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Fundamentals of Nursing

8. The notation AA & O 3 indicates that

the patient is awake, alert, and oriented to


person (knows who he is), place (knows

1. After turning a patient, the nurse should


document the position used, the time that

the patient was turned, and the findings of

where he is), and time (knows the date and

9. Fluid intake includes all fluids taken by

skin assessment.

mouth, including foods that are liquid at

2. PERRLA is an abbreviation for normal

and ice cream; I.V. fluids; and fluids

pupil assessment findings: pupils equal,

round, and reactive to light with

room temperature, such as gelatin, custard,

administered in feeding tubes. Fluid output
includes urine, vomitus, and drainage (such


as from a nasogastric tube or from a wound)

3. When percussing a patients chest for


postural drainage, the nurses hands should

as well as blood loss, diarrhea or feces, and

be cupped.

10. After administering an intradermal

4. When measuring a patients pulse, the

area because massage can irritate the site

nurse should assess its rate, rhythm, quality,

and strength.
5. Before transferring a patient from a bed to
a wheelchair, the nurse should push the
wheelchair footrests to the sides and lock its
6. When assessing respirations, the nurse
should document their rate, rhythm, depth,
and quality.
7. For a subcutaneous injection, the nurse
should use a 5/8 to 1 25G needle.

injection, the nurse shouldnt massage the

and interfere with results.
11. When administering an intradermal
injection, the nurse should hold the syringe
almost flat against the patients skin (at
about a 15-degree angle), with the bevel up.
12. 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
13. The nurse should count an irregular
pulse for 1 full minute.

14. A patient who is vomiting while lying

22. States have enacted Good Samaritan

down should be placed in a lateral position

laws to encourage professionals to provide

to prevent aspiration of vomitus.

medical assistance at the scene of an

accident without fear of a lawsuit arising

15. Prophylaxis is disease prevention.

from the assistance. These laws dont apply

to care provided in a health care facility.

16. Body alignment is achieved when body

parts are in proper relation to their natural

23. A physician should sign verbal and


telephone orders within the time established

by facility policy, usually 24 hours.

17. Trust is the foundation of a nurse-patient


24. A competent adult has the right to refuse

lifesaving medical treatment; however, the

18. Blood pressure is the force exerted by

individual should be fully informed of the

the circulating volume of blood on the

consequences of his refusal.

arterial walls.
25. Although a patients health record, or
19. Malpractice is a professionals wrongful

chart, is the health care facilitys physical

conduct, improper discharge of duties, or

property, its contents belong to the patient.

failure to meet standards of care that causes

harm to another.

26. Before a patients health record can be

released to a third party, the patient or the

20. As a general rule, nurses cant refuse a

patients legal guardian must give written

patient care assignment; however, in most


states, they may refuse to participate in


27. Under the Controlled Substances Act,

every dose of a controlled drug thats

21. A nurse can be found negligent if a

dispensed by the pharmacy must be

patient is injured because the nurse failed to

accounted for, whether the dose was

perform a duty that a reasonable and

administered to a patient or discarded

prudent person would perform or because


the nurse performed an act that a

reasonable and prudent person wouldnt

28. A nurse cant perform duties that violate


a rule or regulation established by a state

licensing board, even if they are authorized

36. The nurse shouldnt dry a patients ear

by a health care facility or physician.

canal or remove wax with a cotton-tipped

applicator because it may force cerumen

29. To minimize interruptions during a

against the tympanic membrane.

patient interview, the nurse should select a

private room, preferably one with a door that

37. A patients identification bracelet should

can be closed.

remain in place until the patient has been

discharged from the health care facility and

30. In categorizing nursing diagnoses, the

has left the premises.

nurse addresses life-threatening problems

first, followed by potentially life-threatening

38. The Controlled Substances Act


designated five categories, or schedules,

that classify controlled drugs according to

31. The major components of a nursing care

their abuse potential.

plan are outcome criteria (patient goals) and

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

nursing interventions.

high abuse potential and have no currently

accepted medical use in the United States.

32. Standing orders, or protocols, establish

guidelines for treating a specific disease or

40. Schedule II drugs, such

set of symptoms.

as morphine, opium,
and meperidine (Demerol), have a high

33. In assessing a patients heart, the nurse

abuse potential, but currently have accepted

normally finds the point of maximal impulse

medical uses. Their use may lead to

at the fifth intercostal space, near the apex.

physical or psychological dependence.

