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Hesi Exit Version 3
Get Quizlet's official HESI A2 - 1 term, 1 practice question, 1 full practice test
Terms in this set (239)
Cleft Lip - Feeding
Nipples with flange to occlude cleft
Large, soft nipples with large holes
hold baby at 60-80 degrees
bubble baby frequently
after surgical procedure feed from the side
Myocardial Infarction (MI)
Wider Q Wave
Early Decelerations - Fetal Heart Rate
Means Head compression
mirror image of contraction
Normal fetal HR 120-160
CPR in Pregnancy
L lateral uterine displacement
no Sodium based drugs
Mag toxicity = Calcium Gluconate to fix
Hyperglycemia in elderly
Greater than 110 if fasting
Greater than 140 for 2 hour test
normal is 80-125
Excessive urine output
Have pt. administer their own insulin
Sliding scale insulin
Colorectal cancer - Surgical Care and care of Colostomy
Monitor vital signs, stoma, Q 4 hours
Should be Beefy Red (normal)
Dusky appearance (necrotic)
Small amount of bleeding is normal
NG suctioning until bowel sounds are present
No lifting greater than 10 lbs or pulling for 6 weeks
wash with mild soap, warm H20, pat dry
do not wash off markings
KNOW! Low fat, high fiber cruciferous diet (Brussel Sprouts, cauliflower, broccoli, cabbage )
Osteoporosis plan of care
RISK IS LOW CALCIUM INTAKE
Watch for stairs, waxed floor, rugs,
medicate for pain
High Protein, High calcium, High iron diet
Weight bearing and strengthening exercises
fall prevention: Non-skid socks
encourage activity of D.L.
Side rails in bathrooms
unilateral or bilateral abd. pain
Burn Neck Contractures
Neck stabilized and aligned
Splinting, neck collars
Pedicuosis (head lice)
No sharing personal items
Nits (whitish sacs)
Keeping staff separate
SCHOOL NURSE - send note home to parents
Ask if consensual - had any conceptual sex recently
Metabolic Acidosis - PH < 7.15
Prepared when person is still alive competent, able to make decisions about life sustaining measures
used for hip dysplasia in infants
Remove only to take baths
Cystectomy / Urinary Diversion
Bricker Ileal Conduit
Proximal end of ileal is closed
Distal end out through Stoma in Abdominal wall
Pouch for urine collection worn continuously
Stent may be in place for 3 weeks after surgery to promote Urine Flow
KNOW - Clean skin with mild soap, warm water, pat dry
Don't wash off ink mark outlining radiation field.
Can pick up blood from lab
Cocaine Abused Baby - overdose
Cocaine Abused Baby - withdrawal
Treats Venous Stasis Ulcers
Layers of Gauze and Unna Paste
Can cause PTSD
Pyelonephritis - Chronic
Psychosocial part - how they deal with it.
Disaster Training - Safety/priority
Nurses own safety first
Red - first priority - immediate treatment
Yellow - 2nd - systemic injury - treat within 30-6- minutes
Green - minor injury - can wait several hours
Black - NO HOPE
How to avoid Medication Errors
Ventilated / Intubated Patient
Check for necrosis / erosion from bleeding and trauma related to tube insertion or balloon overinflated
Medications delayed due to Procedure
Give when PT comes back an reschedule next dose accordingly
Make sure accurate fit
If it's whistling, take it out and re-insert
Monitor for Compartment syndrome and bleeding
Monitor for presence of breath sounds
Chest X- Ray
O2 stats improved
remove air to fix collapsed lung
priority is ABC/s
check insertion site for redness, swelling, warmth, drainage
change position Q 2 hours
Endo f life care?
