienic practices.
Transmission precautions (tier two):
 Airborne precautions: to protect against droplet infections smaller than 5 mcg (Measles, Varicella,
pulmonary/laryngeal Tuberculosis).
 Private room.
 Masks and respiratory protection devices for caregivers and visitors – use an N95 or high efficiency
particulate air (HEPA) respirator for TB.
 Negative pressure airflow exchange in the room of at least 6 to 12 exchanges per hour.
 If splashing or spraying is a possibility wear full face protection (eyes, nose mouth).
 Client should wear a mask while outside of the room or home.
Question 16: Know what to do in preventing the transmission of a patients infection.
A nurse uses infection control practices (medical asepsis, surgical asepsis, standard precautions) to break the chain
and thus stop the spread of infection.
Medical asepsis – refers to the use of precise practices to reduce the number, growth and spread of micro-organisms
(“clean technique”). It applies to administering oral medication, managing nasogastric tubes, providing personal
hygiene, and performing other nursing tasks.
 Hand hygiene; Protective clothing; Physical environment.
Practicing Basic Principles of Medical Asepsis in Patient Care:
 Practice good hand hygiene.
 Carry soiled linens or other used articles/equipment so that they do not touch your clothing.
 Do not place soiled bed linen or any other items on the floor, which is grossly contaminated. It increases
contamination of both surfaces.
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Avoid allowing patients to cough, sneeze, or breathe directly on others. Provide them with disposable tissues,
and instruct them to cover their mouth and nose to prevent spread by airborne droplets.
Move equipment away from you when brushing, dusting, or scrubbing articles. This helps prevent
contaminated particles from settling on the hair, face, and clothing.
Avoid raising dust. Use a specially treated cloth or a dampened cloth. Do not shake linens. Dust and lint
particles constitute a vehicle by which organisms may be transported from one area to another.
Clean the least soiled areas first and then the more soiled ones. This helps prevent having the cleaner areas
soiled by the dirtier areas.
Dispose of soiled or used items directly into appropriate containers. Wrap items that are moist from body
discharge or drainage in waterproof containers, such as plastic bags, before discarding into the refuse holder
so that handlers will not come in contact with them.
Pour liquids that are to be discarded, such as bath water or mouth rinse, directly into the drain to avoid
splattering in the sink and onto you.
Sterilize equipment suspected of containing pathogens.
Use practices of personal grooming that help prevent spreading microorganisms. Examples include
shampooing the hair regularly, keeping hair short or pinned up to limit the possibility of carrying
microorganisms on hair shafts, keeping fingernails short and free of broken cuticles and ragged nail edges,
and avoiding wearing rings with grooves and stones that may harbor microorganisms.
Follow guidelines conscientiously for standard and transmission-based precautions as prescribed by your
facility.
Surgical asepsis – refers to the use of precise practices to eliminate all micro-organisms from an object or area and
prevent contamination (“sterile technique”). It applies to parenteral medication administration, insertion of urinary
catheter, surgical procedures, sterile dressing changes, and other common nursing procedures.
Preparing a Sterile Field:
1. Gather necessary supplies.
2. Perform hand hygiene.
3. Open the sterile drape by removing the outer wrapping.
4. Place sterile kit or tray in the center of the work surface.
5. Open the flap farthest from the body by reaching around the sterile area.
6. Open the side flaps, then the flap closest to the body.
7. Using fingertips, pick up the sterile drape, touching only the 1-inch margin. Lay the drape on the work
surface with the fluid-resistant side facing down.
ADDING STERILE ITEMS TO THE FIELD
1. Open the sterile item without touching the inside of the packaging or the sterile item.
2. Drop the item gently into the center of the sterile field from a height of 6 inches.
3. Do not touch the sterile field.
4. Dispose of the wrapper in the appropriate waste container.
Standard precautions – applies to all body fluids (except sweat), non-intact skin, and mucous membrane. A nurse
should implement standard precautions for all clients.
Standard precautions (tier one):
 Hand hygiene (ATI book p. 55).
 masks, eye protection, and face-shields required when care might cause splashing or spraying of bodily
fluids.
 Clean gloves are worn when touching anything that has the potential to contaminate the hands of the nurse.
 Hand hygiene is required after removal of the gown; bag soiled items and tie the bag at the top.
 Properly clean all equipment for client care; dispose of one-time use items according to facility policy.
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