34. The S1 heard on auscultation is caused

41. Schedule III drugs, such as paregoric

by closure of the mitral and tricuspid valves.

and butabarbital (Butisol), have a lower

abuse potential than Schedule I or II drugs.

35. To maintain package sterility, the nurse

Abuse of Schedule III drugs may lead to

should open a wrappers top flap away from

moderate or low physical or psychological

the body, open each side flap by touching

dependence, or both.

only the outer part of the wrapper, and open

the final flap by grasping the turned-down

42. Schedule IV drugs, such as chloral

corner and pulling it toward the body.

hydrate, have a low abuse potential

compared with Schedule III drugs.

43. Schedule V drugs, such as cough syrups

51. The nurse should provide honest

that contain codeine, have the lowest abuse

answers to the patients questions.

potential of the controlled substances.

52. Milk shouldnt be included in a clear
44. Activities of daily living are actions that

liquid diet.

the patient must perform every day to

provide self-care and to interact with society.

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

confused patient, consistency in nursing

45. Testing of the six cardinal fields of gaze

personnel is paramount.

evaluates the function of all extraocular

muscles and cranial nerves III, IV, and VI.

54. The hypothalamus secretes vasopressin

and oxytocin, which are stored in the

46. The six types of heart murmurs are

pituitary gland.

graded from 1 to 6. A grade 6 heart murmur

can be heard with the stethoscope slightly

55. The three membranes that enclose the

raised from the chest.

brain and spinal cord are the dura mater, pia

mater, and arachnoid.

47. The most important goal to include in a

care plan is the patients goal.

56. A nasogastric tube is used to remove

fluid and gas from the small intestine

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

preoperatively or postoperatively.

and should be omitted from a low-residue


57. Psychologists, physical therapists, and

chiropractors arent authorized to write

49. The nurse should use an objective scale

prescriptions for drugs.

to assess and quantify pain. Postoperative

pain varies greatly among individuals.

58. The area around a stoma is cleaned with

mild soap and water.

50. Postmortem care includes cleaning and

preparing the deceased patient for family

59. Vegetables have a high fiber content.

viewing, arranging transportation to the

morgue or funeral home, and determining

60. The nurse should use a tuberculin

the disposition of belongings.

syringe to administer a subcutaneous

injection of less than 1 ml.

61. For adults, subcutaneous injections

68. When providing hair and scalp care, the

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

nurse should begin combing at the end of

children, elderly, or very thin patients, they

the hair and work toward the head.

require a 25G to 27G needle.

69. The frequency of patient hair care
62. Before administering a drug, the nurse

depends on the length and texture of the

should identify the patient by checking the

hair, the duration of hospitalization, and the

identification band and asking the patient to

patients condition.

state his name.

70. Proper function of a hearing aid requires
63. To clean the skin before an injection, the

careful handling during insertion and

nurse uses a sterile alcohol swab to wipe

removal, regular cleaning of the ear piece to

from the center of the site outward in a

prevent wax buildup, and prompt

circular motion.

replacement of dead batteries.

64. The nurse should inject heparin deep

71. The hearing aid thats marked with a

into subcutaneous tissue at a 90-degree

blue dot is for the left ear; the one with a red

angle (perpendicular to the skin) to prevent

dot is for the right ear.

skin irritation.
72. A hearing aid shouldnt be exposed to
65. If blood is aspirated into the syringe

heat or humidity and shouldnt be immersed

before an I.M. injection, the nurse should

in water.

withdraw the needle, prepare another

syringe, and repeat the procedure.

73. The nurse should instruct the patient to

avoid using hair spray while wearing a

66. The nurse shouldnt cut the patients hair

hearing aid.

without written consent from the patient or

an appropriate relative.

74. The five branches of pharmacology are

pharmacokinetics, pharmacodynamics,

67. If bleeding occurs after an injection, the

pharmacotherapeutics, toxicology, and

nurse should apply pressure until the


bleeding stops. If bruising occurs, the nurse

75. The nurse should remove heel

should monitor the site for an enlarging

protectors every 8 hours to inspect the foot


for signs of skin breakdown.

76. Heat is applied to promote vasodilation,

should use a small-gauge needle and apply

which reduces pain caused by inflammation.

pressure to the site for 5 minutes after the


77. A sutured surgical incision is an example

of healing by first intention (healing directly,

84. Platelets are the smallest and most

without granulation).

fragile formed element of the blood and are

essential for coagulation.

