~

Nursing Next Live

,._,...t ~ al ,_,..ing (dUl:Gllan
Nursing Foundations
• - - - ... ------- ·---
GOLDEN POINTS

CHANTING SESSIONS 16. Other terms used to describe the types and phases of
fever are :
Vital signs include five param eters, namely
l . temperature, pulse, respi ration, blood pressure and
a. Low pyrexla - 90°F to 100°F
b. Medium pyrexia - Includes whP.n tha
pain.
temperature is between
2. Pain is the S"' vital sign . 1oo•F and 103"F
3. The normal oral temperature of an adult is 98.G" F or c. High pyrexia - 103"F to 10':;°F
37•c.
d. Hypertherm ia > 105"F
• · Different routes of checking the temperature Include
(in adult) e. Hypothermia - includes <95°F/35"C
♦ Oral route: Normal range 98.6°F/37°C 17. Disposable tempadot is used to ch eck the temperature
for single use.
♦ Axillary Route:
0 18. The site of pulse in t he neck is called 'carotid'.
a. Subtract (l degree from oral route, then it
)

becomes the axillary route temperature (in 19. Other sites of checking pulse include:
case of Fahrenheit) 97 .6°F ♦ Apical
b. In case of Celsius, subtract 0.6°C, then it
• Temporal
becomes axillary route temperature, i.e.,
• Brachia!

s.
36.4°C.
• Radial
Rectal route temperature includes:
• Femoral
99.6°F/38.6°C- Here, to the normal oral temperature,
add +1 degree in both Fahrenheit and Celsius. •
♦
Popliteus
Posterior tibial
6. The normal axillary temperature of a newborn is ♦ Dorsalis pedis
between 97.s°F and 99.3°F (Ol); and 36.5°C and
20. Location of apical pulse in case of infant/child includes
37.4°C.
4th intercostal space midclavicular line; and in t he
7. Most preferred site to check the temperature in a adults, 5th lntercostal space midclavicular line.
newborn is the rectal route, 97.9°F to 100.2°F is the
21. Pulse deficit is defined as a deficit in pulse when there
normal rectal temperature in a newborn.
is a difference between apical pulse and radial pulse,
8. Temperature of 98.6°F is approximately equal to 37"C, mainly seen in the case of atrial fibrillation.
i.e., the normal oral temperature of an adult.
22. The normal respiration is known as 'Eupnea'.
9. The sudden fall of temperature from high to normal
23. The normal respiratory rate in newborns is 3~ 60
within a few hours is called crisis.
beats/min.
10. If the temperature falls from high to normal, then it is
24. The normal respiratory rate in adults is 12 to 20 beats/
called crisis.
min.
11. If the temperature gradually falls from high to normal,
25. If respiratory rate is less than 10 beats /min, it is called
then it is called 'lysis'.
bradypnea (in adults).
12. Crisis is of 2 types: true crisis and false crisis.
26. If respiratory rate is more than 24 beats/min in adults,
13. In true crisis, temperature falls from high to normal It is called tachypnea.
suddenly with Improvement in body condition. 27. Cheyne-Stokes respiration is an abnormal respiratory
14. Remittent fever is characterized by variation of more pattern that includes progressive rapid deep breathing
~ 2 degrees between morning and evening but followed by a gradual decline with a temporary period
pOt reach normal temperature. of apnea.
level/ constant fever: includes a variation 28. Biot's respiration ls also an abnormal pattern, it
temperature between morning and Includes rapid and progressive breathing with periods
does not reach normal. of apnea; here, the apnea periods are irregular.

•
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\................~~".No1ea t3•Pllt¥1
·- ~ ., . - ~-~~
-"Ct•

r ··········· ........ ------- -· -- The ..... -..

29
. Biot's respirati on is seen in tra uma to pons (or) 50. Preferred position . to . administ er \'e lltrem,_'
Medulla . -,
inj ect ion is lateral posit ion.
. The preferred site for intramuscular lnjecti,,_
30. ~u:smau l' respiration is also an abnormal pattern 51 -""\
infants includes vastus lat eralis.
it_ mcl~des faster, rapid and deep breathing , seen i~ 52. Iron injection is a_dminhist~ red by using 2 '
d1abet1c ketoacidosis. techni que, mai nly th is tee mque prevents ~ ~~
31. Normal systolic blood pressure Is 120 mm of Hg and of medicat ions to the subcutan eous tissue. ~
range includes (100-140 ) mm of Hg. _ The ideal length of insertion of rectal sup~ ,
53
32. Normal diastolic BP is 80 mm of Hg (60 to 90 mm of adult is 7.5 to 10 cm . 1

Hg). 54. Agents that prevent the multiplic ation of b~

33. If the BP cuff is t oo large narrow, it gives fa lsely high inhibit bacterial growth are known as 'Bactef~'
I
Cf,

reading. agents .
34. If the Bp cuff is too wider, then low read ings are seen. 5, Different methods of providing regjo~al ant~
5
spinal anesthesia, " : rve bl~ck ~nd epidura l~
35. Instrume nt used to measure blood pressure is
56. Abbrevia tions used ,n med1cat1on mana~ ~
sphygmomanometer.
36. The difference between the systolic and diastolic blood stat ➔ immediat ely ·

pressure is called pulse pressure . ➔ As needed

prn
(3D-60 mm of Every other day
37. The normal range is 40 mm of Hg Qod ➔
Hg). ➔ at Bed t ime
hs
38. The normal pulse oximeter reading is 95 to 99%. drops
➔
gtts
39. Different routes of medication administration include: qhs ➔
every night at Bed time
57. 0.45% of normal saline is an example of a ~
• Intravenous

• Intramuscular solution.

