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Fundamentals HESI

Terms in this set (221)

Presence of yellow purulent drainage during a wound dressing change means
Indicative of infection and health care provider must be notified prior to any other actions
A nurse cannot irrigate a wound without
a prescribed order
1 tablespoon is how many ml
15 ml
When administering oral meds through a gastrostomy tube
crush meds, dilute in water, let meds flow by gravity, and flush with 30 ml of water
When caring for a patient with TB what should you do when you enter the client's room
apply a respirator prior to entering
IM injection of 1.5 what location do you use
ventrogluteal because it is preferred site and free of major nerves and can hold large volumes
Max ml to administer IM medication in deltoid
< 1 ml
A client has brought in their own radio to a hospital room what do you do
Ask them not to use it until it can be checked by environmental services
When evaluating outcomes of care look at
the goals established in nursing diagnosis
When evaluating if the plan of care has been followed look at
the actions implemented in care
When brushing teeth of an unconscious patient if they start to choke you should
suction
Always instruct patients to prescribe topical medication when
after showering or bathing because damp skin absorbs better
If a patient who is terminally ill asks for no more treatment and says they want to go home to die you should
contact the physician about patient's decision
Patient with obstructive sleep apnea (chronic) has low PaO2 and high PCO2 what intervention should you implement
demonstrate how to use a positive airway pressure to device in order to prevent the airways from collapsing during sleep and maintains airflow through the night
If patient is demonstrating sundowning behavior (confused) during evening shifts what should you do
stay with patient and reorient his location
When ambulating down the hall your patient frequently stops to talk or adjusts clothing before walking again what is this a sign of
activity intolerance
Normal serum potassium levels are
3.5-5.0
What technique should be used to reposition a client with spinal injury or recovering from spinal surgery
logrolling with other staff members to assist
To assess for residual urine the technique used it
a bladder scan
to expel residual from the bladder what technique is used
Crede method (it will not provide accurate assessment of amount of urinary retention)
Patient is scheduled to have sutures removed but is not due for another dose of pain meds for hours what pain control method can you use to help the patient
progressive relaxation or guided imagery
1 oz is how many mL
30 ml
After inserting an indwelling catheter into a male client and the flow of urine has started and you have inserted the length of tubing through client's meatus what should you do ?
Inflate the balloon with 10 ml of sterile water; after this step you can tap the catheter to client's leg
After a patient bathes you notice the saline lock on their arm is partially separated from the skin and the patient says the insertion site is sore what should you do?
Remove saline lock and prepare to insert a new one at a different site prior to the next medication dose
Saline locks must be inserted using which technique
sterile
When there is a dislodged saline lock do you need to notify the physician?
No just prepare to insert a new one during next meds
Once the nursing diagnoses have been prioritized the next step when planning the client's care would be to
discuss goals of care with the patient
Despite the procedure being discussed with the patient the evening before, your patient asks you what is going to happen what should the nurse do?
Notify the surgeon so that the client can receive info about the procedure
A client is prescribed humidified oxygen via face mask, but the water canister for the oxygen is empty what should the nurse do?
Notify respiratory therapy to refill the water canister or add water to canister if available, DO NOT SHUT OFF THE OXYGEN the client needs it
During a counseling session a female and a male client begin arguing about what the male client just said what should you do?
Ask the female client to allow the male to continue talking without interruption
A patient is prescribed 500 mg of a med every 8 hrs. The med comes as 250 mg in 10 ml. How many ml will the patient receive in 24 hours?
first do 10ml/250mg x 500mg and you get 20 ml then do 20ml/dose x 1dose/8hrs x 24 hrs and you get a total of 60 ml in 24 hours
You are following a critical pathway for the client recovering from a total hip replacement. According to the pathway he should be moved to rehab on day 3, but he has a postop wound infection and has not progressed properly according to the pathway what should you do?
document a variance on the pathway and reason why the pathway is not being followed.