78. Healing by secondary intention (healing

by granulation) is closure of the wound when

85. To insert a nasogastric tube, the nurse

granulation tissue fills the defect and allows

instructs the patient to tilt the head back

reepithelialization to occur, beginning at the

slightly and then inserts the tube. When the

wound edges and continuing to the center,

nurse feels the tube curving at the pharynx,

until the entire wound is covered.

the nurse should tell the patient to tilt the

79. Keloid formation is an abnormality in

head forward to close the trachea and open

healing thats characterized by overgrowth of

the esophagus by swallowing. (Sips of water

scar tissue at the wound site.

can facilitate this action.)

80. The nurse should

86. Families with loved ones in intensive

administer procaine penicillin by deep I.M.

care units report that their four most

injection in the upper outer portion of the

important needs are to have their questions

buttocks in the adult or in the midlateral thigh

answered honestly, to be assured that the

in the child. The nurse shouldnt massage

best possible care is being provided, to

the injection site.

know the patients prognosis, and to feel that

there is hope of recovery.

81. An ascending colostomy drains fluid

feces. A descending colostomy drains solid

87. Double-bind communication occurs

fecal matter.

when the verbal message contradicts the

nonverbal message and the receiver is

82. A folded towel (scrotal bridge) can

unsure of which message to respond to.

provide scrotal support for the patient with

scrotal edema caused by vasectomy,

88. A nonjudgmental attitude displayed by a

epididymitis, or orchitis.

nurse shows that she neither approves nor

disapproves of the patient.

83. When giving an injection to a patient

who has a bleeding disorder, the nurse

89. Target symptoms are those that the

96. On-call medication should be given

patient finds most distressing.

within 5 minutes of the call.

90. A patient should be advised to take

97. Usually, the best method to determine a

aspirin on an empty stomach, with a full

patients cultural or spiritual needs is to ask

glass of water, and should avoid acidic foods


such as coffee, citrus fruits, and cola.

98. An incident report or unusual occurrence
91. For every patient problem, there is a

report isnt part of a patients record, but is

nursing diagnosis; for every nursing

an in-house document thats used for the

diagnosis, there is a goal; and for every

purpose of correcting the problem.

goal, there are interventions designed to

make the goal a reality. The keys to

99. Critical pathways are a multidisciplinary

answering examination questions correctly

guideline for patient care.

are identifying the problem presented,

formulating a goal for the problem, and

100. When prioritizing nursing diagnoses,

selecting the intervention from the choices

the following hierarchy should be used:

provided that will enable the patient to reach

Problems associated with the airway, those

that goal.

concerning breathing, and those related to


92. Fidelity means loyalty and can be shown

as a commitment to the profession of

101. The two nursing diagnoses that have

nursing and to the patient.

the highest priority that the nurse can assign

are Ineffective airway clearance and

93. Administering an I.M. injection against

Ineffective breathing pattern.

the patients will and without legal authority

is battery.

102. A subjective sign that a sitz bath has

been effective is the patients expression of

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

decreased pain or discomfort.

insurance company.
103. For the nursing diagnosis Deficient
95. The formula for calculating the drops per

diversional activity to be valid, the patient

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

must state that hes bored, that he has

(volume to be infused drip factor) time in

nothing to do, or words to that effect.

minutes = drops/minute

104. The most appropriate nursing diagnosis

111. Listening is the most effective

for an individual who doesnt speak English

communication technique.

is Impaired verbal communication related to

inability to speak dominant language

112. Before teaching any procedure to a


patient, the nurse must assess the patients

current knowledge and willingness to learn.

105. The family of a patient who has been

diagnosed as hearing impaired should be

113. Process recording is a method of

instructed to face the individual when they

evaluating ones communication

speak to him.


106. Before instilling medication into the ear

114. When feeding an elderly patient, the

of a patient who is up to age 3, the nurse

nurse should limit high-carbohydrate foods

should pull the pinna down and back to

because of the risk of glucose intolerance.

straighten the eustachian tube.

115. When feeding an elderly patient,
107. To prevent injury to the cornea when

essential foods should be given first.

administering eyedrops, the nurse should

waste the first drop and instill the drug in the

116. Passive range of motion maintains joint

lower conjunctival sac.

mobility. Resistive exercises increase

muscle mass.