• lntradermal 58. IV fluids are of 2 types, namely crystalloidsand "'-

Colloids have large molecul ar weight and erar.,
• Intranasal 59 .

• Subcutaneous include 5% albumin and dextran.

60. Crystalloids include isotonic, hypoton ic,and hypena,
•Buccal

•Intra osseous solutions.

ations cl m
• lntrathecal
40. Route of administration for insulin and route
61. Isotonic fluids nears the concentr
is equivale nt to intracell ular fluids it is usel i
of administration for prefilled insulin syringe is hypovole mic shock.
subcutaneous. E.g., 0.9% NS
41. IM injections are given at 90°. Ringer lactate
42. Subcutaneous injections are given at 45°_ Dextrose 5% in water
-
1
'o 43. lntradermal injections are given at 15°.
Insulin syringe, if used, needs to be given at 45°_
Dextrose 5% in 0.22% NaCl
i 44.
62. Hypoton ic fluids mean the concent ration of sdi'.
45. Insulin pen should be administered at 90°. is less than the intracell ular fluids, cells get~·
46. lntrad~rmal route of administration includes where case of hypoton ic fluids adminis tration.
the svnnge should be in an almost flat position against
E.g., 0.45% NaCl
th~ patient's skin at an angle of 1s•, with the bevel up d•
whde administering medication.
63 Hyperto nlc fluids mean the concentration
solution is high as compare d to body fluid.
47. Ther~ are 4 sites of intramuscular injection, namely
deltoid, dorsolateral, ventrolateral, vastus lateralls. E..., 3" NaCl, 5% Nad, Dextrose lD"
lnJ calculate the body mass indd ·
48. In deltoid muscle, if you need to
the acromion process and place a
that drug can be injected.
49· To administer ventrogluteal I
over the greater trochant er Underw eight
superior iliac spine with the Normal
the middle finger away towa
OVerweight
adm!nister the drug in the s
and index fingers. ity
•
66,
---~-~.......
Nursing Next Live
~

The IV cannula used in hypovolemic shock is gray color

~ ~ .... ~ ___ ... _ ___

86. OtMr m~hods to di~k th'! right pt¥~

t.ube tndud~·
- --
______ Nu,$-Jng F -
.. -- -- ... ..
, ..,,

ut t,-..,
-
___ 1

67
_
(16 G).
rv cannula Color Flowrate
- 250 - 300 ml/min
a, A,;piration of gastr" ,ont~nt an~ pH M-'¥-tt(lr'"~1t
b. BP.sid~ "M ay
it
1• Gauze cannula - Orange
16 G ... Gray ... 220 - 180 ml/min c, Whoosh tett r~-
t8G -...
Green ... 90rnl/min d. Cher,king the placement by ms~t<;>n; tf 9J
t9 60 t::m is ln~ld~, t~n it i,; r()nfiun~ 1,Jf e~~
~
1
20G Pink - SSmlJmin l,.
Blue pl~,."!m~rit
22 G
~
- 33 ml/min i~
24G - Yellow
- 21 ml/min
87. The fird a<.ti<J1\ in ca'.'.e ~ f:.,lr)(Jd t,an-;l,.i",ol,t'.)(! ,~~.-..y,
Is Immediately stopping the i.,li,A tr3nsf1.>SKJO. ~~t-f, •
26G - Purple
- 10-1S ml/min one blood transfu~ion should o. o.,m~-,d 1r-t-J-: •ri 4
~
~
68. The 18G cannula is commonly used for blood hours time and th~n start 0.9% oormaJ ~t,r,-... 2
transfusion. 88. Blood transfusion bag should be disr.¥~ m -rt.1.r,11 f
I
69. The potential complications associated with peripheral bag, ,t
N therapy include phlebitis, edema, thrombophlebitis 89. logroll technique is used to har,g eth posftj(.)t) ,n tt-7~ 2
and infiltration.
70. Thrombophlebitis means palpable lnduration with
erythema.
clients undergone the spinal wrg.e ries {or) tollowlr.g
Trauma. Here without di~turbance to ~,,,aj wr'1
patient is turned.
'
•
!
~

~
71. Infiltration means if fluids leak into the tissue, swelling 90. Position of child in nose bleeding, i.e., m ~~~
cs observed. includes pinch the nose and lean foflow'!d for 10
...
;if
.D
~
72. Mainly vesicant drugs lead to extravasation. minutes, to prevent backflow of ble~ir.g.
73. The concentration of oxygen in inspired air is '21%' 91. Trendelenburg position is used in shock ~ e the foot z=
?:-
and in expired air is '16%'. end is elevated. •
=
92. In reverse Trendelenburg position~ head end is
74. CVP line dressing should be changed every 5-7 days or
when It gets soiled to prevent infections (CLABSI). elevated. I
~

