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65 terms

Fundamentals HESI

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Temperature range for adults
36-38 C (96.8-100.4 F)
Average oral temp
37 (98.6)
Average rectal temp
37.5 (99.5)
Average axillary temp
36.5 (97.7)
Pulse range
60-100 bpm
Respiration range
12-20 bpm
Prehypertension range
120-139/80-89
Stage 1 Hypertension
140-159/90-99
Stage 2 Hypertension
Over 160/ over 100
Where should a blood pressure cuff NOT be placed?
Not on site of IV, fistula, mastectomy
What should a patient do before having their blood pressure taken?
Avoid caffeine/smoking, rest 5 minutes before taking BP
What sounds represent blood pressure noises?
Korotkoff's sounds (1st-systolic, 4th-diastolic)
What is the most BP can vary between arms and still be considered normal?
10
Normal respirations in newborns
35-40
Normal respirations for infants
30-50
Normal respirations for toddlers
25-32
Normal respirations for children
20-30
Normal respirations for adolescents
16-20
Normal respirations for adults
12-20
Intervention for insomnia
Sleep and exercise; encourage client to begin walking routinely during the day, but not 2-3 hours before bedtime
Who can perform catheter insertions?
RNs. UAP can only position patient, report discomfort, report characterization of urine
How far should a catheter be inserted?
2-3 inches for female; 7-9 inches for male
Chain of infection
Infectious agent/pathogen --> reservoir/source for growth --> portal of exit from reservoir --> mode of transmission --> portal of entry to host --> susceptible host
Showering with an IV
Adjust IV flow rate to KVO and remove IV tubing from pump. Reset after shower is over.
Logrolling
Obtain assistance; place pillow between client's knees (prevents tension on the spinal column). Cross client's arms (prevents injury).
Measuring intake and output
I-O= Total; when you flush a GI tube, have an IV running, or wash the perineum, yo have subtract this from your output. Check I&O every 8 hours. Weight can tell if fluid retention
Two types of contact transmission
Direct and indirect
Direct contact transmission
Applied to care and handling of contaminated body fluids
Indirect contact transmission
Involves transfer of an infectious agent through a contaminated intermediate object
Droplet precautions
Used for diseases that are transmitted by large droplets that are expelled into the air 3-6 feet. Mask, hand hygiene, dedicated care equipment. Ex. influenza
Airborne precautions
Used for diseases that are transmitted by smaller droplets that remain in the hair for long periods of time. Requires negative air flow; air filtered through HEPA filter
Protective environment
Focuses on clients w/ transplants or gene therapy; positive airflow (>12 exchanges/hour).
Basic contact precautions for protective environments
Hand hygiene before and after entering room; dispose of contaminated supplies in a way that prevents the spread of germs; use protective barriers; protect all persons who might be exposed during transport
Heat application guidelines
Must have health care provider's orders
Do's for applying heat/cold therapy
Explain sensations to be felt; report changes immediately; provide timer and call light; look up safe temps
Don'ts for applying heat/cold therapy
Don't let client adjust temp; don't allow client to move application or place hands on wound; make sure client can move away from temp source; don't leave client who can't feel temp changes
How long can a restraint order be good for?
4 hours for adults, 2 hours for children (9-17) and 1 hour for under 9
IM site/ ventrogluteal
Deep site situated away from major nerves and blood vessels; less chance of contamination; easily ID by bony landmarks; total IM volume is 3mL
6 Rights of Medication Administration
Right dose, right time, right patient, right route, right documentation, right medication
Syringe sizes used for IM and subQ injections
1-3ml
When are syringes larger than 5 mL used?
Administer IV meds, add meds to IV solutions, irrigate wounds
Insulin syringes
.3-1 mL (calibrated in units). Most are 100 U
Tuberculin syringe
16ths of minim and 100ths of a mL. (capacity of 1mL). intradermal or subQ
Incident pain
Pain that is predictable and elicited by a specific behaviors such as physical therapy or wound dressing changes
End-of-dose failure pain
Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic
Spontaneous pain
Pain that is unpredictable and not associated with any activity or event
Pulse Ox site
Finger (remove nailpolish) or earlobe
Oxygen flow meter
Meter that controls the amount of oxygen when using a nasal cannula or mask
What level should O2 stats remain above?
90%
What is prune juice used for?
Bowel stimulation
Diarrhea nursing diagnosis
Diarrhea related to...
NG tubes
Cannot be delegated; have patient sip water; can go into lungs; clients w; impaired LOC are at risk for aspiration
Intermittent tube feedings
Done periodically
Bolus tube feeding
Large feeding done over 20-30 minutes
Continuous tube feeding
Done continuously
Elimination in bedside chair
Can be delegated; remind assistant to report any abnormal findings
C. diff
Can't use hand sanitizer; must wash with soap and water
SBAR
Situation, background, assessment, recommendation
Noctural emissions
Normal
Cultural/spiritual nursing process
You must know yourself/your values before you can help the patient. Always.
Penrose drain
Lies under dressing; pin placed in drain to prevent it from slipping into the wound
Skin break down
Related to shear, friction, altered LOC, impaired mobility/sensory perception and moisture; lead to ulcers
How should darker skinned individuals be assessed for skin breakdown?
Use natural/halogen light; will appear darker than surrounding tissue with purplish/bluish hue; have initial warmth with coolness as tissue devitalizes; may appear taut, shiny, scaly
Wound dressings
Protect, aid in homeostasis, promotes healing, supports, promotes thermal insulation, protects client from seeing it; provides moist environment
Hypokalemia
Low K; normally 3.6 to 5.2 mmol/L; lower than 2.5 mmol/L can be life-threateningin