108. After administering eye ointment, the

nurse should twist the medication tube to

117. Isometric exercises are performed on

detach the ointment.

an extremity thats in a cast.

109. When the nurse removes gloves and a

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

mask, she should remove the gloves first.

control theory of pain.

They are soiled and are likely to contain


119. Anything thats located below the waist

is considered unsterile; a sterile field

110. Crutches should be placed 6 (15.2 cm)

becomes unsterile when it comes in contact

in front of the patient and 6 to the side to

with any unsterile item; a sterile field must

form a tripod arrangement.

be monitored continuously; and a border of

1 (2.5 cm) around a sterile field is
considered unsterile.

120. A shift to the left is evident when the

128. For the patient who abides by Jewish

number of immature cells (bands) in the

custom, milk and meat shouldnt be served

blood increases to fight an infection.

at the same meal.

121. A shift to the right is evident when the

129. Whether the patient can perform a

number of mature cells in the blood

procedure (psychomotor domain of learning)

increases, as seen in advanced liver disease

is a better indicator of the effectiveness of

and pernicious anemia.

patient teaching than whether the patient

can simply state the steps involved in the

122. Before administering preoperative

procedure (cognitive domain of learning).

medication, the nurse should ensure that an

informed consent form has been signed and

130. According to Erik Erikson,

attached to the patients record.

developmental stages are trust versus

mistrust (birth to 18 months), autonomy

123. A nurse should spend no more than 30

versus shame and doubt (18 months to age

minutes per 8-hour shift providing care to a

3), initiative versus guilt (ages 3 to 5),

patient who has a radiation implant.

industry versus inferiority (ages 5 to 12),

identity versus identity diffusion (ages 12 to

124. A nurse shouldnt be assigned to care

18), intimacy versus isolation (ages 18 to

for more than one patient who has a

25), generativity versus stagnation (ages 25

radiation implant.

to 60), and ego integrity versus despair

(older than age 60).

125. Long-handled forceps and a lead-lined

container should be available in the room of

131. When communicating with a hearing

a patient who has a radiation implant.

impaired patient, the nurse should face him.

126. Usually, patients who have the same

132. An appropriate nursing intervention for

infection and are in strict isolation can share

the spouse of a patient who has a serious

a room.

incapacitating disease is to help him to

mobilize a support system.

127. Diseases that require strict isolation

include chickenpox, diphtheria, and viral

133. Hyperpyrexia is extreme elevation in

hemorrhagic fevers such as Marburg

temperature above 106 F (41.1 C).

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

135. When a patient expresses concern

143. Increased gastric motility interferes with

about a health-related issue, before

the absorption of oral drugs.

addressing the concern, the nurse should

assess the patients level of knowledge.

144. The three phases of the therapeutic

relationship are orientation, working, and

136. The most effective way to reduce a


fever is to administer an antipyretic, which

lowers the temperature set point.

145. Patients often exhibit resistive and

challenging behaviors in the orientation

137. When a patient is ill, its essential for

phase of the therapeutic relationship.

the members of his family to maintain

communication about his health needs.

146. Abdominal assessment is performed in

the following order: inspection, auscultation,

138. Ethnocentrism is the universal belief

percussion & palpation.

that ones way of life is superior to others.

147. When measuring blood pressure in a
139. When a nurse is communicating with a

neonate, the nurse should select a cuff thats

patient through an interpreter, the nurse

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

should speak to the patient and the

thirds the length of the extremity thats used.

148. When administering a drug by Z-track,
140. In accordance with the hot-cold

the nurse shouldnt use the same needle

system used by some Mexicans, Puerto

that was used to draw the drug into the

Ricans, and other Hispanic and Latino

syringe because doing so could stain the

groups, most foods, beverages, herbs, and


drugs are described as cold.

149. Sites for intradermal injection include
141. Prejudice is a hostile attitude toward

the inner arm, the upper chest, and on the

individuals of a particular group.

back, under the scapula.

142. Discrimination is preferential treatment

150. When evaluating whether an answer on

of individuals of a particular group. Its

an examination is correct, the nurse should

usually discussed in a negative sense.

consider whether the action thats described

promotes autonomy (independence), safety,
self-esteem, and a sense of belonging.