93. Hospital-acquired infection (HAJ} is also known as ~

75. Cl.ABS! -Central line-associated bloodstream infection •
nosocomial infection. a
76. Sim's position/left lateral position is used to administer
94. HAI is referred to as an infection acquin~d afr..er- 48 'i
enema.
77. The enema that is used to relieve the gaseous
hours of admission. ia.
95. The most common site of hospital-acquired infection !
distention from the abdomen is called antispasmodic .!
is CAUTI.
enema. """
•e
96. Other HAis include:
78. Carminative enema increases the intestinal peristaltic
movements, which decreases distention.
CAUTI
SSI
Catheter associated urinary tract infection
Surgical site infection
•l...
79. Turpentine+ soap water is used as carminative enema. £
VAP Ventilator associated pneumonia 15
80. Insertion of a tube inside the stomach through the l:'.
nose is called "Nasogastric intubation". It is done with CLABSI Central line-associated b&oodstream !
rylestube. infection I
81 Gastric gavage includes NG tube feeding.
97. The single most important technique for prevention of
hospital-acquired infection is 'hand hygiene'. '
:::i
-6
•
82. Gastric lavage means Irrigation of the gastric content
done In case of poisoning.
IJ. ,.,.,. for the patient with continuous ryles tube
98. There are S moments of hand hygiene recommended
by WHO:
-
!
~z
C

a. Before touching a patient

-
15
Jndudes Fowler's position. ~
b. Before clean/sterile procedure 'C
feeding Is done with gravity bags.
1n NG Intubation Is done to check the
c. In case of exposure to body fluids !
of NG tube where air Is pushed
d. After touching a patient i
the NG tube and slmultaneously
whoosh sound with the help of a
e. After touching a patient's surroundings
99. Universal precautions are followed to prevent the
-a
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!
u
ns It on the epigastrlc region. transmission of AIDS.
i
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-- . -
- -
. - - - - -- care of dying:
100 ti o n s include: 11 7· ath, the sub·
. U ni ve rs al p re ca u t: Fo llo w in g
de
hi ng ♦ Bereavemen g loved ones ,-s~~
a. H an dw as by the su rv iv in ~
ti ve e . response
se o f pe rs on al pr ot ec qu ,p m en t like
face
b. U
gg le s m as k es 'Bereavement'. c_li~nt is aware
ti._
sh ie ld , go ' , gown, gl ov
The ty pe o f lo
ss in w hi ch th e C1patory •0ss. -"'
. te m an ag em en t • kn ow n as ant1
c. B io m ed ic al w as lo ss w ill occur is afte r dea th is
called IL
io n pr a f t ne ed le stick in t he bo dy ·,
d. S af e in je ct c ices to pr ev en ♦ S tif fn ess
in ju ri es M or tis . ,s te m pe rat ure a er deavi
ft
bo dy
n Decrease in
e. Disinfectio ens w hi le
•
· k o f transferring pathog called Algor M
or ti s. , '"°"-.
as e th e ns h is ca lle d Uvo
ec
1 0 1 . To d . re
gl ov es, pu ll caver
cu ff an d
• Discolo ration after de at
am in at ed iously.
~emovmg co nt d th en re move them caut
es an
in ve rt th e glov from needle stic
k in ju ry is
NURSING PRO
CESS co lle ct io n of
~
ct io n co nt in uo us ;
on in fe
10 2 - T he ~ o. st co m m hepatitis c and then HIV. st em at ic an d
s is ca lle d un
•N
en 11 8. The sy rs in g pr oc es
hepat1t1s B, th edle prick are as part of th e nu
in g he pa titis B af te r ne
10 3. C ha nc es
of ge tt
at iti s Care 2-
3% an d fo r HIV Assessment". m ea su ra bl e piece
sa
ce s fo r H ep es al l th e
22 - 23%, ch an th at in cl ud
11 9. Data je ct iv e da ta .
ca lle d ob
-0 .3 %. in fo rm at io n is ude 3 ~
te managemen
t: em en t sh ou ld incl
Biomedical w as st at
fe ct ed co tto n, 12 0. The di ag
no st ic
sign an d sym
ptom.
1 0 4.
ic al w as te (placenta), in s of gy , an d th en
H um an anatom expired medication, these type le m , et io lo to tit
10 5. pr ob si s is linked
ia l, rs in g di ag no
dr es si ng mater 121. The nam
e of th e nu
la te d to'.
llo w bi n . th e ph ra se 're
w as te go in to ye les are discarde
d in w hi te et io lo gy w ith is kn ow n as "F
idelit;1
es an d ne ed ep a pr om is e
10 6. S ha rp blad ag re em en t to ke
f container. 12 2. An
pu nc tu re proo s are discar
ded in bl ue
al pr in ci pl es :
pu le 12 3. Ethic od/Benefit 1
10 7. Vials an d brok
en am
e of B en ef ic ence:· D oi ng go
aste bin. d a. Principl
bi om ed ic al w
eq ui pm en t is
done by a metho th e pa tie nt n
n of su rg ic al o ha rm to patie
10 8. Sterilizatio e o f N on m al ef ic en ce : N
claving. b. P rin ci pl and fl
known as auto st he at st er ili
za tio n. ov id e eq ua l
kn ow n as m oi ci pl e of Ju st ic e: To pr
la ve is also c. P rin
10 9. Autoc
tr ea tm en t omise
11 0. In autocl
ave: ep in g on e' s pr
= 15 Psi e of fid el ity : In cl ud es ke
12 4. P rin ci pl nt
The pres re su is fu l to th e patie
= 12 1° c ci pl e o f ve ra ci ty: B ei ng tr u th to ~
125. P rin th e rig ht
Temp P at ie nt has
= 15 -2 0 m in s e of au to no m y:
tment
Time nt us ed to 12 6. P rin ci pl d to th e trea
a hi gh -le ve l di si nf ec ta he r ow n de ci si on re la te
so lu tio n is e th e his or duals 11
111. Cidex es an d en do scopes, etc. plac in cl ud es w he re th e indivi
rosc op ab ili ty
di si nf ec t lapa in ut es . 127. A cc ou nt ei r ac tio ns an
d have th e obli~- I
t fo r at le as t 20 m le fo r th
in st ru m en so lu tio n to an sw er ab
od uc in g a di si nf ec ta nt
ess o f in tr n so m eo ne to ac t lut/6
112. The proc th e bo dy w he l to rt "; it inc
vi ro nm en t o f
an "u ni nt en tio na
th e in te rn al en in g". 128. N eg lig en
ce is
ocols/po lic ie sc ii
0
ay is ca lle d "E m ba lm e fa ils to fo llo w th e prot irf
z passes aw at io n is when a nurs ot he rs ar e follow
he at ap pl ic
to th e sa m e ti m e
t 113. Physiolog
ical re
va so di la tio n
an d ph
sp on
ys
se
io lo gi ca l response to
co ld is ho sp ita l w hi ch at
gl ig en ce is "M
ed ic at io n er
rors".
I!' vasocons tri ct io n.
rs w hi ch
129. E xa m pl e of ne
t in ca se o f a m ed ic al emer
gency wht.!
va so di la tio n oc cu 130. Type o f co ns
en an d no imm1
j t ap pl ic at io n,
an d increase
s lo ca l in fo rmed co ns en t,
114. A ft er ho pa ti en t ca n' t gi ve decisio(IS
'6 increases th e
bl oo d flo w
d viscosity. be re ac he d to m ak e su ch
y de creasing bl oo fa m ily ca n