A week old full-thickness wound is healing well if it appears
a pink wound bed, soft and bumpy appearance and bleeds easily (pink soft and bumpy is granulation tissue and it bleeds easily because it is highly vascularized)
What should you do with a PEG tube
After measuring the residual content the aspirate should be returned to the stomach
The residual of stomach content should never exceed what
200 ml
When initiating oxygen through a non-rebreathing mask the nurse should
The reservoir bag should be filled with oxygen before the mask is placed on the face
Non-rebreather masks require how many L/min to stat inflated
15L/minute
Systolic blood pressure readings obtained on the legs are usually
higher than those obtained in the arms so a bp of 160/80 from the leg is within normal limits
When blood pressure is lower in the arms than legs what is suspected
peripheral vascular disease
Precaution for patient with HIV?
standard because HIV transmission only occurs with contact with blood products and body fluids
A fully immunized child is experiencing coughing attacks, the nurse knows the coughing is most likely not caused by
pertussis, if child is fully immunized they have received the DPT vaccine which covers diphtheria, pertussis, and tetanus
Croup
is most often caused by the HPIV and there is no vaccine available at this time
You are planning a heparin injection for an obese patient. What technique will you use?
25G 1/2" needle, does not aspirate, injects at 90 degree angle, does not massage injection site (pay attention to key word: OBESE, so you know the needle length needs to be 1/2" rather than 5/8" and it must a be a 90 degree angle rather than 45)
Patient with left-sided weakness you should stand
on affected side for support
A valid outcome criteria to evaluate the risk of compartment syndrome in the lower extremities is
testing capillary refill (should be less than 3 seconds)
A client with carbon monoxide toxicity requires oxygen therapy which oxygen delivery system should you use
non-rebreather mask (nasal cannula does not deliver high enough concentrations of oxygen)
Simple oxygen face-mask is suitable for
short-term oxygen therapy with lower oxygen concentrations
After giving the proper dosage of a narcotic to your patient you have some left over what do you do with it?
Dispose of vial immediately with a witness
Client who takes prednisone for asthma reports difficulty sleeping what should the nurse do first
consult physician to change medication time to earlier in the day
while endotracheal suctioning a patient you note deceleration of HR what do you do first
stop suctioning and re-oxygenate client (suctioning needs to be limited to 10 seconds to prevent bradycardia from occuring)
During suctioning repositioning a patient would
put them at risk for aspiration
Potent topical corticosteroid to be applied to scalp to treat psoriasis, the scalp should not
ever be cleaned with alcohol prior (however side effects do include thinning of skin and this medication should not ever be used more than 2 days in a row)
patient with cellulitis is experiencing edema and pain of the extremity how should you assist
apply warm compresses, leg elevation, skin hydration with topical creams, application of warm and cold compresses.
mucus membranes on your client are pale and the extremities are cool and white what else can you expect to see
rapid pulse because these are all signs of anemia
Maslow's hierarchy of needs
PT is 25 seconds whats that mean
25 seconds is above normal limits and indicates patient is at a high risk for bleeding (we prescribe vitamin K to reverse bleeding risk
Increased PT/INR can be seen in patients
with hepatic dysfunction, vit. K deficiency or anticoagulation therapy
Patient with increased intracranial pressure what position should you put them in
head of bed raised to 30 degrees with head in neutral midline position, this will promote cerebral venous drainage and help lower the intracranial pressure (ICP)
KCL 40 mEq IV now is your order what do you do
call doc to specify order because infusion rate and dilution are missing
You never squirt an enema
the enema should never be administered with force, but rather allow gravity to regulate the flow
For a patient with overactive bladder, you should tell them to
After urinating, wait a few minutes then try again, schedule a toilet break every 90 mins, don't run to the bathroom when you have the strong urge to go (double voiding technique releases residual urine and don't run with the urge you should try really hard to stay on the 90 minute schedule and regain control of your bladder.
patient is bedfast with CHF and diabetes at risk for skin breakdown what should be addressed first
the fact that the client is in the fowler's position which puts them at severe risk of pressure ulcer development
Anti-depressants can actually help with
neuropathic pain (such as peripheral neuropathy in the legs of a patient with type 2 diabetes)
During the evaluation phase the nurse determines if
the established goals were met and if adjustments to the care plan are needed.
The critical care pathway states that a patient recovering from shoulder surgery should be able to life arm to 45 degrees on the second day after surgery without assistance. The patient is unable to do so and you must change your care plan. Which step of the nursing process is the nurse completing this revision?
