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Foundations HESI review 2021
Get Quizlet's official HESI A2 - 1 term, 1 practice question, 1 full practice test
Terms in this set (97)
what happens to bp if the BP cuff is too wide?
false low reading
what happens to bp if the bp cuff is too narrow/too short or if its on the arm too loosely
false high reading
what happens to the bp if the cuff is placed below the heart level?
falsely high reading
what happens to the bp if the cuff is placed above the heart level?
falsely low reading
how to palpate for systolic BP
palpate radial pulse
-inflate cuff 30mmHg above the point at which you can no longer palpate the pulse
when taking the bp in the leg (popliteal artery) is the bp usually higher or lower?
the systolic is usually 10-40mmHg higher than the brachial, the diastolic stays the same usually
how to obtain orthostatic bp readings
obtain bp while pt is supine, sitting, and standing
-1-3 min in between each reading
-observe pt for dizziness, fainting, lightheadedness
what is considered hypotension?
when the systolic becomes 90 or below
Where is the point of maximal impulse?
located at the 4th or 5th intercostal space just medial or left of the mid clavicular line
what do you do if you feel a pulse deficit?
assess the next pulse up, if that pulse is weak, move up again
what are back rubs beneficial for?
-can be apart of a patients hygiene
-slow stroke back massages of 3 minutes and hand massages of at least 10 minutes can promote relaxation in older clients
when should a patient exercise around bedtime to promote fatigue and relaxation?
2 hours before bedtime, they should not exercise any closer to bedtime
what is the antidote for benzodiazepines (-lam/-pam)
What do Benzodiazepines do? what to check for on a patient taking these?
can help with sleep, nurse needs to assess respirations because this medication may cause respiratory depression
what are risk factors for sleep apnea?
obesity & HTN (major)
-type 2 diabetes
-positive family hx of sleep apnea
what are the nonverbal cues that a patient is in pain?
-rigid body posture
how to assess for the quality of a patients pain
ask the patient "tell me what your discomfort feels like"
what does acupuncture treat?
-low back pain
how to manage breakthrough pain?
may need to include a "rescue dose" of medication such as adding an immediate release opioid in between doses
-another option is decreasing both dose and increasing frequency of opioid medication
how to manage pain with non-pharmacological measures?
-cutaneous simulation (TENS unit, massage, hot&cold therapy)
how to insert a catheter in a male patient?
-lift penis 90 degrees to patient body and apply gentle upward traction
-ask pt to bear down and slowly insert through urethral meatus
-advance catheter until urine flows (7-9 in) (stop here with straight Cath)
-for indwelling Cath, advance to bifurcation
how to insert catheter in a female patient?
-ask pt to bear down gently, slowly insert Cath through urethral meatus
-advance (2-3in) or until you see urine
-advance another 1-2 inches but do not force
what position should the female patient be in while inserting the catheter?
-dorsal recumbent with knees flexed
-or side lying (sims) with upper leg flexed at hip and need
what allergies to assess for with catheter insertion?
assess for latex and iodine!!
what to do if there is no urine coming out of the catheter?
-check for a kink
-irrigate indwelling urinary Cath
-after irrigating, evaluate and there should be more fluid returned than the amount of fluid used for irrigation
what is the priority assessment after a catheter is removed?
report time and amount of first voiding
what is a urinary diversion system?
-procedure that creates a new way for urine to exit your body when urine flow is blocked (ileal conduit)
-may need with a patient with cystectomy (removal of bladder)
how to do a timed urinary specimen?
-discard the first voided specimen and then start collecting
-pt voids into a clean receptacle and then urine is transferred into the special collection container
-urine needs to be kept cool or on a bed of ice
-specimen must be free of feces & toilet tissues
-missed specimens make the whole test innacurate
what to do if a specimen becomes contaminated?
give an example of a contaminated urinary specimen
start over (obtain new specimen)
ex: if urine specimen contains multiple colonies it is likely contaminated, you need a new specimen
how to collect a clean-void or midstream (culture and sensitivity)
-urine may be collected by the patient after detailed instructions are given
-always use a sterile specimen cup
how to obtain a sterile specimen for culture and sensitivity if a patient has a urinary diversion?
-pt needs to have the stoma catheterized to obtain an accurate specimen
what are the common causes of residual urine?
-chronic retention, there may be a bladder outlet obstruction (prostatic enlargement, urethral obstruction)
-absent or weak bladder contractility
-side effect of certain medications (anesthesia, anticholinergics, antispasmodics, antidepressants)
what are signs and symptoms of a UTI?
-dysuria (burning/pain with urination)
-cystitis (irritation of the bladder)
-urgency, frequency, incontinence, suprabupic tenderness, foul-smelling cloudy urine
what nursing interventions promote normal elimination?
if a patient has an impaction, does this required provider orders?
-yes, impaction removal requires orders
does there have to be visible blood on feces to be sampled for occult blood testing?
-no visible blood is needed for occult blood testing
how to do a fecal occult blood test
-need to repeat test 3 times with 3 different bowl movements
-avoid eating red meat for 3 days before testing
-stop takin NSAIDS for 7 days before this can give a false positive
-avoid vitamin C and citrus fruits for 3 days before test
what is bowel training and what patients need this?
-program that sets up a daily routine that attempts the patient to defecate at the same time each day
-this focus is on older adults, and patients with chronic constipation or incontinence
what do to if a patient with a colostomy has gas?
vent the bag, DO NOT poke holes in it
what is the purpose of colostomy irrigation?
to regulate colon emptying
what is the primary and secondary nursing diagnosis for a patient with diarrhea?
primary: fluid volume deficit
secondary: impaired skin integrity (potential)
what is the correct position for tube feeding?
