The physician’s orders.
The action of a clinical nurse specialist who is recognized expert in the field.
The statement in the drug literature about administration of terbutaline.
The actions of a reasonably prudent nurse with similar education and experience.
“Digoxin .1250 mg P.O. once daily”
“Digoxin 0.1250 mg P.O. once daily”
“Digoxin 0.125 mg P.O. once daily”
“Digoxin .125 mg P.O. once daily”
Ineffective peripheral tissue perfusion related to venous congestion.
Risk for injury related to edema.
Excess fluid volume related to peripheral vascular disease.
Impaired gas exchange related to increased blood flow.
A 34 year-old post operative appendectomy client of five hours who is complaining of pain.
A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid.
Assess temperature frequently.
Provide diversional activities.
Check circulation every 15-30 minutes.
Socialize with other patients once a shift.
Prevent stress ulcer
Block prostaglandin synthesis
Facilitate protein synthesis.
Enhance gas exchange
Increase the I.V. fluid infusion rate
Irrigate the indwelling urinary catheter
Notify the physician
Continue to monitor and record hourly urine output
“My ankle looks less swollen now”.
“My ankle feels warm”.
“My ankle appears redder now”.
“I need something stronger for pain relief”
Have condescending trust and confidence in their subordinates.
Gives economic and ego awards.
Communicates downward to staffs.
Allows decision making among subordinates.
Provides continuous, coordinated and comprehensive nursing services.
One-to-one nurse patient ratio.
Emphasize the use of group collaboration.
Concentrates on tasks and activities.
Standard written order
Loss of urge to defecate
Hard, brown, formed stools
Liquid or semi-liquid stools
Pulling the lobule down and back
Pulling the helix up and forward
Pulling the helix up and back
Pulling the lobule down and forward
Protect the irritated skin from sunlight.
Eat 3 to 4 hours before treatment.
Wash the skin over regularly.
Apply lotion or oil to the radiated area when it is red or sore.
Encourage the client to void following preoperative medication.
Explore the client’s fears and anxieties about the surgery.
Assist the client in removing dentures and nail polish.
Encourage the client to drink water prior to surgery.
Blood pressure above normal range.
Presence of crackles in both lung fields.
Hyperactive bowel sounds
Sudden onset of continuous epigastric and back pain.
Provide high-fiber, high-fat diet
Provide high-protein, high-carbohydrate diet.
Monitor intake to prevent weight gain.
Provide ice chips or water intake.
Blood pressure and pulse rate.
Height and weight.
Calcium and potassium levels
Hgb and Hct levels.
Takes a set of vital signs.
Call the radiology department for X-ray.
Reassure the client that everything will be alright.
Immobilize the leg before moving the client.
Place client on reverse isolation.
Admit the client into a private room.
Encourage the client to take frequent rest periods.
Encourage family and friends to visit.
Risk for infection
Notify the physician.
Place the client on the left side in the Trendelenburg position.
Place the client in high-Fowlers position.
Stop the total parenteral nutrition.
50 cc/ hour
55 cc/ hour
24 cc/ hour
66 cc/ hour
Assess the IV for type of fluid and rate of flow.
Assess the client for presence of pain.
Assess the Foley catheter for patency and urine output
Assess the dressing for drainage.
BP – 80/60, Pulse – 110 irregular
BP – 90/50, Pulse – 50 regular
BP – 130/80, Pulse – 100 regular
BP – 180/100, Pulse – 90 irregular
Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart.
Measure the client’s arm, if you are not sure of the size of cuff to use.
Have the client recline or sit comfortably in a chair with the forearm at the level of the heart.
Document the measurement, which extremity was used, and the position that the client was in during the measurement.
Planning and goals
Diagnostic test results
History of present illness
Trochanter roll extending from the crest of the ileum to the midthigh.
Pillows under the lower legs.
Second intention healing
Primary intention healing
Third intention healing
First intention healing
Distended neck veins
It’s a common measurement in the metric system.
It’s the basis for solids in the avoirdupois system.
It’s the smallest measurement in the apothecary system.
It’s a measure of effect, not a standard measure of weight or quantity.
Accepting limitations while developing assets.
Increasing loss of muscle tone.
Failing eyesight, especially close vision.
Having more frequent aches and pains.
Checking and taping all connections.
Checking patency of the chest tube.
Keeping the head of the bed slightly elevated.
Keeping the chest drainage system below the level of the chest.
Check the client’s identification band.
Ask the client to state his name.
State the client’s name out loud and wait a client to repeat it.
Check the room number and the client’s name on the bed.
Clamp the catheter
Call another nurse
Call the physician
Apply a dry sterile dressing to the site.
Palpation, auscultation, and percussion.
Percussion, palpation, and auscultation.
Palpation, percussion, and auscultation.
Auscultation, percussion, and palpation.
Dorsal surface of the hand
Ulnar surface of the hand
Twice per year
Once per year
Every 2 years
Once, to establish baseline
To help the client find appropriate treatment options.
To provide support for the client and family in coping with terminal illness.
To ensure that the client gets counseling regarding health care costs.
To teach the client and family about cancer and its treatment.
Massaging the area with an astringent every 2 hours.
Applying an antibiotic cream to the area three times per day.