Evaluation
The key for restraints should
not leave the patient's room in case the need to be immediately removed
tracheostomy care
humidification of the oxygen source is required at all times to prevent damage to the respiratory mucosa and keep secretions liquefied. Area around the stoma should be cleaned with normal saline only and catheters for suctioning should not exceed 50% of the lumen. Cuff pressure should range between 15-30 and should be measured twice daily to prevent damage to respiratory tract when pressure is too high or air leakage when pressure is too low
The mother of an infant with cerebral palsy asks if her child is going to die, how do you respond?
"your child's condition is very serious and will likely cause him to pass away at a an early age" you need to be honest and answer her questions
Japanese culture and pain
people often show a stoic response to pain, so it is important to look for physical clues
prone position
Can be used to palpate popliteal arteries
Pain localized at the sternal border that intensifies with palpation is characteristic of
costochondritis which is benign and can be treated with an NSAID to reduce inflammation
If you hear expiratory wheezes over a patient's lower lobes what should you do
raise head of bed to a 60 degree angle to improve ventilation
If you are unable to determine if a client has jugular vein distention what should you do
use a tangential lighting
Which organs can be assessed through the left lumbar region of the abdomen
descending colon and lower half of left kidney
Abstract reasoning
would be a patient not being able to determine the similarities or differences between two objects
Lack of judgment would be
if a patient was taking other things without permission and thinks that is okay
If no bruit can be auscultated over the fistula site you should
use a doppler
Thin, depressed, and concave nails implies
Koilonychia (often see in iron deficiency anemia)
Clubbing
convex nails
Acute sinusitis symptoms would be
tender areas on the face with purulent nasal discharge
Patient with positive romberg sign
loss of balance when standing with eyes closed
Patient with irregular menstrual periods, weight gain, and hirsutism (excessive hair growth) would be experiencing a disorder of which body sysem
endocrine (not reproductive because weight gain and hair growth are not reproductive)
Placing your hands on the chest of a patient with pneumonia to feel for vibrations would be assessing for
tactile fremitus
black dots periodically with vision are
considered normal as long as they do not obstruct vision
A bacterial infection that has spread to the lymph nodes you would also see
warm and tender lymph nodes
borborygmi
A long continuous gurgling present in all four abdominal quadrants
Symptoms of sleep deprivation include
slurred speech, flat facial affect and red conjunctiva
Paresthesia
refers to a burning or prickling sensation that is usually felt in the hands, arms, legs, or feet, but can also occur in other parts of the body seen with carpal tunnel
Patient with limited abduction and internal hip rotation, they have
hip disease
Patient with COPD has barrel chest this is consistent with
chronic hyperinflation
dehydration in a newborn; you would also see
rapid pulse and sunken forehead
Acrocyanosis in infants
is a common finding that can be caused by crying or as a result of decreased body temperature
common changes seen with aging
reduced upward gaze, sluggish pupil reflex, high frequency hearing loss, absent ankle reflex
Hearing a pop inside the ears for a patient with otitis media
the eardrum perforated
to asses for crepitus in the knee joint you should
palpate
patient comes in with right sided abdominal pain but normal assessment values what should you do
inspect stool sample for presence of clay color or fatty streaks
Symptoms of acute pancreatitis
severe gnawing epigastric pain that radiates to the back, and patient will assume the fetal postition
Presbycusis
age-related hearing loss
Fine tremor of hands when holding the arms outstretched
postural tremor
Murphy's sign
sudden stop of inhalation in the middle of a breath during deep palpation of the upper right quadrant and is used to diagnose cholecystitis
koilonychia
spoon shaped nails with a concave shape, they are a manifestation of chronic iron deficiency and yuou should look at a hemoglobin (HB) lab test
a transverse (horizontal) line across nail grooves (Beau's line)
occur in several illness
one eye being red or unilateral redness suggests
a toxic, chemical, or mechanical origin of conjunctivitis