I :::t , th er eb curs
metabolism ns tr ic tio n oc en t"•
115• Following cold applic
at io n, va so co "I m pl ie d co ns sibility to ~er
lit y, an d al so hours respon
ry pe rm ea bl
I decrea se s ca pi lla
d viscos . ity tJents, it is te rm ed pn
d Increases bl oo
• eases bloo d flo w an
te ns io n to ,,
Il 116. ~ h e ra p y
used.temperatu
: Ex po
re and comm
sing the tissue
only llquld n as "s yn dr om e ·

e
 ~
rsing Next Live
,.,u a1..,,..~ Nursing Foundations
11,j

•
--"--:-'-------- ----~---- ---- ---- --- - ---- ---- ---=- ----- ---,
·- .- supervision of patients with a chronic 153. If the score 16 - 22 - Low risk
Part t1me
133, • n is called respite care. 13 - 15 - Medium risk
cond1t10
I m
entarv health care refers to an alternate 10- 12 - High risk
34. comPe .
1 tem of medicine. 9 or Below - Very high risk
:Sdevice used to aid immobilization of a patient Is 154. Before giving the skin incision to a patient, 'Time out'
135. called restraint. surgical safety protocol is followed.
6. A inflammation of the oral mucosa Is termed 1S5. Pressure ulcer stages include:
13 ..•
"stomat,tts . Stage 1: Skin is Intact and non~blanchable redness
tack of 0 ,cygen in the blood is called "Hypoxemia". Stage 2: Includes dermis involvement
137. f I f
Cheilosis means cracking o ang es o mouth. Stage 3: Involvement of subcutane<J 1JS tissue
138.
Lack of oxygen in tissue is called hypoxia. Stage 4: Bone is involved
139,
9orborygmi means rumbling/hyperactive bowel Unsaleable: Base of wound is covered with dead
1.0.
sounds. tissue.
11 number blade is also known as "stab surgical blade". Deep tissue injury: purple color blisters are seen.
141.
site for arterial
142, Radial artery is the most preferred 165. Eruption of bowel through surgical site is called
blood gas analysis. evisceration.
Test performed to check the patency of the ulnar
1u, 157. An opening of surgical wound edges rs called
artery is •Modified Allen's test". dehiscence.
1.._ In total parenteral nutrition (TPN), proteins, 158. Surgical removal of infected or dead tissue from the
carbohydrates and water electrolytes are given. wound is called debridement.
145. If TPN is given to a malnourished patient, refeeding 159. Around where the skin layers have been scrapped of is
syndrome can occur which causes a decrease in "Abrasion".
phosphate, magnesium and potassium levels.
146. Indications of the Swan-Ganz catheterization include PODCASTS
checking for pulmonary artery pressure and measuring
160. Point of care testing, also known as bedside testing, is
carcfiac output.
a diagnostic procedure. It is performed near or at the
147. Jaw thrust maneuver is done to lift the mandible. patient's bedside. Examples of point of care testing are
148. The order in which an abdominal assessment is blood glucose testing, ABG tests, ECG monitoring and
performed is: fecal occult blood testing.
a. Inspection 161. Blood lancet is a small medical equipment used for .8
b. Auscultation capillary blood sampling.
c. Percussion 162. Coagulation studies such as PT/INR are collected in
d. Palpation citrate tube (light blue).
149. If any patient is lying on the floor, the first action to be 163. Blood sugar sample is collected in fluoride tube (gray
performed is to check the response. color tube).
150. Sc.ale used to assess the risk of pressure ulcer is Braden 164. Hematology tests are collected in EDTA tube (lavender
risk assessment scale. color).
151. Braden risk assessment scale includes the following 165. Purple blood bottles contain EDTA (ethylenedi-
CX>mponents: aminetetraacetic acid), which acts as a potent antico-
a. Sensory perception agulant by binding to calcium in the blood.
b. Moisture 166. The purple tube needs inverting about 8 times to mix
the sample with the EDTA.
C. MobUlty
167. Blue blood VACUTAINER contain buffered sodium
citrate, which acts as a reversible anticoagulant.
168. Yellow VACUTAINER are used for the analysis of tests
related to biochemistry, endocrinology, oncology,
toxicology, microbiology and immunology.
169. The blood culture bottle ideally requires 8-10 ml
of blood to ensure a good chance of catching any
organisms.
 •
Nnt~ . .
: Revlalon Not••flefti:fJ.-j
'• ·- • • ••• 40 • ~- ···· ·· · -
2 CLINICAL SUBl(CTS Nursing Next L~
n .. Next l - ol N\J I
""Illa
v..,:
""•u..,
170. Sodium polyanethole sulfonate is the most common 190. Insulin is administered 2 finger widths away fro
ADDITIVE used in commercial blood culture bottles. umbilical site. rn the
171. CDC recommends the use of 2% chlorhexidlne 191. Rotation of site of injection is important to Pre
gluconate solution for dressing the CVP line. llpodystrophy. '-'ent