Thyroid Tumor - removed
Head of bed 35-45 degrees
No talking to family
Talk to nurse only for assessment
Use nipple shield
After feeding clean and dry
Breaks during feeding
use breast pump or other suction device immediately before feeding
OB Meds - Antepartum Meds
Antacid can't be sodium based
DO NOT give sodium based drugs
Don't give anything with sodium
Stop insulin infusion is blood sugar is < 50 and begin sliding insulin scale
Condyloma (genial warts)
Inform sexual partner
Hearing will be muffled initially
Excision of a vertebral arch
looking for neuro - loss of sensation
always log roll them
loss of urination
Inter Cranial Pressure (ICP)
Glasgow coma scale less than 8
widening pulse pressure
decreased motor functioning
Deep, repetitive gasping respiratory pattern
Sign of impending death
Caused by vomiting and diarrhea,
and prolonged nasogastric suctioning
Check when giving Coumadin
Levels 2.0-3.0 or 3.5
Radial Artery Catheter
no requirements for radial - compress for 2 hours after
1 minute and 5 minutes
8-10 is normal
4-6 is moderate
0-3 means aggressive resuscitation
Upper arm, thighs, abdomen, buttocks
kids 4-6 mm needles
27-30 g needle
0.1-0.2 mg administered
Adults and kids > 3 straight back
kids < 3 years old - down and back
4 mL/Kg/% TBSA burned
Infuse 1/2 over first 8 hours, rest over next 16 hours
BP measurement in legs
Mid thigh - listen over popliteal artery behind knee in prone position
hands lower than elbows
water flows from elbows to fingertips
pat dry fingers to forearm
lower the number, higher the risk
less than 17 = risk for pressure ulcers
pH < 7.15
Sodium above 1.6
Monitor airway obstruction
watch for STRIDOR
if dressing is tight call HCP!
watch for excessive draining and bleeding
No P waves
No QRS complex
**Intubation, rapid D-Fib, Epinephrine, Lidocaine
Turn PT and deep breath Q 2 hours
Monitor for : Hypovolemia
Stools/Emesis for blood
LOOK for behavior changes - stupor, lethargy, hallucinations, level of consciousness.
TEACH - Don't strain for bowel movement, blow nose, sneeze
soft toothbrush, electric razor
egg grate/ air mattress
Change diaper more frequently
Barking, seal like cough,
Maintain patent airway - provide adequate gas exchange
Pop on pillows, fowlers position.
Tetanus / Lockjaw
Airway management / suctioning
ABC's - seizure precaution - quiet dark room, put into coma and maintain airway
Benign Prostate Hypertrophy (BPH)
Enlargement of prostate
S/S Frequent urination
straining to urinate
incomplete emptying of bladder
difficulty initiating flow
Kidney Stones - Renal Calculi
Flank pain radiating to lower abdomen and groin
Keep hydrated 200 ml/Hr and 2.5 L a day PO
Low Sodium Diet - TUREY IS OK
Risk for Deficient fluid volume and excess fluid volume
Monitor weight same time each day
S/S Difficulty breathing, edema, orthopnea, nocturnal dyspnea
NOTIFY if weight gain 3-5 lbs in 1 week
Acute Renal Failure
Report weight gain greater than 2 lbs in 24 hours
End Stage liver failure
Swelling / Edema
When in vault of skull bone is depressed - driven upward
Spinal cord injury (SCI)
Airway then immobilization
Inhibition of bone marrow function - immunosuppressed
Can flare up
immune system dysfunction
susceptible to viruses
Pernicious Anemia (Addisons Anemia)
Can't store B-12
Confusion and delirium and disorientation are normal especially in elderly
Shows EKG changes
Substantial crushing pain radiating to left arm and up into jaw for men
Indigestion for women
PVC's occurring in pairs
Goal of rehab is to achieve optimal functional outcome that will allow pt. to be discharged to least restrictive environment
Have pt. assist with and perform personal hygiene themselves
Adhesive tape to skin - perform lots of skin care and monitor closely
Align long axis of gone arm or leg
weights applied by rope for free motion
promote return of bowel function
low continuous suction until bowel sounds return
note color and amount of drainage
Facilitate ambulation have family help with ROM exercise
To remove clots by a triple lumen 3 way catheter
Irrigate and flush
splint pt, neck collars, 3/4 mattress (extension)
Sterile, room temp normal saline 3x day
diet of 2400 plus calories a day to promote healing
onset 2-4 hours
peak 6-12 hours
roll to mix
type 1 usually under age 20
type 2 usually over 30 years old
