The top number in a blood pressure reading, representing the pressure during ventricular contraction, is known as the systolic pressure.
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systolic
Systolic pressure is the maximum pressure exerted on the arteries during the contraction of the left ventricle.
Question 2
Nurses should perform handwashing with soap and water for at least 20 seconds when hands are visibly soiled.
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handwashing
Handwashing with soap and water is essential for removing visible soil and microorganisms from the hands.
Question 3
Placing the call light within reach and keeping the bed in the lowest position are key interventions for fall prevention.
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fall
These actions reduce the risk of patients attempting to get out of bed unassisted and falling.
Question 4
The initial phase of the nursing process involves systematically collecting patient data, which is called assessment.
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assessment
Assessment is the foundation of the nursing process, where comprehensive data about the patient's health status is gathered.
Question 5
Accurate and timely documentation serves as a legal record of nursing care and patient responses.
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documentation
Thorough documentation is a critical legal requirement and reflects the care provided to the patient.
Question 6
Listening to internal body sounds, such as heart and lung sounds, using a stethoscope is a basic assessment technique called auscultation.
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auscultation
Auscultation involves using a stethoscope to listen to sounds produced by the body, aiding in the assessment of various systems.
Question 7
Pain is often referred to as the fifth vital sign due to its subjective nature and significant impact on patient well-being.
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fifth
Recognizing pain as a vital sign emphasizes its importance in comprehensive patient assessment and management.
Question 8
A nurse caring for a patient with C. difficile should wear a gown and gloves, which are examples of PPE.
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PPE
Personal Protective Equipment (PPE) like gowns and gloves protects healthcare workers from exposure to infectious agents.
Question 9
Before administering medication, a nurse must verify patient identity using at least two identifiers, such as name and date of birth.
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identifiers
Using two patient identifiers is a critical safety measure to prevent medication errors and ensure the correct patient receives care.
Question 10
Carrying out the planned nursing actions to achieve patient goals occurs during the implementation phase of the nursing process.
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implementation
Implementation involves performing the specific nursing interventions identified during the planning phase.
Question 11
Nurses should record patient data and care provided in a timely manner to ensure the record is current and accurate.
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timely
Timely documentation ensures that the patient record reflects the most current information and care provided.
Question 12
The initial step of a physical assessment involves careful inspection, observing the patient's appearance and visible characteristics.
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inspection
Inspection is the process of visually examining the patient for any signs or symptoms.
Question 13
When assessing the radial pulse, the nurse notes its rate, rhythm, and strength.
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strength
Pulse strength, or amplitude, indicates the volume of blood ejected with each heartbeat and the condition of the arterial wall.
Question 14
Standard precautions are applied to all patients in any healthcare setting, regardless of their diagnosis, to prevent the spread of infection.
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Standard
Standard precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status.
Question 15
Physical restraints should only be used as a last resort and with a physician's order, after less restrictive measures have failed.
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restraints
Restraints are a safety measure of last resort, used to prevent harm to the patient or others when other interventions are ineffective.
Question 16
Determining whether patient goals have been met or partially met is the focus of the evaluation phase of the nursing process.
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evaluation
Evaluation is the final phase where the effectiveness of nursing care is judged against established patient outcomes.
Question 17
Many healthcare facilities now use an EHR to manage patient information digitally, improving accessibility and coordination of care.
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EHR
Electronic Health Records (EHRs) are digital versions of patients' paper charts, enhancing efficiency and accuracy in healthcare.
Question 18
Information reported by the patient, such as "I feel nauseous," is considered subjective data.
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subjective
Subjective data consists of information that the patient states or perceives, which cannot be directly measured or observed by others.
Question 19
Maintaining a sterile field during a dressing change is an example of employing aseptic technique to prevent contamination.
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aseptic
Aseptic technique involves practices that reduce the risk of infection by preventing the spread of microorganisms.