172. The gravity enteral feeding bag should be used for 24 192. Insulin pen Is Injected at a 90-degree angle into h
hours, then it should be discarded. subcutaneous t issue because the size of tho lw t _e
,11 1in
173. Continuous feeding is administered over a period of pen is ½ Inches.
24 hours; it usually includes a break of 4 hours to allow 193. Priming of insulin pen should be done bet
the stomach to re-acidify. . I . ore
administration. For prIming, a P unger 1s pressed
174. Behavioral pain scale (BPS) is used to assess the level that a droplet of Insulin appears at the needle tip, so
of pain in an intubated patient. 194. s back slaps between the infant's shou lder followed r,
175. Richmond agitation sedation scale is used to assess S chest thrust are given to the infant w ho is choking. 1
the level of sedation as well as agitation level. 195. Enteric-coated tablets should not be crushed
Or
176. fLACC stands for face, legs, activity, crying and chewed; they should be swallowed with a sufficient
consolability. It is used to assess the level of pain in amount of water.
children. 196. The Heimlich maneuver (abdominal thrusts) is a rapid
177. Wong-Baker FACES pain rating scale is a pain first-aid procedure to treat choking that occurs due to
assessment tool designed around a set of faces that upper airway obstruction in case of adu lt choking.
display different emotions. 197. During choking, parents should avoid using the blind
178. Braden risk assessment scale is used to assess the risk finger sweep for removing an ingested obj ect.
of pressure ulcer formation in an unconscious patient. 198. Magill forceps are angled forceps used to guide a
179. The position of bedridden patients should be changed tracheal tube into the larynx or nasogastric tube
every 2 hours to avoid the pressure sore formation at into the esophagus. They are used to rem ove foreign
pressure points. bodies.
180. Always lift the patient and avoid dragging as friction 199. Sponge holding forceps are used to pick up cotton
and shear can disrupt the skin integrity. swabs and sponges during surgical procedures.
181. An unconscious or semiconscious patient should be 200. A sentinel event is any unanticipated event in a health
placed in a lateral position to prevent the obstruction care setting that results in death or serious physical or
of airway by the tongue. psychological injury to a patient.
182. Guedel airway or oropharyngeal airway prevents the 201. WHO recommends hand hygiene for 20-30 sec with an
tongue from falling back on the posterior pharyngeal alcohol-based hand rub solution.
wall or epiglottis. 202. Alcohol-based hand rub is the best measure for hand
183. Chest drains, also known as water sealed drains, are hygiene, if the hands are not visibly soiled.
inserted to allow draining of the pleural spaces of air, 203. Handwashing with soap and water is recommended
blood and fluid. for 40-60 sec, if the hands are visibly soiled.
184. Oscillation/swing/tidaling in chest tube drain is a 204. According to WHO, the recommended time for
0 normal finding. performing surgical handwashing is 3 to S minutes.
z
185. Bubbling in chest tube drain reflects the amount of 205. Handwashing is performed to remove transient fiora
air draining out of the pleural space. It usually occurs from the skin.
during expiration or coughing. 206. Dr. Ignaz Semmelweis is also known as the father of
186. Continuous bubbling in water seal drainage system handwashing and infection control.
indicates an air leak. 207. Surgical mask, also known as a triple-layer mask, is
187. Spontaneous cessation of swing may indicate that the recommended to prevent droplet transmission of
tube is blocked or kinked. infection.
188. The most effective general measure to be applied 208. Respirators are respiratory protective devices designed
in case of active bleeding is the application of direct to achieve a very efficient filtration of airborne
pressure over the bleeding site. particles.
189. Tourniquet is used to control bleeding which is not 209. Respiratory seal check is a procedure conducted bY
controlled by direct pressure and elevation of limb 11
a respiratory wearer to determine if the respirator
above the heart level. being worn properly.
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t common type of re spirato r is N9S 225 . Infestation is the state of being Invaded by PE"its or
21 rec0mmen ded by an American standard managed by
0. The mos parasites.
,osH-Part of CDC. 226. WHO recomm ends at least S ml or 3 dos es of liquid
N d air-purifying resp irators ca n be used as an solution for effective h;indwashing.