151. When answering a question on the

including a foreign object, fluid from an

NCLEX examination, the student should

upper respiratory infection, and edema from

consider the cue (the stimulus for a thought)

trauma or an allergic reaction.

and the inference (the thought) to determine

whether the inference is correct. When in

157. B = Breathing. This category includes

doubt, the nurse should select an answer

everything that affects the breathing pattern,

that indicates the need for further

including hyperventilation or hypoventilation

information to eliminate ambiguity. For

and abnormal breathing patterns, such as

example, the patient complains of chest pain

Korsakoffs, Biots, or Cheyne-Stokes

(the stimulus for the thought) and the nurse


infers that the patient is having cardiac pain

(the thought). In this case, the nurse hasnt

158. C = Circulation. This category includes

confirmed whether the pain is cardiac. It

everything that affects the circulation,

would be more appropriate to make further

including fluid and electrolyte disturbances


and disease processes that affect cardiac


152. Veracity is truth and is an essential

component of a therapeutic relationship

159. D = Disease processes. If the patient

between a health care provider and his

has no problem with the airway, breathing,


or circulation, then the nurse should

evaluate the disease processes, giving

153. Beneficence is the duty to do no harm

priority to the disease process that poses

and the duty to do good. Theres an

the greatest immediate risk. For example, if

obligation in patient care to do no harm and

a patient has terminal cancer and

an equal obligation to assist the patient.

hypoglycemia, hypoglycemia is a more

immediate concern.

154. Nonmaleficence is the duty to do no


160. E = Everything else. This category

includes such issues as writing an incident

155. Fryes ABCDE cascade provides a

report and completing the patient chart.

framework for prioritizing care by identifying

When evaluating needs, this category is

the most important treatment concerns.

never the highest priority.

156. A = Airway. This category includes

161. When answering a question on an

everything that affects a patent airway,

NCLEX examination, the basic rule is

assess before action. The student should

168. Utilization review is performed to

evaluate each possible answer carefully.

determine whether the care provided to a

Usually, several answers reflect the

patient was appropriate and cost-effective.

implementation phase of nursing and one or

169. A value cohort is a group of people who

two reflect the assessment phase. In this

experienced an out-of-the-ordinary event

case, the best choice is an assessment

that shaped their values.

response unless a specific course of action

is clearly indicated.

170. Voluntary euthanasia is actively helping

a patient to die at the patients request.

162. Rule utilitarianism is known as the

greatest good for the greatest number of

171. Bananas, citrus fruits, and potatoes are

people theory.

good sources of potassium.

163. Egalitarian theory emphasizes that

172. Good sources of magnesium include

equal access to goods and services must be

fish, nuts, and grains.

provided to the less fortunate by an affluent


173. Beef, oysters, shrimp, scallops,

spinach, beets, and greens are good

164. Active euthanasia is actively helping a

sources of iron.

person to die.
174. Intrathecal injection is administering a
165. Brain death is irreversible cessation of

drug through the spine.

all brain function.

175. When a patient asks a question or
166. Passive euthanasia is stopping the

makes a statement thats emotionally

therapy thats sustaining life.

charged, the nurse should respond to the

emotion behind the statement or question

167. A third-party payer is an insurance

rather than to whats being said or asked.

176. The steps of the trajectory-nursing
model are as follows:
177. Step 1: Identifying the trajectory phase
178. Step 2: Identifying the problems and
establishing goals
179. Step 3: Establishing a plan to meet the


191. No pork or pork products are allowed in

180. Step 4: Identifying factors that facilitate

a Muslim diet.

or hinder attainment of the goals

181. Step 5: Implementing interventions

192. Two goals of Healthy People 2010 are:

182. Step 6: Evaluating the effectiveness of

193. Help individuals of all ages to increase

the interventions

the quality of life and the number of years of

optimal health

183. A Hindu patient is likely to request a

194. Eliminate health disparities among

vegetarian diet.

different segments of the population.

184. Pain threshold, or pain sensation, is the

195. A community nurse is serving as a

initial point at which a patient feels pain.

patients advocate if she tells a

malnourished patient to go to a meal

185. The difference between acute pain and

program at a local park.

chronic pain is its duration.

196. If a patient isnt following his treatment
186. Referred pain is pain thats felt at a site

plan, the nurse should first ask why.

other than its origin.

197. Falls are the leading cause of injury in
187. Alleviating pain by performing a back

elderly people.

massage is consistent with the gate control


198. Primary prevention is true prevention.

Examples are immunizations, weight control,

188. Rombergs test is a test for balance or

and smoking cessation.