secondary amenorrhea is
lack of menstruation for more than 6 months in a menopausal female
During palpation of the thorax you feel a quarter sized area of pulsation in the 6th intercostal space along the lateral axillary line what else is a likely finding
a low frequency gallop heard just before S1
2 year old aspirated a penny where do you think it will be lodged
right main bronchus, aspirated items are most likely to enter the right main bronchus and/or right lower lobe because the left main bronchus is smaller in diameter
aspiration
means whatever the object is will enter the respiratory tract rather than the stomach
Positive Homan's sign
associated with deep vein thrombosis
Positive Brudzinski's sign
is flexion of the hips and knees when the neck is flexed in a client with meningitis
what should you do first with a patient with a rapidly decreasing level of consciousness
assess airway and breathing
what should you do to assess jugular venous distention in a client with heart failure
raise head of bed from 0 to 45 and measure from the highest point of visible distention to the sternal angle
Bright red patch in the internal lateral side of the left eye with no other abnormalities what is important to assess
history of trauma because a red patch is a manifestation of a subconjunctival hemorrhage
A client with history of heart disease has an enlarged liver and ascites how can you distinguish between a cardiogenic or hepatic cause
assessment of hepatojugular reflux, heart failure can cause enlargement of the liver ascites formation this reflux supports right heart failure
a scaly spot on a sun-exposed area that comes and goes and sometimes bleed is associated with
squamous cell carcinoma you should look for fine lines and wrinkles in the skin with rough patches and flat brown marks
classical triad of mononucleosis is
low-grade fever, cervical lympadenopathy and pharyngitis so you should also inspect the throat and oral cavity for tonsillar enlargement
tympanic sounds
heart throughout abdomen
dullness
heard when percussing a solid organ (like liver, spleen, heart)
resonance
heard over the lungs
pretibial myxedma
erythema, thickening, and induration of the skin overlying the shins which is associated with graves disease
flaky, crusty, erythematous skin around areolar can be
mammory pagent disease which is a sign of underlying breast cancer
difficulty with extending the 4th and 5th finger of the left hand what should you do to obtain more information
this patient has dupytren and you should palpate the palm and assess for nodules and thickening
newborn with dysplasia of the hips
flex hips to 90 degrees and gently adduct thighs from midline while applying downward and lateral pressure (barlow maneuver)
older male patient with mild aching pain and occasional swelling in the groin area whats the next assessment step
ask client to strain while holding his breath, this will make a hernia more obvious
osteomalacia
look at vitamin D levels
strabimus
crossed eyes, should perform cover/uncover eye test
Assessing a patient with type 2 diabetes how should you assess for foot ulcers
peripheral neuropathy is best assessed with a pin prick test to assess loss of sensation
first systolic bp should be
>10 if not auscultate the heart
patient with ventricular septal defect you would hear
a murmur between S 1 and S2
the radial artery is being considered for a client needing cardiac bypass surgery. What is most important for nurse to do
compress radial and ulnar artery; observe for flushing of the hand when pressure over the ulnar is released (allen test; used to assess the blood supply to the hand and the patency of the ulnar artery
mitral stenosis you'd hear
a louder S 1
S1
closing of the mitral and tricuspid valves sound
S2 is
louder than S1 normally
S2
closing of the aortic and pulmonic valves
split S2
is normal during inspiration
right ventricle
receives more blood than left
2nd cranial nerve
perform snellen chart test (optic nerve)
eye movements
CN 3, 4, 5
CN 1
smell
Technique to determine lung border changes during respiration
percussion of the lower posterior lung fields
rhinosinusitis
cough and clear nasal dischargeky
kyphosis
excessive convexity of the thoracic spine
patient with history of chronic alcohol abuse and cirrhosis what else do you expect to find
firm, well defined edge felt at the fingertips in the right upper quadrant during inspiration (a soft edge is healthy);
hepatomegaly
increased area of dullness to percussion either in midclavicular line of RUQ or extending in the LUQ
cirrhotic liver appears