excessive thirst, urination, hunger, fatigue, blurred vision, infections, numbness, tingling
numbness and tingling in extremities
sweating, fatigue, palpitation, blurred vision, headache, confusion, tachycardia, numbing lips and tongue
TX - rapid glucose
Nausea/vomiting/ anorexia, cramping, THIRST, KUSSMALL BREATHING, dry skin, FRUITY BREATH
TX - fluid/electrolytes/insulin
Depression / panic disorder
don't take with MAOI's, tricyclic antidepressants, SNRI's,
Anticonvulsant / headache suppressant/ migraines
Eat healthy foods to heal faster
risk for skin cancer increases
wait 2 years to become pregnant
**Antirejection meds for life
**Steroids - prevent rejection, lower inflammation
PRADAXA / DABIGATRAN
Anticoagulant - lowers risk of emboi
reduces risk for stroke from A Fib
used for leukemia
Side effect is renal failure
CATOPRIL - CAPOTEN
NOT for OB
Avoid salt substitutes and sodium
Give EPI in case of anaphylaxis
pt. didn't have reaction the first time but had reaction the second time -
CAN"T HAVE DRUG IN FUTURE
Treats constipation and encephalopathy in
CIRRHOSIS OF LIVER - produces diarrhea
Sedative / Hypnotic
SOMNABULISM - sleep driving/eating/walking/sex
Hep B Vaccine
Birth within 12 hours, then 1-2 months but before 6 weeks
then 2-4 weeks after that, then 8 weeks after that.
MONITOR BOWELS PATTERN
Should decrease diarrhea and lessen abd. pain
abdominal pain and frequence
quality and consistency of stools
look for bloody diarrhea, fever, headache, cramping, rash
Can delegate to UAP
Central Line Video
Monitor for infiltration
What do you use for an implanted port to administer fluid?
Looks like a port at the end
Pt that is weak and refuses help
4 point crutch
End Stage Liver Disease
Measure abdominal Girth
Serum Albumin and Globulin
Note Swelling and Edema
Chart comes up and you look through it
What is a sign of Autism in toddlers?
Giving a pt with an SSRI, when you do provide to provider?
They are taking headache or migraine medicine
Pt. with otosclerosis gets a stapedectomy
Hear muffled hearing at first
get to destat and assess a young person not breathing
look at airway to see if they take spontaneous breaths
Older client discharge teaching you tell them what?
Don't share meds with family and friends (older people like to share medicine)
When giving medicine to a patient with issues from a CVA
Assess for what side the weak side is and then give it on the strong side
Patient needs help with sleep, what statement do you report to provider?
A patient with Acute Renal Failue, what instructions do you give if they are getting dialysis?
Report weight gain of 2 lbs in 24 hours
What do you tell a mom who has a baby with a red area on buttocks?
Change diaper more often
You find an alert patient with osteoporosis on the floor, what do you implement
Client that lost a son from a drunk drivers states "I should have made him stay home that night" - what are they experiencing?
How do you know an infant taking Captopril is having the desired effect?
decreased Blood pressure
Patient with cancer, pitting 4+ Edema
Elevate on pillows - palliative care
Right sign absent lung sounds, trachea is deviated, nurse already called the code... what's next?
Position pt. in a comfortable position
Pt. with pain recovering from abdominal surgery and respiration of 8/min on morphine - what do you give?
Patient has Muscular Dystrophy and wants to be independent, what is best to do?
Have family help perform ROM
Hands and forearms lower than elbows
Patient with HF and osteoarthritis , what action to take?
Refer to physical Therapy
Pt. experiencing hallucination, what question to ask for assessment?
What are the voices saying?
Pt. comes to ER after Cholysisectomy, having pain and has ascites
Auscultate all quadrants of the abdomen (possible bowel obstruction from surgery)
Patient complains of pain in the ART line...
Remove it immediately (it can mean swelling and decreased flow, remove to avoid necrosis)
Nurse calculates intake on patient for 12 hours...
answer is 1920
charge nurse gets a complaint that the maching is not working and is getting wrong temperatures. Best thing to do?
Take temps and compare two machines
18 year old being assessed.. what needs to be reported to hCP right away?
large, warm tender preauricular nodes
Older adult that becomes confused - nurse advises him to what?