Bag and handle contaminated laundry to prevent leaking or contamination of clothing or skin.
Enable safety devices on all equipment and supplies after use; dispose of all sharps in a puncture-resistant
container,
Client does not need private room unless they are unable to maintain appropriate hygienic practices.
Question 17: Know the values of CBC and what they are for? Such as recognizing a patient may have an
infection.
 Elevated white blood cell (leukocyte) count—normal value is 5,000 to 10,000/mm3
 Increase in specific types of white blood cells—referred to as a differential or differential count (percentage of each
cell type)
Normal =
Increased in acute infections that produce pus; increased risk for acute bacterial
Neutrophils
60–70%
infection if decreased; may also be increased in response to stress
Lymphocytes
Monocytes
Eosinophil
Basophil
Normal =
20–40%
Normal =
2–8%
Normal =
1–4%
Normal =
0.5–1%
Increased in chronic bacterial and viral infections
Increased in severe infections: function as a scavenger or phagocyte
May be increased in allergic reaction and parasitic infection
Usually unaffected by infections
•Elevated erythrocyte sedimentation rate—red blood cells settle more rapidly to the bottom of a tube of whole blood
when inflammation is present.
•Presence of pathogen in cultures of urine, blood, sputum, or other (wound) drainage
Question 18: Know which action the nurse takes with an occult test specimen = guaiac test.
Fecal occult blood (guaiac) test: Obtain a fecal sample using medical asepsis while wearing gloves. Collect stool
specimes for serial guaiac testing, 3 times from 3 different defecations. Some foods (red meat, citrus fruit, raw
vegetables) and medications can cause false positives.
Equipment:
 Specimen containers.
 Soap/cleansing solution or wipe.
 Clean gloves.
 Specimen label.
 Fecal occult blood test cards.
 Wooden applicator or tongue depressor.
 Developer solution.
 Stool collection container (bedside commode, bedpan, receptacle in toilet)
Procedure:
1. Explain the procedure.
2. Ask the client to collect a specimen in the toilet receptacle, bedpan or bedside commode.
3. Don gloves
4. With a wooden applicator, place small amounts of stool on the windows of the test card or as directed.
5. Follow facility procedures for handling; apply label to the cards and send them to lab; or place a couple of
drops of developer on the opposite side of the card. Blue color indicates (+) for blood.
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6. Remove gloves and perform hand hygiene.
Question 19: Know what is the meaning of HIPAA and its purpose.
HIPAA – Health Insurance Portability and Accountability Act. It helps ensure the confidentiality of health
information. A major component of HIPAA, the Privacy Rule, promotes the use of standard methods of maintaining
the privacy of protected health information (PHI) among healthcare agencies.
Question 20: Know everything about wrist restraints, indications for placing patient on restraints and how to
assess hands w/ restraints.
 Nurses must know and follow federal, state, and facility policies for the use of restraints.
 Use the restraints for the shortest duration necessary and only if less restrictive measures are not sufficient.
They are for the physical protection of the client or other clients and staff.
 Restraints can cause complications, including pneumonia, incontinence, and pressure injuries.
 It is inappropriate to use restraints for: 1. convenience of the staff; 2. punishment for the client; 3. clients who
are extremely physically or mentally unstable.
 Restraints should: 1. never interfere w/ treatment; 2. restrict movement as little as is necessary. 3. fit properly
and be as discreet as possible; 4. be easy to remove or change.
 When all other less restrictive means have failed to prevent a client from harming themselves or others, the
following must occur before using restrains – the provider must prescribe restraints in writing, after face to
face assessment of the client.
 * in an emergency situation when there is immediate risk to the client or others, nurses can place
restraints on a client; nurse must obtain a prescription from the provider asap, within 1 hour!*
 The prescription must include: reason for the restraints, location of restraints, how long to use the
restraints, and the type of behavior that warrants using the restraints.
 Prescription allows only for 4 hrs of restraints for adult, 2hrs for clients 9 to 17 y/o; and 1 hr. for clients
younger that 9 y/o. Providers can renew prescriptions for a maximum of 24 consecutive hours.
 Providers cannot write PRN prescriptions for restraints.
Nursing responsibilities for clients in restraints:
1. Explain the need for restraints to client and family, emphasizing that the restraints keep client safe and are
temporary.
2. Ask client or guardian to sign consent form.
3. Review manufacture’s instructions for correct applications.
4. Asses skin integrity, and provide skin care according to facility’s protocol, usually q12 hrs.
5. Offer food and fluid.
6. Provide means for hygiene and elimination.
7. Monitor vital signs.
8. Offer range of motion exercises of extremities.
9. Pad bony prominences to prevent skin breakdown.
10. Secure restraints to a movable part of the bed frame. If restraints with buckle strap are not available use a
quick release knot.
11. Make sure restraints are loose enough for range of motion and that there is enough room to fit 2 fingers
between restraint and client.
12. Remove or replace restraints frequently to ensure good circulation to the area and allow for full range of
motion to the limbs.
13. Conduct ongoing evaluation of the client.
14. Regularly determine the need to continue using restraints.
15. Never leave the client alone w/o restraints.
16. Check facility policy regarding types of restraints.
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Question 21: What is Battery, Assault, Invasion of privacy, Malpractice, Negligence, and False Imprisonment.
Battery: Intentional and wrongful physical contact with a person that involves an injury or offensive contact.
Assault: the conduct of one person makes another person fearful and apprehensive (threat).
False imprisonment: a person is confined or restraint against their will.
Invasion of privacy: the right against invasion of privacy as a constitutional right. State courts have also
strongly protected a patient’s right to have information kept confidential. All information about patients is
considered private or confidential, whether written on paper, saved on a computer, or spoken aloud.
Protecting the privacy and confidentiality of health care records is the duty of every nurse.
Malpractice: (professional negligence) is the failure of a person who has professional training to act in a reasonable
and prudent manner.
Negligence: performing an act that a reasonably prudent person under similar circumstances would not do, or failing
to perform an act that a reasonably prudent person under similar circumstances would do.
Question 22: Know how to provide oral care on an unconscious client who is immobile.
The implementation of oral care for a dependent patient may be delegated to nursing assistive personnel (NAP) or to
unlicensed assistive personnel (UAP) after assessment by the registered nurse, as well as to licensed
practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient’s
needs and circumstances, as well as the qualifications of the person to whom the task is being delegated.
Equipment:


Suction toothbrush or soft toothbrush
Suction swab


Suction catheter with suction apparatus
Toothpaste or other oral cleanser


Emesis basin
Glass with cool water


Disposable gloves
Additional PPE, as indicated


Towel
Mouth rinse (optional)


Dental floss in holder or other inter-dental cleaner
Mouth prop or second toothbrush


Denture-cleaning equipment (if necessary)
Denture cup


Denture cleaner
4 × 4 gauze


Washcloth or paper towel
Lip lubricant (optional)