shrunken
hairy leukoplakia
hairy white plaques on the lateral side of the tongue caused by HIV
oral thrush is associated with
chronic use of inhalation of corticosteroids in clients with asthma
first sign of puberty in males
testicular enlargement
After 8 hours a patient should have how many ml of urine
240 ml
Solutions labeled as opened within 24 hours can be used when
for clean procedures but not sterile procedures
For an IV catheter where should you put it
cephalic vein; brachial is too high up
inhaler medication should be
inhaled through the mouth simultaneously
when taking lower extremity bp where should the cuff be placed
on the thigh and have the popliteal exposed so you can auscultate the popliteal pulse
when taking lie-sit-stand blood pressure you should use the same/different arms
same
medications prescribed during post must be
renewed post op
to insert an NG tube to and UNCONSCIOUS patient, what position should they be in
left side-lying
what levels should be monitored during prolonged NG suctioning
sodium and potassium because of the loss of fluid
patients taking birth control are at a higher risk for what during post op
development of thrombi
sodium
135-145; breads, cereal, canned foods
Potassium
3.5-5, bananas, fish (but not shellfish) whole grains, nuts, broccoli and cabbage, carrots, celery cucumbers potato skins, spinach, tomatoes appricots cantalope nectarine orange and tangerines
calcium
8.5-10.5 dairy, rhubarb, spinach, tofu
Magnesium
1.5-2.5, cashews halibut swiss chard leafy greens, tofu, dried fruit
chloride
95-105, seaweed, rye, tomatoes lettuce celery olives table salt
phosphate
1.7-2.6 milk meat nuts legumes grains
pH
7.35-7.45
pCo2
35-45
hco3
22-26
Po2
80-100
albumin
3.5-5.0
Fiber
20-35
protein
0.8 g/kg of body weight
BUN
7-20
creatine in women
0.6-1.2
creatine in men
0.8-1.4
BUN to creatine ratio
20:1
hemoglobin in males
14-16
hemoglobin in females
12-15
Hematocrit in male
42-52%
hematocrit in female
35-47%
hematocrit to hemoglobin ratio of
3:1
phosphorus
3-4.5
nasal cannula cannot exceed
6L/ min
oxygen mask flow rates
6-15 L/min
women who is breastfeeding need more
protein
pure liquid
clear liquid no pulp jello is okay
full liquid
foods that melt pulp is okay creamed soups ice cream
pureed diets
food is blended in blender pulp like mixture
mechanical soft diets
ground meat or soft cooked foods (difficulty chewing)
thickened liquids
risk for aspiration
diabetic diet
control carb intake
cardiac diets
low cholesterol low sodium less meat
renal diets
constricts potassium, sodium, protein, phosphous only eat fresh fruits and veggies
kosher diet
no pork shellfish blood cant combine meet and dairy
islamic
no alcohol, pork or caffeine
mormon
avoid alcohol tobacco caffeine
buddhist and hindus
avoid meat and meat by products
Normal CBC in men
4.32-5.72 million cells
Normal CBC in women
3.90-5.03 million cells
Normal WBC
4,500 to 11,000
PICC line is changed how often
every 24 hours
The accepted range of oxygen delivery with a non-rebreather mask is
10 to 15 L/min.
mitral valve stenosis enlarges which heart chamber
left atrium
PaO2
more than 80
low paO2 causes
cyanosis
A person normally uses _____ as the drive to breathe
increased PaCO2 levels
A patient with COPD has chronic elevation of _____and has lost sensitivity to it as a drive to breathe
PaCO2
clinical manifestation that occurs with hemorrhage
Increased heart rate
when a person is hemorrhaging the bp
decreases
After administering intravenous medication, check the patient in
15 to 30 minutes for relief from pain
An increased prothrombin time indicates
prolonged bleeding times
(HDL) cholesterol are_____ for males
>45 mg/dL
(HDL) cholesterol are_____ for females
>55 mg/dL
total cholesterol
>200
LDL
>130
triglyceride levels in males
<60 mg/dL
triglyceride levels in females
<135
what should be collected using sterile technique and in sterile containers
Clean-catch urine, urine from a Foley catheter, wound drainage, and sputum
The nurse is attempting a fingerstick on a diabetic patient and is having difficulty obtaining a suitable drop of blood. Which intervention may facilitate this process?
a warm compress vasodilates
most common type of sleep apnea is caused by
airway collapse
Corticosteroids
increase serum glucose levels and inhibit the inflammatory response
JP drain
Usually is inserted in surgery and Allows for accurate measurement of wound drainage
a wound should
wound should be irrigated with normal saline before the culture is taken so the dressing is removed
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