-head of bed minimum of 30 degrees or higher if tolerated
what is the nursing diagnosis for a patient vomiting?
fluid volume deficit
what to assess with a patient with dehydration?
what is one of the best indicators for fluid retention/loss
weight, 1kg = 1 liter fluid
what is included in a full liquid diet?
clear liquids, ice cream, custard, strained or blended soups, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, putting, frozen yogurt
what kind of liquids should a patient with dysphagia drink?
thickened liquids (NOT THIN)
what foods are high in calcium?
dairy products, canned fish with bones, broccoli, oranges
-requires vitamin D for best absorption
what are interventions for a patient with constipation?
-increase fluids (warm prune juice)
What does hypokalemia cause?
muscle weakness and dysrhythmias
how often should oral care with an NG tube be?
every 2 hours
how to perform oral mouth care on an unconscious client?
-have another person assist and properly position patient
-be aware of aspiration precautions
-use an oral suction catheter
-report any lesions or bleeding of mucosa or gums, excessive coughing or choking
what is stomatitis?
inflammation of the mouth
patient teaching for stomatitis
-avoid hot beverages and foods as well as salty, spicy, and citrus based foods
-use pain relievers like Tylenol or ibuprofen
-gargle with cool water
-suck on popsicles
how to feed a debilitated patient?
tuck chin to chest with each bite, place food on the strong side of their mouth
how to apply ace wraps, or other bandages?
apply distal to proximal to promote venous return
how should a patient with crutches go up the stairs?
-use hand rail, have pt stand with the strong leg closest to the hand rail
-lead with strong leg
how should a patient with crutches go down the stairs?
-use hand rail, have pt stand with the affected leg closest to the hand rail
-lead with the crutches and then the affected leg and then the strong leg
how to prevent ulcers from shearing forces?
elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces
what to do during a fire?
how to enter a room if a patient is on contact precautions?
put on gloves before entering, take off before exiting
what kind of precautions does a patient with MRSA have?
how to go into a room with a patient with C. diff?
wear gown and gloves, also required washing with soap and water
what are airborne precautions? what type of patient will be on these precautions?
-private room, negative pressure airflow, mask or respiratory protective device, N95 depending on condition
-measles, chickenpox (varicella), herpes zoster, shingles (VZV), TB
-mnemonic: My Chicken Hez TB
how to bathe a patient with hep A?
hep A is transmitted through feces, wear gloves
what is the priority assessment for hypoxia?
elevate head of bed and provide oxygen if needed
what to do when obtaining a pulse ox reading and it is low?
change to a different site, you can move from a digit (finger) to the ear (required a probe)
what does it mean if a patients lips are cyanotic?
what to do if you see this?
patient is experiencing central cyanosis
-apply O2 at 2L and notify HCP
how to assess pedal pulses?
use light pressure to prevent obliterating the pulse
what is the Braden scale?
risk assessment tool for pressure ulcers
-low score is greater risk for pressure ulcers
is purulent drainage normal
no, purulent drainage is abnormal
how to clean a linear wound?
-cleanse down first and then wipe away from the incision
-use one swab for each wipe
what lab to check if a patients wound is not healing?
check albumin levels
what is autonomy?
right to self-determination
what is beneficence?
to do good
what is nonmaleficence?
duty to do no harm
what is confidentiality?
Protecting information against unauthorized access
how to waste a narcotic medication if a patient is refusing to take it?
must have a witness to waste the medication
What is the goal of palliative care?
help patients manage disease-related symptoms while living life fulling with an incurable condition
what is euthanasia? is this okay to be apart of as a nurse?
medically assisted suicide
-this violates the code of ethics for nurses and is against the Florida Nurse Practice Act
advanced directives/DNR, how to document
-documentation that the HCP has consulted with the patient and/or family is required before writing a DNR order in the patients record
how to evaluate effectiveness of communication and/or teaching to clients of different cultures
use the teach back method
how to identify patient?
Name and DOB (2 identifiers)
What are the six rights of medication administration?
how to give a liquid medication that is less than 5mL or an unusual dose like 6.3mL?
you cannot measure with a med cup, you have to use an oral syringe
how to prepare the skin for ointment?
wash the area gently with soap and water prior to med application
how to administer ear drops if a child is under the age of 3?
pull down and back
what is the preferred IM injection site?
-"recommended for sites greater than 2mL"
what is the max mL allowed to be administered in the deltoid?
no more than 1mL
patient education needs to be at what grade level unless you know the patient is well educated?
education needs to be at 5th grade reading level
what is an atheist?
they do not believe in the existence of God.
-they search for meaning in life through their work and relationships with others.
what is an agnostic?
someone who believes there is no known ultimate reality
-they discover meaning in what they do or how they live because they find no ultimate meaning for the way things are, they believe people bring meaning to what they do
What are the 4 P's of hourly rounding?
Potty, positioning, pain, personal needs (possessions)
how to promote sleep in older adults?
-maintain regular bedtime and wake schedule
-eliminate naps unless they are part of your routine
-limit naps to 20 min or less twice a day
-go to bed when sleepy
-use warm bath and relaxation techniques
-if unable to sleep within 15-30 min, get out of bed
-avoid stimulating activities before bedtime such as exercise or watching television
how to give NG meds
flush the tubing with saline
flush tubing again
when to reassess for pain after giving a PO med?
within an hour of giving med
if you just pulled a narcotic out to give to a patient, how much time do you have to give the medication?
must give within 15 min of pulling it out of drawer
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