Have an alert family member give him his medications (NOT give him verbal and written instructions)
Older lady with anemia husband calls in to say his wife hasn't had a change in memory - she is still confused
common when there is a decrease in B-12
Client with Hunington's disease is going to cafeteria, what should nurse do?
Escort him there.
Pt. experiencing fast speech, flight of ideas, only slept 3 hours in pas 48 hours - what lab value needs to be assessed?
Pt. had surgery but has an Aldrete post score of 8. what to do?
Transfer the patient - 7-8 is normal - this is a scale that tells when the patient is ready to leave the PACU.
Patient has AFib - what question to report to provider
Dabigatran - it's an anticoag - NO NSAIDS
Pt. in psychiatric dept. pacing hallways and hitting walls
Try to get pt. to "verbalize frustrations"
Nurse needs UAP to change the dressing of what pt. first?
Pt. that's skin is damp every time the sheets are changed or turned
Pt. has AIDS - prior to administering medication combination, what needs to be made sure of?
Willingness to comply
Pt. that has cushings that when the nurse goes to administer Heparin, notices purple and red stria. What do do?
Nothing. Document finding and give med. This is normal.
Respt infection , UTI
Finish full course
Decrease PO2, Cerebral vaso constriction, HOB raised to 30 degrees, head alignment
Nurse planning care for child who has scabies and keeps itching
keep nails trimmed and have him wear mittens
disaster - outage and a generator
tell UAP to tell pts. to stay in their rooms
Discharge teaching for HF
Weight themselves same time everyday
Metabolic syndrome - wants to start exercising
monitor BP as exercise increases
pain distal to insertion site
DNR in another state doesn't honor it
honor clients wishes
sample of sputum from water chamber for chest tube. where to you take sample from?
Rubberized port at bottom of catheter chamber
Acute phase of burn - how to change dressings?
Change each dressing separately
Morning meds, pt will take them later...
Make pt a deal on a time to return and give the meds
Client with SARS
Gown, gloves and N95 mask
Chest tightness respiratory acidosis - what lab increase?
client in DKA - receiving insulin sliding scale, blood sugarhas been 520 = what action?
Get order for IV insulin
Child with cystic fibrosis what treatments ?
Give pancreatic enzymes with each snack at home
Punishing child for wetting pants
provid toilet training pants and calm the mother
When conducting assessment on 6 month old infant
Keep child on lap
Pt. comes in vomiting
Maintain NPO status
Use breast shield
anxiety when driving over bridge?
Listen to music
MONO kissing disease
patient with hearing aid is ringing
have pt. reinsert them
Guillen Bare Syndrom - cause?
Cold within last two weeks
Cellulitis on lower right arm
start IV in left arm
explosion - which black tag
nearest to death
Nurse usually works on step down unit - moved to critical care - which patient do you assign?
Terminally ill child and death is immnent - what do you tell parents?
Knee surgery can't transfer to bedside commode due to pain
Get assistive devices for weight bearing
can't swallow, on palliative care, dehydrated, doesn't want IV
Keep him comfortable
female scared client going in for biopsy, wants husband there
give him gown and mask and allow him to stay with her
Bipolar client - not taking medications
Assign who to RN?
Suicide - one on one supervision
Date rape 2 days ago...what do you ask?
Find out if she had any consensual sex in the last couple of days
Child with juvenile arthritis develops low grade fever and is already taking aspirin - what does the nurse tell the mom to give the child?
Stop aspirin and give NSAIDS
RN assess client one hour after administration of blood, what instruction does she tell the UAP to do?
continue monitoring vitals q 30 min
Client needs low sodium diet - what choices is best?
Turkey Salad Sandwich
Burns - don't want them to become contracted
turn head side to side 90 degrees
4 pts in ER 15 min apart, who do you see first?
2 year old with Stridor
Lupus - information you would give?
Characterized by periods of flare-ups and remission
client is admitted with acute pancreatitis and admits drinking bourbon daily, what would your report immediately?
Confusion and tremors
Postpartum who should assess first?
Saturating 2 pads on an hour
Pt. with Cirrhosis has new onset of dyspepsia (heartburn)
Tell client to see HCP
Sensory deficit and at risk for falls
Reoriente client to surroundings
Pt. receiving Lovastatin - what do you monitor for?