199. Secondary prevention is early
189. Pain seems more intense at night

detection. Examples include purified protein

because the patient isnt distracted by daily

derivative (PPD), breast self-examination,


testicular self-examination, and chest X-ray.

190. Older patients commonly dont report

200. Tertiary prevention is treatment to

pain because of fear of treatment, lifestyle

prevent long-term complications.

changes, or dependency.

201. A patient indicates that hes coming to

210. A hypotonic enema softens the feces,

terms with having a chronic disease when

distends the colon, and stimulates

he says, Im never going to get any better.


202. On noticing religious artifacts and

211. First-morning urine provides the best

literature on a patients night stand, a

sample to measure glucose, ketone, pH, and

culturally aware nurse would ask the patient

specific gravity values.

the meaning of the items.

212. To induce sleep, the first step is to
203. A Mexican patient may request the

minimize environmental stimuli.

intervention of a curandero, or faith healer,

who involves the family in healing the

213. Before moving a patient, the nurse


should assess the patients physical abilities

and ability to understand instructions as well

204. In an infant, the normal hemoglobin

as the amount of strength required to move

value is 12 g/dl.

the patient.

205. The nitrogen balance estimates the

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

difference between the intake and use of

patient must decrease his weekly intake by


3,500 calories (approximately 500 calories

daily). To lose 2 lb (1 kg) in 1 week, the

206. Most of the absorption of water occurs

patient must decrease his weekly caloric

in the large intestine.

intake by 7,000 calories (approximately

1,000 calories daily).

207. Most nutrients are absorbed in the

small intestine.

215. To avoid shearing force injury, a patient

who is completely immobile is lifted on a

208. When assessing a patients eating


habits, the nurse should ask, What have

you eaten in the last 24 hours?

216. To insert a catheter from the nose

through the trachea for suction, the nurse

209. A vegan diet should include an

should ask the patient to swallow.

abundant supply of fiber.

217. Vitamin C is needed for collagen

218. Only the patient can describe his pain

227. Collegiality is the promotion of


collaboration, development, and

interdependence among members of a

219. Cutaneous stimulation creates the


release of endorphins that block the

transmission of pain stimuli.

228. A change agent is an individual who

recognizes a need for change or is selected

220. Patient-controlled analgesia is a safe

to make a change within an established

method to relieve acute pain caused by

entity, such as a hospital.

surgical incision, traumatic

injury, labor and delivery, or cancer.

229. The patients bill of rights was

introduced by the American Hospital

221. An Asian American or European


American typically places distance between

himself and others when communicating.

230. Abandonment is premature termination

of treatment without the patients permission

222. The patient who believes in a scientific,

and without appropriate relief of symptoms.

or biomedical, approach to health is likely to

expect a drug, treatment, or surgery to cure

231. Values clarification is a process that


individuals use to prioritize their personal


223. Chronic illnesses occur in very young

as well as middle-aged and very old people.

232. Distributive justice is a principle that

promotes equal treatment for all.

224. The trajectory framework for chronic

illness states that preferences about daily

233. Milk and milk products, poultry, grains,

life activities affect treatment decisions.

and fish are good sources of phosphate.

225. Exacerbations of chronic disease

234. The best way to prevent falls at night in

usually cause the patient to seek treatment

an oriented, but restless, elderly patient is to

and may lead to hospitalization.

raise the side rails.

226. School health programs provide cost-

235. By the end of the orientation phase, the

effective health care for low-income families

patient should begin to trust the nurse.

and those who have no health insurance.

236. Falls in the elderly are likely to be

242. To increase patient comfort, the nurse

caused by poor vision.

should let the alcohol dry before giving an

intramuscular injection.

237. Barriers to communication include

language deficits, sensory deficits, cognitive

243. Treatment for a stage 1 ulcer on the

impairments, structural deficits, and

heels includes heel protectors.

244. Seventh-Day Adventists are usually
238. The three elements that are necessary


for a fire are heat, oxygen, and combustible

239. Sebaceous glands lubricate the skin.
240. To check for petechiae in a darkskinned patient, the nurse should assess the
oral mucosa.
241. 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.

245. Endorphins are morphine-like

substances that produce a feeling of wellbeing.
246. Pain tolerance is the maximum amount
and duration of pain that an individual is
willing to endure.