Oral health assessment tool
Additional care giver, as indicated
Procedure:
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient. Explain the procedure to the patient.
3. Assemble equipment on over-bed table or other surface within reach.
4. Close the room door or curtains. Place the bed at an appropriate and comfortable working height, usually elbow
height of the caregiver. Lower one side rail and position the patient on the side, with head tilted forward. Place towel
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across the patient’s chest and emesis basin in position under chin. Depending on equipment in use, connect the suction
toothbrush or suction catheter to suction tubing and turn on suction. Put on gloves.
5. Gently open the patient’s mouth by applying pressure to the lower jaw at the front of the mouth. Do not use fingers
to hold the patient’s mouth open. Use another toothbrush or mouth prop to keep the mouth open. Remove dentures, if
present.
6. If using a regular toothbrush and suction catheter, one care giver provides oral cleaning and the other removes
secretions with the suction catheter.
7. Brush the teeth and gums carefully with toothbrush and paste or other oral cleanser. Lightly brush the tongue.
8. Moisten toothbrush with water to rinse the oral cavity. Position patient’s head to allow for return of water. If using
regular toothbrush, use suction catheter to remove the water and cleanser from oral cavity.
9. Using the suction swab, apply a therapeutic antiseptic mouth rinse as indicated. Apply oral moisturizer as indicated.
10. Clean the dentures before replacing.
11. Apply lubricant to patient’s lips.
12. Remove equipment and return patient to a position of comfort. Remove gloves. Raise side rail and lower bed.
13. Remove additional PPE, if used. Perform hand hygiene.
Question 23: Know the difference of hand hygiene with alcohol disinfectant & hand washing with soap, also timeframe for each.
Hand Hygiene: is the primary behavior for asepsis. Wash hands with antimicrobial or plain soap and water, or using
alcohol -based products.
 All healthcare personnel must perform hand hygiene, either with alcohol-based product or w/ soap and water
before and after every client contact, and after removing gloves.
 When hands are visibly soiled, after contact w/ body fluids, before eating and after using the bathroom, wash
them with non-antimicrobial or antimicrobial soap and water. Also soap and water recommended for C.
difficile & spores.
 Perform hand hygiene using recommended antiseptic solutions when caring for clients that are immunocompromised or have infections with multi-drug resistant organisms (MDRO) or extremely virulent microorganisms.
 Perform hand hygiene after contact with anything in clients’ rooms and after touching any contaminated
items, whether or not gloves were worn, and before putting gloves on and after taking them off.
 Performing hand hygiene might be necessary between tasks and procedures on the same client to prevent
cross-contamination of different body sites.
 Wash hands with soap and warm water. Rub hands together vigorously, and rinse under running water. Wash
for at least 15 seconds to remove transient flora and up to 2 minutes when hands are more soiled. After
washing dry hands with clean paper towel before turning off faucet. If sink does not have foot/ knee pedal for
turning off water used a clean, dry paper towel to turn off faucet.
 For hand hygiene with alcohol-base product, dispense the recommended amount (usually 3 to 5 ml) in the
palm of the hand. Rub hands together vigorously covering all the surfaces of both hands and fingers.
Continue to rub until hands are completely dry.
Question 24: Know how to instruct and assist with using a cane properly.
 The cane should fit so that when the patient stands with the cane’s tip 4 in (10 cm) to the side of the foot, the
cane extends from the floor to the crease in the patient’s wrist.
 The elbow should be flexed 15 degrees when holding the cane.
 Rubber tips on the cane prevent slipping and accidents. Inspect these regularly to ensure that they are intact.
 Teach patients to stand erect when walking with a cane and not to lean out over the cane.
 When walking with a cane, instruct patients to hold the cane in the hand opposite to the side that needs
support.
 If the cane is used for stability, the patient may hold it in either hand.
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Cane:
To stand up put one hand on the cane – the cane should be on the unaffected side – and the other on the side rail of the
bed and push up into a standing position, both feet should be flat on the floor
1. Maintain 2 points of support on the ground at all times.
2. Keep the cane on the stronger side of the body.
3. Support body weight on both legs.
4. Move cane forward 15 to 25 cm (6 to 10 in)
5. Next, move the weaker leg forward toward the cane, place it even with the cane.
6. Finally, advance the stronger leg past the cane. (repeat process: steps 4, 5. 6)
Question 25: Know how to transfer a patient from the bed to wheelchair properly.
Transferring a Patient From the Bed to a Chair
EQUIPMENT