Using normal saline solution to clean the ulcer and applying a protective dressing as necessary.
Using a povidone-iodine wash on the ulceration three times per day.
Throbbing headache or dizziness
Nervousness or paresthesia.
Drowsiness or blurred vision.
Tinnitus or diplopia.
Prepare for cardioversion
Prepare to defibrillate the client
Call a code
Check the client’s level of consciousness
On the unaffected side of the client.
On the affected side of the client.
In front of the client.
Behind the client.
Urine output: 45 ml/hr
Capillary refill: 5 seconds
Serum pH: 7.32
Blood pressure: 90/48 mmHg
Wiping the port with an alcohol swab before inserting the syringe.
Aspirating a sample from the port on the drainage bag.
Clamping the tubing of the drainage bag.
Obtaining the specimen from the urinary drainage bag.
Immediately walk out of the client’s room and answer the phone call.
Cover the client, place the call light within reach, and answer the phone call.
Finish the bed bath before answering the phone call.
Leave the client’s door open so the client can be monitored and the nurse can answer the phone call.
Ask the client to expectorate a small amount of sputum into the emesis basin.
Ask the client to obtain the specimen after breakfast.
Use a sterile plastic container for obtaining the specimen.
Provide tissues for expectoration and obtaining the specimen.
Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it.
Puts weight on the hand pieces, moves the walker forward, and then walks into it.
Puts weight on the hand pieces, slides the walker forward, and then walks into it.
Walks into the walker, puts weight on the hand pieces, and then puts all four points of the walker flat on the floor.
Erases the error and writes in the correct information.
Uses correction fluid to cover up the incorrect information and writes in the correct information.
Draws one line to cross out the incorrect information and then initials the change.
Covers up the incorrect information completely using a black pen and writes in the correct information
Moves the client rapidly from the table to the stretcher.
Uncovers the client completely before transferring to the stretcher.
Secures the client safety belts after transferring to the stretcher.
Instructs the client to move self from the table to the stretcher.
Gown and goggles
Gown and gloves
Gloves and shoe protectors
Gloves and goggles
Single straight-legged cane
Prone with head turned toward the side supported by a pillow.
Sims’ position with the head of the bed flat.
Right side-lying with the head of the bed elevated 45 degrees.
Left side-lying with the head of the bed elevated 45 degrees.
Keep the identities of the subject secret
Obtain informed consent
Provide equal treatment to all the subjects of the study.
Release findings only to the participants of the study
Use of laboratory data
Solomon-Four group design
Post-test only design
Res ipsa loquitor
The Board can issue rules and regulations that will govern the practice of nursing
The Board can investigate violations of the nursing law and code of ethics
The Board can visit a school applying for a permit in collaboration with CHED
The Board prepares the board examinations
Is no longer allowed to practice the profession for the rest of her life
Will never have her/his license re-issued since it has been revoked
May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173
Will remain unable to practice professional nursing
Formulating the research hypothesis
Review related literature
Formulating and delimiting the research problem
Design the theoretical and conceptual framework
Cause and effect
Plans to include whoever is there during his study.
Determines the different nationality of patients frequently admitted and decides to get representations samples from each.
Assigns numbers for each of the patients, place these in a fishbowl and draw 10 from it.
Decides to get 20 samples from the admitted patients
Sr. Callista Roy
Degree of agreement and disagreement
Compliance to expected standards
Level of satisfaction
Degree of acceptance
Sr. Callista Roy
Span of control
Unity of command
Avoid wearing cotton socks.
Avoid using a nail clipper to cut toenails.
Avoid wearing canvas shoes.
Avoid using cornstarch on feet.
Fresh orange slices
Ground beef patties
Sims’ left lateral
Arrange for typing and cross matching of the client’s blood.
Compare the client’s identification wristband with the tag on the unit of blood.
Start an I.V. infusion of normal saline solution.
Measure the client’s vital signs.
To increase blood flow to the heart
To observe the lower extremities
To allow the leg muscles to stretch and relax
To permit veins in the legs to fill with blood.
Instructing the client to report any itching, swelling, or dyspnea.
Informing the client that the transfusion usually take 1 ½ to 2 hours.
Documenting blood administration in the client care record.
Assessing the client’s vital signs when the transfusion ends.
Give the feedings at room temperature.
Decrease the rate of feedings and the concentration of the formula.
Place the client in semi-Fowler's position while feeding.
Change the feeding container every 12 hours.
Invert the vial and let it stand for 3 to 5 minutes.
Shake the vial vigorously.
Roll the vial gently between the palms.
Secure the elastic band tightly around the client's head.
Assist the client to the semi-Fowler position if possible.
Apply the face mask from the client's chin up over the nose.
Loosen the connectors between the oxygen equipment and humidifier.
1 hour before administering the next dose.
Immediately before administering the next dose.
Immediately after administering the next dose.
30 minutes after administering the next dose.
The nurse can implement medication orders quickly.
The nurse receives input from the pharmacist.
The system minimizes transcription errors.
The system reinforces accurate calculations.
Dullness over the liver.
Bowel sounds occurring every 10 seconds.
Shifting dullness over the abdomen.
Vascular sounds heard over the renal arteries.