Cirrhosis client becomes confused - ammonia levels are up
Client with terminal cancer has pneumonia and wants no heroic measures - impeding death - what do you do?
keep comfortable - if it says Do No Perform CPR then Chose that answer!
Compound fractures to tibia and fibula in traction?
Assess pin sites for infection
Dissociate disorder -
constantly changes the subject
Older male client comes in with confusion - what lab do you perform?
Female client 40 years old - family history of colectoral cancer, wants to take preventive measures
Admitted to rehab following CVA has aphasia, LS paralysis, difficulty swallowing - what is most important?
Obtain consult with speech therapist
Pt. with syncope as history of aspiration - drinking from a straw
Multiple response: pt. using quad cane has unsteady gait - wants to use a wheelchair - what interventions are important
Lower bed to lower position
keep things within reach
When speaking at a community health fair in Hispanic community, remember to
respect their culture
Total laryngectomy 2 days ago being transferred from ICU to unit, client is anxious, what intervention is most important?
respond to call light immediately
When obtaining isolation supplies for client, what information is most important for nurse to obtain?
How is or will the infection be transmitted?
Child arriving by ambulance with flu like symptoms, R 16, BP 9060, HR 168 -
Start an IV
Acuity of group of clients in ICU has matrix system, a nurse calls off, what should the charge nurse do now?
Client acuity Mix
Saline lock to be d/c in client receiving antiplatelet meds -
apply pressure for 3-5 minutes after removing
Pt. admitted with hypopituitarism and is hypotensive, diaphoretic - what requires immediate action?
Medication question about zofran
Question about pneumothorax -
male client with bipolar disorder resports he hasn't been taking meds
intellect of speech
VFib and defibrillator nurse giving CPR which action should the nurse give UAP after getting crash cart?
take over CPR
Client with compound fracture with internal fixation - diminished pedal pulses - pt at greatest risk for?
Nurse has home visit for client with symptoms that should be controlled with medication prescribed - what nursing diagnosis?
Ineffective health maintenance
Kidney transplant on immunosuppresants
avoid large crowds
pt. living with son comes in with ulcer smelling of urine
Contact adult services
Pt. says she may be pregnant and is on medicine for acne
Stop the medication
Female client cries that her family hasnt' visited her in an long time
determine when they last visited.
where is pain for renal calculi?
intense pain radiating through groin
ICP secondary to head injury - what med?
IV with thyroid
Parkinsons disease lacks?
dopamine and aceticholine
high school football team travels on a bus together - all contact MRSA -
Female client frequently tells the nurse that she is thinking of hurting herself
taking your own life?
11 year old client - how to get him to verbalize ways to deal with things at home?
Play a board game
Multiple response: nurse teaching pt. about s/s of preeclampsia
edema, headache, blurred vision
nures manager observes staff nurse persuading a student nurse to do her job
Pt. brought to ER after a MVA - highest priority?
Drag and Drop: UAP leaves floor without permission on several occasions -how to handle it?
have a private conversation
set up breaks
make sure she is complying
Pt. with breast cancer - started chemo - what shows she understands ?
picks out movies and books to pass the time at home
Prevention of osteoperosos - client who is post menopausal -
increase calcium - NOT QUIT SMOKING! - not the right answer
Male client is admitted to ER with COPD - breathing is getting worse - what intervention?
pt. taking 300 mg of a beta blocker and zantac - wat should the nurse assess?
Pt. who is feeding herself - has inelastic skin laceration -
keep skin dry in folds
Combative old man - nursing diagnosis is best?
risk for others self-direct harm or violence
male client born at 28 weeks gestation
Ischemia / GI bleed
pt. in constant pain is at risk for
confusion and tremors
Post-op patient with urinary drainage / clot
make sure they are having output and no kinks in tubing
Question aout T wavesa nd PVC's
Patient in ICU
patient with terminal cancer - pneumonia - no heroic measures
NO CPR should be provided
left foot tingling and pulses diminished
Multiple response about hypopituitarism
Multiple response: Rheumatoid arthritis
Low grade fever and cough
swollen dn tender
bruising over several areas
Juvinile rheumatoid arthritis
use warm blanket before getting them up
Patient hit by a car
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