Chair or wheelchair
Gait belt


Stand-assist aid, if available
Additional staff person to assist


Blanket to cover the patient in the chair
Non-sterile gloves and/or other PPE, as indicated
Procedure
1. Review the medical record and nursing care plan for conditions that may influence the patient’s ability to move or
to be positioned. Assess for tubes, IV lines, incisions, or equipment that may alter the positioning procedure. Identify
any movement limitations. Consult patient handling algorithm, if available, to plan appropriate approach to moving
the patient.
2. Perform hand hygiene and put on PPE, as indicated.
3. Identify the patient. Explain the procedure to the patient.
4. If needed, move equipment to make room for the chair. Close the curtains around the bed and close the door to the
room, if possible.
5. Place the bed in the lowest position. Raise the head of the bed to a sitting position or as high as the patient can
tolerate.
6.Make sure the bed brakes are locked. Put the chair next to the bed. If available, lock the brakes of the chair.
If the chair does not have brakes, brace the chair against a secure object.
7. Encourage the patient to make use of a stand-assist aid, either freestanding or attached to the side of the bed, if
available, to move to the side of the bed and to a side-lying position, facing the side of the bed on which the patient
will sit.
8. Lower the side rail, if necessary, and stand near the patient’s hips. Stand with your legs shoulder width apart with
one foot near the head of the bed, slightly in front of the other foot.
9. Encourage the patient to make use of the stand-assist device. Assist the patient to sit up on the side of the bed; ask
the patient to swing his or her legs over the side of the bed. At the same time, pivot on your back leg to lift the
patient’s trunk and shoulders. Keep your back straight; avoid twisting.
10.Stand in front of the patient and assess for any balance problems or complaints of dizziness. Allow the
patient’s legs to dangle a few minutes before continuing.
11. Assist the patient to put on a robe, as necessary, and nonskid footwear.
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12. Wrap the gait belt around the patient’s waist, based on assessed need and facility policy.
13. Stand facing the patient. Spread your feet about shoulder width apart and flex your hips and knees.
14. Ask the patient to slide his or her buttocks to the edge of the bed until the feet touch the floor. Position yourself as
close as possible to the patient, with your foot positioned on the outside of the patient’s foot. If a second staff person is
assisting, have him or her assume a similar position. Grasp the gait belt.
15. Encourage the patient to make use of the stand-assist device. If necessary, have second staff person grasp the gait
belt on opposite side. Rock back and forth while counting to three. On the count of three, using the gait belt and
your legs (not your back), assist the patient to a standing position. If indicated, brace your front knee against the
patient’s weak extremity as he or she stands. Assess the patient’s balance and leg strength. If the patient is weak or
unsteady, return the patient to bed.
16. Pivot on your back foot and assist the patient to turn until the patient feels the chair against his or her legs.
17. Ask the patient to use his arm to steady himself on the arm of the chair while slowly lowering to a sitting position.
Continue to brace the patient’s knees with your knees and hold the gait belt. Flex your hips and knees when helping
the patient sit in the chair
18. Assess the patient’s alignment in the chair. Remove gait belt, if desired. Depending on patient comfort, it could be
left in place to use when returning to bed. Cover with a blanket, if needed. Make sure call bell and other essential
items are within easy reach.
19. Clean transfer aids, per facility policy, if not indicated for single patient use. Remove gloves and any other PPE, if
used. Perform hand hygiene.
Question 26: Know what is subjective and objective data.
Subjective data: information perceived only by the affected person; these data cannot be perceived or verified by
another person.
Objective data: information perceptible to the senses; may be verified by another person. Objective data are
observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them.
Question 27: Know how to assess a dark skin patient with cyanosis.
Cyanosis: bluish discoloration for light skin tones in general, and on the palm and soles for darker skin tones; for
brown skin tones, a change to yellow-brown; for darker skin tones, black pigmented skin turn grayish.
Location: nail beds, lips, mouth mucosa, skin, palms.
Indication: Hypoxia or impaired venous return.
Question 28: What phase of the nursing process will a nurse ask for the client’s allergy?
During the Assessment /Data Collection – Assessment is the first step in the nursing process and always involves
gathering data. Data can be obtained from the patient, family, or other sources as well as from the physical
examination.
Purpose: Make a judgment about the patient’s health status, ability to manage his or her own health care, and need for
nursing. Plan individualized holistic care that draws on patient strengths and is responsive to changes in the patient’s
conditions.
Activities:
1. Establish the database:
 Nursing history
 Physical assessment
 Review of patient record and nursing literature
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 Consultation with the patient’s support people and health care professionals
2. Continuously update the database.
3. Validate data.
4. Communicate data.
Question 29: Know what is an AE hose and how to properly measure for a proper fit.
Anti-embolism stockings: provide continues pressure to the lower extremities to keep blood from pooling, and blood
clots from developing in the deep veins of the lower extremities. It cause external pressure on the muscles of the lower
extremities to promote blood return to the heart.
Measure the circumference of the patient’s legs at various points to determine the proper size of stocking. Each leg
should have a correct fitting stocking; if measurements are different, then two different sizes of stocking need to be
ordered to ensure correct fitting on each leg. The manufacturer whose stockings are being used gives directions for
measuring. Some stockings fit either leg; others are designated right or left. An improperly fitting stocking is
uncomfortable and ineffective and possibly even harmful.
Equipment: tape measure.
Procedure:
1. Perform hand hygiene.
2. Assess skin, circulation, and presence of edema in the legs.
3. Measure the calf and/or thigh circumference and the length of the leg from the base of the heel to the buttocks
fold to select the correct size stocking.
Question 30: Know the nurse’s action during active listening.
Active listening – show the client that they have your undivided attention. It helps the nurse to develop trust.
Use active listening phrases (“Go on” and “Tell me more”) to convey interest and to prompt disclosure of the entire
story. Maintain eye contact.
Active listening helps the nurse hear, observe and understand what the client communicates and provide feedback.
Question 31: What is Xerostomia, Halitosis, Bruxism.



Xerostomia – reduced salivation; alters appetite.
Halitosis – offensive breath, is often systemic in nature. A mouthwash cannot remove halitosis when odors
are being eliminated by respiration. If the cause of halitosis is poor oral hygiene, cleaning reduces the odor.
Bruxism is a condition in which you grind, gnash or clench your teeth. If you have bruxism, you may
unconsciously clench your teeth when you're awake (awake bruxism) or clench or grind them during sleep
(sleep bruxism). Sleep bruxism is considered a sleep-related movement disorder.
Question 32: Know the urine output of the client must be greater that 30 ml/hr.