211. poweretive to N-95 for use by HCWs d uring aerosol 227. Following medical handwashing with s1Jap and w.iter,
altema
enerating procedures. the hands are kept below the waist lev~I Y:> t hat the
~ per CDC guidelines, thesequen ce of donn ing Is as wa ter droplets dribble from less conta m ,n.r~rJ area
212· follows: hand hygiene, gown, mask, goggles or fa ce (elbow) to more contaminated area (hands).
shield and gloves. 22 8. Gloves should be worn and removed from the nor;-
H pital-acquired infections are acqu ired within 48 dom inant hand first.
213 · ~~rs after the hospital admission, or within 30 days
229. Asepsis is th e state of being free from disease-causing
after an operation. contam inants such as bacteria, viruses, fu ngi and
A central line-associated bloodstream infection parasites.
21
'-· (ClABSI) is defin_ed as a laborato~-conf_irmed 230. Sterilization refers to any process that ki lls or
bloodstream infection not related to an infection at deactivates all forms of life including spores.
another site that develops within 48 hours of a central 231 . Disinfection is the process of eliminating the
tine placement. pathogenic microorganisms, exclud ing bacterial spores
us. Catheter-associated urinary tract infections (CAUTI) on inanimate objects.
are one of the most common healthcare-associated 232. Antiseptics are antimicrobial substances that are
infections {HAis). applied to living tissue/skin to reduce t he possibility of
0
216. Surgical site infections (SSls) are defined as infections infection, sepsis or putrefaction . E
occurring up to 30 days after surgery (or up to one 233 . Contact precautions are recommended for infections ~
year after surgery in patients receiving implants) and or germs that are spread by touch ing the patient or
affecting either the incision or deep tissue at the items in the room (examples: MRSA, diarrheal illnesses,
operation site. open wounds, respiratory syncytial virus infection ).
217. Ventilator-associated pneumonia is defined as 234. Droplet precautions are used for diseases or germs
pneumonia occurring more than 48 hours after that are spread through t iny droplets caused by
patients have been intubated and have received coughing and sneezing (examples: pneumo nia,
mechanical ventilation. influenza, whooping cough, bacterial meningitis).
218. Keeping the head of the bed elevated between 30-45 235. Airborne precautions are used for diseases or very
degrees {semi-recumbent position) is recommended small germs that are spread through air from one
to reduce reflux and subsequent risk for ventilator- person to another (examples: tuberculosis, measles,
associated pneumonia. chickenpox).
219. Care bundles are a group or set of evidence-based 236. Cohort isolation refers to placing patients w it h t he
practices meant to reduce the transmission of same infection in the same place to receive treatment
healthcare-associated infections. and prevent the spread of infection.
220. According to CDC, it is recommended to perform CVP 237. Positive pressure isolation rooms are used to isolate
line dressing every 5 to 7 days with a transparent immunocompromised patients, such as transplant
dressing material or every two days with a gauze and cancer patients, to reduce the risk of airborne
dressing. transmission.
221. The ClABSI rate is calculated per 1,000 central line- 238. Air pressure in a room under positive pressure is higher
days by dividing the number of CLABSls by the number than outside so that contaminants (particles, viruses,
of central line days and multiplying the result by 1,000. bacteria) are kept out.
222. The central line should be flushed with 10 ml of 0.9% 239. The positive pressure environment is used to protect
SOdium chloride solution after every medication patients in operating theaters so that infection does
administration to ensure that the line is clear of not enter open body cavities.
medications and to reduce the possibility of infections. 240. The air pressure in a room under negative pressure
223. is lower than outside so that contamination from the
Iatrogenic infection refers to an infection that a person
sets following a treatment modality or procedure. room does not flow out into surrounding areas.
224.
Opportunistic infections (Ols) are infections that occur 241. The negative pressure environment is used for airborne
more frequently and are more severe in people with Infection control to protect people from patients with
Weakened immune system, Including people with HIV. highly contagious diseases (e.g., TB) .
:-------------------- -----------------
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242 . Negative-pressure isolation rooms require a minimum