Adults 1000 to 2000 ml/day
Less than 30 ml/hr, for more that 2 hours is a cause of concern
Question 33: Know that bearing down while client is a defecating can cause vagal response and display
dysrhythmias.
When a person bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in
decreased blood flow to the atria and ventricles, thus temporarily lowering cardiac output. Once bearing down
ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart. This act may cause
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the heart rate to slow and result in syncope in some patients. Therefore, this technique of bearing down, termed the
Valsalva maneuver, may be contraindicated in people with cardiovascular problems and other illnesses.
Question 34: know the type of O2 concentration via nasal canula, venti mask, and non-rebreather mask.



Nasal Canula: delivers oxygen concentration of 24 to 44 % with flow rates from 1 to 6 L/min.
Venti-mask: delivers oxygen concentration of 24 to 50% with flow rates of 4 to 10 L/min.
Non-rebreather mask: delivers oxygen concentration of 80 to 95% with flow rates 10 to 15 L/min.
Question 35: Know what to do with a client that you are assessing in ambulation and it begins to fall.
If a client that you are either assessing or walking begin to fall, it is important to protect both yourself and the client
from injury. Instead of trying to hold the client up or catch them, help ease them gently to the floor, and go down
with the client.
You can do this safely by placing your arms on the gait belt or around the clients waist and then placing a leg forward
allowing them to use it for support as you ease them to the floor. To help prevent injury to your lower back bend at the
knees, as you help the client to the floor.
Question 36: Know what entails patient confidentiality.
Confidentiality: protection of privacy without diminishing access to high-quality care.
 Patients have a moral and legal right to expect that the information contained in their patient health record
will be kept private.
 The confidentiality with which patient information is to be treated should be established with the patient.
Indicate with whom the information that the patient gives will be shared. The patient should know about the
right to specify who might have access to the information. Failure to consider this factor can be considered a
breach of the patient’s right to privacy.
 All information about patients is considered private or confidential, whether written on paper, saved on a
computer, or spoken aloud. This includes patient names and all identifiers such as address, telephone and fax
number, Social Security number, and any other personal information. It also includes the reason the patient is
sick or in the hospital, office, or clinic, the assessments and treatments the patient receives, and information
about past health conditions. Protected health information might be found in the patient medical record,
computer systems, telephone calls, voice mails, fax transmissions, e-mails that contain patient information,
and conversations about patients among clinical staff.
Question 37: Know proper techniques used to prevent pressure injuries on a bed-bound clients.
Avoid skin trauma.
 Keep skin clean, dry and intact. Provide firm wrinkle free foundation.
 Reposition client in bed at least every 2 hr; in chair every 1 hr – and document.
 Keep head of the bed at or below 30 degrees angle unless contraindicated – relieves pressure on sacrum,
bottoms, and heels.
 Raise heels of the bed
 Ambulate client as soon and as often as possible.
 Instruct clients that are mobile to shift weight every 15 min when sitting.
 Keep clients from sliding down in bed. Lift rather than pull, clients up in bed or chair.
Provide supportive devices.
 Use pressure-reducing surfaces and devices (over lays, air mattresses, specialty beds, etc…)
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Maintain skin hygiene.
 Inspect skin frequently and document client’s risk using Branden scale.
 Clean skin w/ gentle non-ionic surfactant and pat dry immediately following urine / stool incontinence.
 Bathe with tepid water and avoid scrubbing.
 Apply dimethicone-based moisture barrier creams to the skin of incontinent clients.
 Do not use powder to prevent friction or repel moisture, due to their abrasive grit.
 Implement active and passive exercises for clients who are immobile.
 Do not massage bony prominence.
Encourage proper nutrition.
 Provide adequate hydration and meet protein and caloric needs.
 Note if blood albumin levels are low (less than 3.5 g/dL)
 Provide nutritional support as indicated (vitamins, mineral supplements, enteral or parenteral nutrition)
Monitor lymphocyte count.
Question 38: know the proper way to take vital signs.
Vital signs – measurements of the body’s most basic functions.
Temperature: normal range 36 to 38 C (96.8 to 100.4 F)
 Perform hand hygiene, provide privacy and apply clean gloves.
 Oral Temp – gently place the oral probe w/ cover under the tongue in the posterior sublingual pocket lateral;
leave it until reading is complete. For clients who are 4 years of age and older.
 Rectal Temp. - (more accurate) assist client to Sims position w/ upper leg flexed. Wearing gloves expose the
anal area. Spread buttocks to expose anal opening, ask client to breathe slowly and relax. Insert rectal probe
w/ cover and lubrication 2.5 ti 3.5 cm (1 to 1.5 in). Hold thermometer until reading is complete. Clean anal
area. Not recommended for infants younger than 3 months old.
 Axillary Temp – place the probe w/ cover in the center of the client’s clean, dry axilla, lower arm over the
probe. Hold arm down until reading is complete.
 Tympanic temp – pull ear up and back (for an adult) or down and back (for child younger than 3 y/o) place
probe w/ cover snugly into outer ear canal and press scan button. Leave it in place until reading is complete.
Carefully remove thermometer and read temperature. Not recommended for infants 3 months old and
younger.
 Temporal Temp Pulse: 60 to 100 /min.
 Perform hand hygiene, provide privacy.
 Locate Radial pulse; on the radial side of the forearm at the wrist: place index and middle fingers gently but
firmly over the pulse.
 Assess for rate, rhythm, amplitude and quality. If regular count for 30 sec and multiply by 2; in irregular
count the whole minute and compare to apical pulse.
 Measure temporal, carotid, brachial, femoral, popliteal, posterior tibial or dorsal pedal using same technique.
 Locate apical pulse in 5th intercostal space at the left mid-clavicular line; place the diaphragm of the
stethoscope, follow same technique.
 Pulse deficit = difference between apical pulse and radial pulse; is the number of ineffective cardiac
contractions in 1 min.
Respiration: 12 to 20 /min.
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




Perform hand hygiene, provide privacy.
Place client in semi-Fowler's position, make sure chest is visible;
have client rest arm across abdomen, or pl ace hand directly on client’s abdomen.
Observe one full respiratory cycle, look at timer and start counting.
If regular count for 30 sec and multiply by 2; if irregular count the whole minute.
Pulse oximetry: non invasive measurement of the oxygen saturation of the blood.
 Can be measured on client’s finger (digital probe); on the earlobe (earlobe probe), or bridge of the nose.
Blood pressure: normal SBP less than 120, DBP less than 80.
The Client should:
 Not use nicotine or drink caffeine for 30 min prior.
 Rest for 5 min before measurement.
 Sit in a chair w/ feet flat on the floor, back ans arm supported and arm at heart level.
The nurse should:
 Use auscultatory method w/ properly calibrated equipment.
 Not measure BP in an arm with IV infusion in progress, or on the side where client had a mastectomy or an
av shunt or fistula.
 Average 2 or more reading taken 2 minutes apart.
 After initial reading measure client’s pulse and BP with client standing.
Procedure:
 Perform hand hygiene, provide privacy.
 Measure BP in both arms, use the arm w/ higher reading for future assessments.
 Apply BP cuff 2.5 cm (1 in) above antecubital space w/ brachial artery in line w/ marking on the cuff.
 Estimate SBP by palpating radial pulse and inflating the cuff until pulse disappears, inflate another 30 mmHg,
and slowly release pressure to note when pulse is palpable again (estimated systolic pressure)
 deflate cuff and wait 1 min.
 position stethoscope over brachial artery and inflate the cuff to 30 mmHg above the palpated systolic
pressure.
 Release pressure not faster than 2 to 3 mmHg per sec, the level at which you hear the first sound id the SBP.
 Continue to deflate the cuff until sounds muffled and disappear – DBP.
 Record SBP over DBP.
 Deflate cuff completely between attempts, wait a full minute before measuring BP again.
Question 39: know the proper body mechanics when lifting boxes.
 Use major muscle groups to prevent back strain, tighten abdominal muscle to increase support to the back
muscles.
 Distribute your weight between the arms and legs large muscles to decrease the strain on one muscle group or
small muscles.

When lifting and object from the floor flex your hips, knees and back. Bring object to thigh level, bending
your knees and keep back straight. Stand up holding the object close to your body, bringing the load to the
center of gravity to increase stability and decrease back strain.
Question 40: Know the procedure for administering medication in NG feeding tube.

Verify proper tube placement

Use a syringe and allow medication to flow in by gravity or push it with the plunger of the syringe.
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
Liquid forms of meds (preferred). If appropriate, crush medication.

Do not admin. sublingual medications

Do not crush specially prepared oral med (extended release, fluid filled, enteric-coated)

Administer each medication separately

Do not mix meds with enteral feedings

Dissolve crushed tabs/capsules contents in 15 to 30 mL of sterile water prior ro administration

To prevent clogging, flush tube before and after each medication with 15 to 30 mL water – Flush with another
15 to 30 mL sterile water after instilling all meds
Procedure:
Enteral Medication Administration
1. Check medication order against the original order in medical record.
2. Assess need for medication, any interactions, safe dosing, adverse effects, and age/condition considerations.
3. Limit distractions and prepare for only one client at a time.
4. Check MAR and remove prescribed medication from the medication supply system.
5. Compare medication label with MAR.
6. Check expiration date and perform calculations.
7. Check form of prescribed medication on hand and evaluate need to crush and dissolve medication.
8. If required, after crushing, dissolve medication in recommended liquid.
9. Gather supplies and take medications to the client’s bedside at correct time.
10. *Introduce yourself to the client.
11. *Perform hand hygiene and put on appropriate PPE if indicated.
12. *Verify client identification and scan bar-code as per facility policy.
13. *Recheck medication label with MAR.
14. *Determine whether the client has allergies.
15. *Complete assessments as indicated by medication.
16. *Provide client education
17. Elevate head of bed to at least 30 degrees.
18. If applicable, pause tube feeding according to facility policy and medication recommendations.
19. Check placement of feeding tube according to facility policy.
20. Check gastric residual volume.
21. Insert 60 mL syringe into gastric tube and flush gastric tube with 30 mL water via gravity.
22. Pour first dose of medication into syringe.
23. Flush between each medication with 15 to 30 mL of water.
24. After administering the last dose of medication, flush gastric tube with 30 to 60 mL of water.
25. Clamp the feeding tube, remove syringe, and cap the end of the feeding tube.
26. Restart feeding, if indicated, according to agency policy and medication recommendations.
27. *Ensure that the client is in a safe position prior to leaving the room and has the call light within reach.
28. Evaluate the outcome at the appropriate time frame
Question 41: Know the proper technique to do tracheotomy suctioning.

Perform hand hygiene and don the require personal protective equipment.

Assist client into high Fowler's or Fowler's position If possible.

Obtain baseline breath sounds and vital signs, including oxygen saturation.

For endotracheal suctioning use a suction catheter that does not exceed one half of the internal diameter of the
endotracheal tube to prevent hypoxia.

Use surgical asepsis
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
Suction pressure no higher than 120 to 150 mmHg

limit each suction attempt to 10 to 15 secs to avoid hypoxemia, repeat suction if need d it.