of 12 air changes of exhaust per hour.
261. Ethylene oxide is a process

like endoscopes.
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of sterilization that us
d 1· .
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temperature gas to sterilize very e 1cate 1nstrunien 1
ts
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243 . Standard precautions are a set of Infection control
practices used to prevent the transmission of diseases 262 . Peel open pouches, also called self-seal ed plasr
k . IC Or
through contact with blood, body fluids and mucous paper pouches, are used to pac instruments th
membranes. have been sterilized by ethylene oxide. at
244. Universal precautions are a standard set of guidelines 263. Bacillus stearothermophilu s is used to biological!
to prevent the transmission of bloodborne pathogens
monitor the effectiveness of stea m autoclave. ~
from exposure to blood and other potentially Infectious 264. Activated cidex solution can be used up to 14 days,
materials. 265. Cidex or 2 percent glutaraldehyde solu tion provide,
245. 1'irborne infection is spread by droplet nuclei which cost-effective, high-level disinfection fo r a wide rar, i
are less than S micron in size that remain suspended In of endoscopic and laparoscopic instruments. llt
air for long periods of time. 266. Ultrasonic cleaners are used to remove microorganisrn
246. The air exiting a negative pressure environment has to and other fine debris from less accessible surface;
be filtered with a high efficiency particulate air (HEPA) instruments.
filter. 267. Louis Pasteur, who is also known as the father of
247. Once a sterile field is set up, the border of one inch at microbiology, introduced sterilization techn ique.
the edge of the sterile drape is considered non-sterile. 268. The thermal death point of a microorgan ism is the
248. 2% Glutaraldehyde is a high-level disinfectant that can lowest temperature at which all the microbes are
be used to sterilize surgical instruments. killed in 10-minute exposure.
249. Terminal disinfection is done when the patient has 269. Autoclaving is based on the principle of moist heat
died or has been discharged from the hospital. sterilization.
250. Concurrent disinfection is the disinfection of the 270. In an autoclave, a temperature of 121 degrees Celsius
infectious agent, which is done for urine, feces, must be maintained for at least 30 min utes under at
ciothes, dressings, etc. least 15 psi of pressure.
251. High-level disinfection kills vegetative microorganisms 271. Hot air oven is a type of dry heat sterilization.
and · inactivates viruses, but not necessarily high
272. Dry heat sterilization requires 160 degrees Celsiusfor
numbers of bacterial spores.
2 hours for effective sterilization .
252. Intermediate-level disinfection kills vegetative micro-
273. Tyndallization is a sterilization method th at kills all
organisms, including Mycobacterium tuberculosis, all
forms of bacterial life including spores.
fungi, and inactivates most viruses.
I 274. Tyndallization involves boiling and exposu re to steam
253. low-level disinfection kills most vegetative bacteria

' except M. tuberculosis and some fungi; and inactivates

some viruses.
254. Glutaraldehyde solutions should be discarded if they
at 100 degrees Celsius for 20 minutes for 3 consecutive
days.
275. Hot air oven is the best method of sterilization for
sharp instruments.
become turbid.
276. The central sterile supply department is responsiblefor
255. Alcohol-based hand rubs are recommended for the
decontamination of lightly soiled hands in situations preparing medical/surgical supplies and equipment
where proper handwashing is inconvenient or not 277. Autoclaving followed by shredding is the final
possible. treatment of waste collected in a red colo r bin.
278. Incineration or plasma pyrolysis or deep burial is1
256. Critical items enter body cavity or sterile tissue
and they require sterilization. For example, surgical recommended method of waste collection in a ve110"'
bin.
Instruments.
279. Wa st e of puncture proof container is disposed of bl
257. Semi•critical items such as anesthesia equipment,
bronchoscopes, laryngoscopes, etc. come In contact autoclaving followed by shredding or encapsulation~
with mucous membranes or non-intact skin. cement concrete (sharp pit).
280. A!I cyto_toxic Items are discarded in a yellow colli
258. Non-critical objects require low-level disinfection as
they come In contact with intact skin only. biomedical waste bin with a cytotoxic label.
281. As per the protocol and new Biomedical wa~e
259. Dynamic air removal test is also known as Bowie-Dick
Management Rule 2016, all the metallic irnP130 ~
test.
should be discarded in a separate blue container.
260. Bowie-Dick test is used to ensure that no air gets
282. Plastic bag infected with blood or blood producll
trapped or leaked into the sterilization chamber of a
should be discarded in a yellow bin.
steam sterilizer.
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cc pain scale is used

to assess pa in In children
n months and 7 years.
__ - ~urslng Foundations_

30S. Cumulative action of drugs refers to greater biological

effect due to the accumulation of repeated doses o f
t,etwee 2
6 faces in Wong-Baker pain sca le. drugs in the body.
, n,ere are
28 · al pain originates from Internal body organ s or 306. ldiosync.ratic response to a drug refers to an individual's
v1scer , .
285 · . ra such as pain in appendicitis. unique and unpredictable respon s.e to tht' rlrn5'
visce
somatic pain originates from skin, muscle, skeleton, 307. Physical and psychological rellancl! on chemic.al agent;
286 . resulting from continued use, abu se or addiction to a
· joints and connective tissu_es .
_ Patient-controlled analgesia (PCA) 1s a method of pain drug Is known as drug dependence.
287 control that gives patients the power to control th eir 308. A paradoxical response to a drug is directly !J$ipr1 -: 1t P. t o
the desired therapeutic response.
pain.
P<:A uses a computerized analgesia pump that contains 309. Hypoglycemia reaction after giving insulin is most
288. likely to occur during peak time.
syringe of pain medication connected to a patient's
1
Nfine. 310. Biotransformation is a process by which a substance
Pain with pressure over McBurney point is associated changes from one chemical to another by a chemical
289.
with acute appendicitis. reaction with in the body.
year on 5 th may 311. The half-life of a drug is the time it takes for the amount
29(). Hand hygiene day is celebrated every
byWHO.
of a drug's active substance in your body to reduce by
1 half.
291. World AIDS Day is celebrated on 1• December every
year. 312. Drug toxicity refers to adverse effects of a drug
292. The 2020 Global Handwashing Day theme was "Hand that occur because dose of the drug or plasma
concentration has exceeded the therapeutic range.
Hygiene for all".
293. WHO has chosen year 2020 as the "Year of Nurse and 313. Lipoatrophy is the breakdown of adipose tissue at
the insulin site causing a depression in the skin at the
Midwife".
injection site.
294. The gravity enteral feeding bag set should be used for
24 hours, then it should be discarded. 314. Occupational Safety and Health Administration (OSHA)
is a large regulatory agency of the US Department of
295. SBAR communication stands for situation, background,
Labor.
assessment and recommendation.
315. The aim of OSHA is to ensure safe and healthy working
296. SBAR is used in health care organizations to implement
conditions for employees.
a standardized approach to hand-over communication
between staff. 316. Placement of an ET Tube is confirmed by a chest X-ray.
297. 16 and 18 gauze IV cannulas are the most commonly 317. The correct placement of an ET tube is 1 to 2 cm above
used in trauma cases. the carina.