Remove bag or ventilator from tracheostomy and insert catheter into lumen, advance catheter until resistance
in met (reached the carina)

pull catheter back 1 cm prior to applying suction.

Apply suction intermittently for 10 to 15 secs.

Apply suction only while withdrawing the catheter and rotating it.

Reattach ventilator and administer100% oxygen.

Rinse catheter and suction tube w/ sterile saline until clear.
Question 42: Know the signs of Phlebitis at the IV insertion site and what to do.
Phlebitis – edema; throbbing, burning, or pain at the site; increased skin temperature; erythema (redness) , slowed
rate of infusion.
Treatment:
 promptly discontinue the infusion and remove the catheter.
 Elevate the extremity.
 Apply warm compresses 3 to 4 times per day.
 Restart infusion in different vein proximal to the site or in a different extremity.
 Obtain specimen for culture at the site.
Prevention:
 Change IV site at least every 72 hrs.
 Avoid the lower extremities.
 Proper hand hygiene.
 Use surgical aseptic technique.
Question 43: Know what safety measures to take with you patient in a case of fire.
All staff must know:

Location of exits, alarms, fire extinguishers, and oxygen shut off valves.

Make sure equipment does not block fire doors.

Know evacuation plan for unit and facility.
Fire response follow the RACE sequence:
R – rescue and protect clients in close proximity to the fire by moving them to safer location – ambulatory clients
can walk independently to such location.
A – alarm; activate facilities alarm system and report the fire details and location.
C – contain/confine the fire by closing doors and windows, turning off any source of oxygen and electrical device.
Ventilate clients who are in life support with bag valve mask.
E – extinguish the fire if possible.
Question 44: Know about TPN infusion and what S&S patient may have in case is not infusing.
Parenteral nutrition is used when client’s GI tract is not functioning, or when a client cannot physically or
psychologically consume sufficient nutrients orally or enterally. TPN provides a nutritionally complete solution. It can
only be administered in a central vein. Parenteral nutrition includes: lipids, electrolytes, minerals, vitamins, dextrose
and aminoacids.
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Components: carbohydrate or dextrose 70%; lipids (fats) 10%, 20%, 30%; protein 3% to 20% (mixed of essential
and non-essential aminoacids).

TPN is used in clients who needs intense nutritional support for extended period of time.

The catheter/ or lumen used for TPN should be labeled and not used for any other infusions.

TPN is administer using an infusion pump for constant rate of delivery.

If TPN solution was refrigerated leave it out for 1 hr to warm up to room temperature. Discard the solution if
not use w/in 24hrs.
Question 45: Know about NGT and what type of electrolyte imbalance may cause.
NG tube is used for short term (up to 4 weeks) nutritional support. NGT is hollow, flexible, cylindrical.
Indications: decompression, feeding, lavage, compression (hemorrhage) ATI book p. 333