298. IV Cannula should be inserted at an angle of 30-45 318. Suction is pulled back 1-2 cm above the carina during
degrees in deep veins. suctioning to prevent complications such as tracheal
mucosal injury.
299. If the vein is superficial, then IV Cannula should be
inserted at an angle of 15-25 degrees.
319. The minimum available size of an uncuffed ET tube is
2.0mm.
JOO. Braden scale is used to assess the risk of pressure
ulcer. 320. The uncuffed ET tube is commonly used in pediatric
301• The Richmond Agitation Sedation Scale (RASS) is an cases.
321. Bruit, also called vascular murmur, is an abnormal
Instrument designed to assess the level of alertness
sound generated by the turbulent flow of blood in
and agitated behavior in critically-ill patients.
302 an artery due to either an area of partial obstruction
• Infiltration occurs when IV fluid or medication leaks or a localized high rate of blood flow through an
Into th e surrounding tissue.
303 unobstructed artery.
· ~asation refers to the leakage of vesicant drugs
322. Strider Is an abnormal, high-pitched sound produced
tJsom blood vessels causing damage to the surrounding by turbulent airflow through a partially obstructed
sues.
I04. Pain
Cornrnon 51 airway at the level of the supraglottis, glottis,
st· &ns and symptoms of extravasatlon Include subglottls, or trachea.
arou'nd ;~sing or burning sensations, and edema 323. Stridor Is most prominently heard during inspiration.
e Intravenous (IV) Injection site.
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t Unintentional torts are unintended acts again

324. Crackles are bubbling or popping sounds that 343 . patient that cause them harm. st a
represent the presence of fluid or secretions, or the
344 Negligence is defined as a failure to provide care that,
sudden opening of closed airways. · reasonably prudent person would have. •
325. A wheeze Is a continuous, coarse, whistling sound
produced in the respiratory airways during breathing. 345. Malpractice is a specific term for neglieence by a
326. Wheezing is commonly experienced by people who Professional, like a registered nurse.
have asthma, foreign body obstruction or malignancy 346. Informed consent is a process of communicatio
of the airways which causes narrowing. bet ween you and your health care provid er that often n
327. The pleural rub sound results from the movement of leads to agreement or permission for ca re, treatment,
inflamed and roughened pleural surfaces against one or services.
another during the movement of the chest wall. 347. Assent means a child's affirmative agreement 1G
328. Percussion over normal, healthy lung tissue should participate in research.
produce a resonant note. 348. Confidentiality refers to the duty to protect privileged
329. Dull percussive sounds are indicative of abnormal lung information and to share entrusted information
density; most commonly seen in atelectasis, tumor, responsibly.
pleural effusion and lobar pneumonia. 349. Autonomy means that patients/clients have a right to
330. Hyperresonance on percussion indicates that too much self-determination.
air is present within the lung tissue. It is commonly 350. Leave Against Medical Advice (LAMA), also called
seen in emphysema or pneumothorax. discharge against medical advice (DAM A), is an act in
331. A rigor is an episode
of shaking or exaggerated which a patient takes his/her discharge contrary to the
shivering which can occur with a high fever. recommendation or will of the attending physician.
332..
Braden scale is composed of six subscales that reflect 351. The Morse Fall Scale (MFS) is a rap id and simple
sensory perception, skin moisture, activity, mobility, method of assessing a patient's likelihood of falling.
friction and shear, and nutritional status.
333. The maximum score on the Braden scale is 23. A score 352. Caloric reflex test is a test of the vestibulo-ocular reflex
that involves irrigating cold or warm water or air into
of 16 or less indicates a higher risk of pressure ulcers.
the external auditory canal.
334. Tongue protrusion test is performed to assess
hypoglossal nerve. 353. Caloric reflex test is used to assess vestibular reflexes
335. Extraocular movement of the eye is controlled by the of the inner ear that control balance.
354. Tympany is high-pitched and sounds like a drum in
JftJ cranial nerve.
336. A tort is an act or omission that gives rise to injury terms of quality with longer duration than resonance
and hyperresonance.
or harm to another and amounts to a civil wrong for
355. Tympany is typically heard over air-filled structures
which courts impose liability.
such as the small intestine and the large intestine.
337. An intentional tort is a willful act that violates a
patient's rights.
356. Dullness is typically heard over fluid or
solid organs
338. Assault is a threat made against a person that makes such as the liver or spleen, which can be used to
them fearful. determine the margins of the liver and spleen.
357. Fremitus refers to the assessment
339. Battery is the harmful, offensive or unauthorized of the lungs by
touching of another person. either the vibration intensity felt on the chest wall
1 340. Defamation of character Is making derogatory called tactile fremitus.
358. Fremitus
f
15
statements about a person that harms their reputation
or character within a community.
341. Slander is any defamation of character that is spoken. 359. E b,
can be heard by a stethoscope on the ches1
wall with certain spoken words called vocal resonance.
· 1st
r s point · he auscultation location for heart so und5

I
I
II!
342. Libel Is any defamation of character that is written. and heart murmurs located at the th ird interco5!3
space and the left lower sternal border.
1