A patient on NG tube will lose Potassium due to suctioning of the gastric content hence is at risk for
hypokalemia.
Steps for administer enteral feedings:
1. Ensure privacy and place your supplies near the client’s bedside.
2. Introduce yourself and explain procedure to the client.
3. Perform hand hygiene.
4. Use two (2) acceptable identifiers to confirm that you have the right client.
5. Confirm with client history of allergies.
6. Confirm the formula with the providers order.
7. Assess clients learning needs – client should understand intent of the feeding and any possible adverse
reaction.
8. Put on gloves.
9. Assess for signs of redness, swelling, irritation, bleeding, drainage or skin breakdown.
10. Assess GI tract function by auscultating bowel sounds.
11. Check expiration date, integrity and cleanliness of the formula container.
12. Formula should be at room temperature to avoid gastric cramping. Shake formula well.
13. Cleanse the top of the canned formula with an alcohol swab and open the can.
14. Verify tube placement by using at least 2 methods after initial verification by abdominal x ray; 1. confirm
length of the tube at the point of entrance with order and documentation to make sure tube has not dislodge.
15. Inject 30 ml of air into the tube, to clear it of formula, medication or flush solution.
16. Gently pull back on the plunger to aspirate 5 to 10 ml of fluid, assess the appearance of aspirate and its pH to
help confirm placement.
17. Clear syringe and inject 30 ml of air.
18. Check the residual volume on the tube, by aspirating until you feel resistance from the plunger, inject residual
back.
19. Flush tube with 30 ml of water.
20. To begin the feeding pinch of the proximal end of the feeding tube, remove plunger from the syringe and
attach barrel to feeding tube.
21. Fill the barrel with formula, and release the feeding tube. Elevate the barrel above the client’s head. The
finfding formula flows by gravity through the tube. Refill the tube until you deliver the prescribed amount.
22. Flush the tube with 30 ml of water.
23. Remove gloves and perform hand hygiene.
24. Keep head of bed elevated at 30 degrees.
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25. Document feeding encounter, including clients response to procedure.
Question 46: what does the nurse do when a patient questions the medication being administer as the wrong
medication.
*Do Not Administer the Medication. Recheck medication against medical record and call attending MD.
If a client refuses a medication return that medication to the storage area as long as the rapper is intact, if not then
discard medication. Document refusal ans reason stated by the client.
Question 47: Know what Physiological changes decline in the older adult?
*Physiological changes:
 thickening of finger nails and toe nails
 loss of subcutaneous fat. skin elasticity.
 Decrease skin turgor.
 Decrease peripheral circulation
 reduce cardiac output.
 Increased blood pressure.
 Decreased touch, smell, taste, visual acuity.
 Decrease production of saliva, digestive enzimes
 decrease gastric motility
 decrease bladder capacity
 Increase pain tolerance
 decreased metabolic rate.
 Loss of height due to inter-vertebral disc changes
 decrease muscle strength and tone
 decalcification of bones
 decreased production of antibodies.
 Increased production of autoantibodies.
 Weak immune response
Question 48: Know lab values for electrolytes – Sodium (Na+), Magnesium (Mg2+), Potassium (K+),
Calcium (Ca2+), Chloride (Cl-).
Sodium (Na+): chief electrolyte of ECF; normal serum concentration of sodium: 135–145 mEq/L.
FUNCTIONS:
Regulates extracellular fluid volume; Na+ loss or gain accompanied by a loss or gain of water
Affects serum osmolality
Role in muscle contraction and transmission of nerve impulses
Regulation of acid–base balance as sodium bicarbonate
Magnesium (Mg2+): second most abundant ICF cation after potassium; normal serum concentration of
magnesium: 1.3–2.3 mEq/L
FUNCTIONS:
Metabolism of carbohydrates and proteins
Role in neuromuscular function
Acts on cardiovascular system, producing vasodilation
Potassium (K+): major cation of ICF; normal serum concentration of potassium: 3.5–5.0 mEq/L
FUNCTIONS:
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Controls intracellular osmolality
Regulator of cellular enzyme activity
Role in the transmission of electrical impulses in nerve, heart, skeletal, intestinal, and lung tissue.
Regulation of acid–base balance by cellular exchange with H+
Calcium (Ca2+): most abundant electrolyte in the body; normal total serum calcium level: 8.6–10.2 mg/dL;
normal ionized serum calcium level: 4.5–5.1 mg/dL
FUNCTIONS:
 Role in blood coagulation and in transmission of nerve impulses
 Helps regulate muscle contraction and relaxation
 Acts on cardiovascular system, producing vasodilation
Chloride (Cl−): major ECF anion; normal serum level of chloride: 97–107 mEq/L
FUNCTIONS:
 Major component of interstitial and lymph fluid; gastric and pancreatic juices, sweat, bile, and saliva
 Acts with sodium to maintain the osmotic pressure
 Combines with hydrogen ions to produce hydrochloric acid
Question 49: Know what is a clear diet?
Clear liquid diet: liquids that leave little residue (clear fruit juices, gelatin, and broth).
Question 50: Know all types of wound.
TYPE
CAUSE
Incision
Cutting or sharp instrument; wound edges in close approximation and
aligned
Contusion
Blunt instrument, overlying skin remains intact, with injury to underlying
soft tissue; possible resultant bruising and/or hematoma
Abrasion
Friction; rubbing or scraping epidermal layers of skin; top layer of skin
abraded
Laceration
Tearing of skin and tissue with blunt or irregular instrument; tissue not
aligned, often with loose flaps of skin and tissue
Puncture
Blunt or sharp instrument puncturing the skin; intentional (such as
venipuncture) or accidental
Penetrating
Foreign object entering the skin or mucous membrane and lodging in
underlying tissue; fragments possibly scattering throughout tissues
Avulsion
Tearing a structure from normal anatomic position; possible damage to
blood vessels, nerves, and other structures
Chemical
Toxic agents such as drugs, acids, alcohols, metals, and substances
released from cellular necrosis
Thermal
High or low temperatures; cellular necrosis as a possible result
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Irradiation
Ultraviolet light or radiation exposure
Pressure
ulcers
Compromised circulation secondary to pressure or pressure combined with
friction
Venous
ulcers
Injury and poor venous return, resulting from underlying conditions, such as
incompetent valves or obstruction
Arterial
ulcers
Injury and underlying ischemia, resulting from underlying conditions, such
as atherosclerosis or thrombosis
Diabetic
ulcers
Injury and underlying diabetic neuropathy, peripheral arterial disease,
diabetic foot structure
Pressure injury: area of compromised skin integrity over a bone prominence that results from prolonged pressure.
6 classifications:
 Suspected Deep Tissue Injury (DTI) (not a stage) an area of discolored but intact skin caused by damanged
to underlying tissue.
 Stage 1: nonblanchable redness caused by pressure typically over a bony prominence.
 Stage 2: partial-thickness skin loss with visible injury or fluid-filled blister.
 Stage 3: full-thickness tissue loss w/o exposed muscle or bone and the possibility of undermining or
tunneling.
 Stage 4: full-thickness tissue loss w/ exposed muscle or bone, the possibility of undermining or tunneling,
and sometimes Eschar (black scab-like material) or Slough (white, yellow dead tissue).
 Unstageable injuries: stage can not be determine because eschar or slough obscures the wound.
Question 51: Know S&S of UTI.
Symptoms of UTIs:
 A burning feeling when urinating.
 A frequent or intense urge to urinate, even though little comes out when you do.




Cloudy, dark, bloody, or strange-smelling urine
Feeling tired or shaky.
Fever or chills (a sign that the infection may have reached your kidneys)
Pain or pressure in your back or lower abdomen.
Question 52: Know which type of patients you assign close to nurse station.




(head injury, seizures)
The most critical patients should be closest to a nursing station to maximize view and accessibility
Clients at risk for falling.
Clients that are confused and at risk of eloping.
Question 53: Know with client prioritizing care consider ABC.
ABC: airway, breathing, and circulation.
ABC stands for airway, breathing and circulation. So these are your top 3 priorities when doing patient care. You need
to make sure your patient has a clear airway (or what we call a patent airway), you need to make sure they are
breathing adequately, and you need to make sure their blood is flowing and circulating.
These are the 3 primary life or death physiological processes. If one of these isn’t happening, it’s game over, so
that’s why the ABCs should be your top priority.
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