Adult 1 HESI Review

Enema

"I should try and hold the fluid as long as possible after it is instilled." "I know that there will be some cramping after the enema administration." "I should tell the nurse if cramping occurs during the instillation of the fluid." not given while on toilet

lipase

0-160 U/L

Creatinine levels

0.6-1.2

Erikson's stages of psychosocial development

1. trust vs. mistrust 2. autonomy vs. shame and doubt 3. initiative vs. guilt 4. industry vs. inferiority 5. identity vs. role confusion 6. intimacy vs. isolation 7. generativity vs. stagnation 8. integrity vs. despair

Urine Specific Gravity

1.010-1.030 high- Glycosuria, Albuminuria, Dehydration low- diabetes insipidus

bilirubin levels

1.2

Magnesium levels

1.5-2.5

Mg levels

1.5-2.5

hypertonic solutions

10% Dextrose in Water, 3% Saline, 5% Dextrose in 0.45% Saline, 5% Dextrose in 0.9% Saline. 5% dextrose in lactated ringer

ammonia levels

10-80

infection

100,000 colony

PT time

11-12.5

hemoglobin

12-16 dehydration, CHF, and COPD- increases

hemoglobin

14-17 12-15

uric acid

2.7-7.3

fibrinogen

200-400

ambient air

21%

Phosphorus levels

3-4.5

Hematocrit

41-52 36-48 increased by dehydration and pernicious anemia

segmented neutrophil

50-65%

medicare

65+

Calcium levels

8.5-10.5

nor epi

<100

epi

<20

ESR (erythrocyte sedimentation rate)

<20 mm/hr

cholesterol

<200

Positive Tb

>15 mm

BP

A 12-year-old client typically has a blood pressure of 110/65 mm Hg. A 1-year-old client would typically have a blood pressure of 95/65 mm Hg. A 6-year-old client would typically have a blood pressure of 105/65 mm Hg. A 14- to 17-year-old client has a typical blood pressure of 119/75 mm Hg.

Skin findings

A circumscribed elevation of the skin filled with serous fluid and a lesion size of less than 1 cm describes a vesicle. A papule is palpable, circumscribed, has a solid elevation, and a size smaller than 1 cm. A nodule is an elevated solid mass, deeper and firmer than a papule, and 1 to 2 cm in diameter. A pustule is a circumscribed elevation of the skin similar to a vesicle but filled with pus and varies in size. erosion into the dermis is known as an excoriation or ulcer, and a solid mass of fibrous tissue is known as a papule

hyponatremia

Addison's disease A severe burn injury Adrenal insufficiency

discomfort for urinary catheter

Aspirate the fluid, advance the catheter farther, and reinflate the balloon

glucose tolerance test

Avoid alcohol, coffee, and tea for 36 hours before and during the test

Lupus

C reactive ESR

CI lumbar puncture

Clients with infection near the LP site Clients with increased intracranial pressure Clients receiving anticoagulation medications

fecal fat collection

Consume a high-fat diet for 3 days before the test

breath sounds

Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli. Vesicular breath sounds are normal. They are quiet, soft, and inspiration sounds that are short and almost silent on expiration. They are heard over the lung periphery. Bronchial breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder. They are heard over the trachea and large bronchi of the lungs. Rhonchi are abnormal breath sounds heard over the large airways of the lungs. They consist of a low pitch and are caused by the movement of secretions in the larger airways; they usually clear with coughing.

hypokalemia

Cushing's ulcerative colitis laxative U waves, depressed ST, inverted T

chloride 40

Cystic fibrosis

increase creatinine

Dehydration Catabolic state High-protein diet Obstructed uropathy

Prevent DVT

Dorsiflex and plantar flex at least 10 times every hour

aspirin overdose

Emesis, tinnitus, and nausea are all early clinical manifestations of acute aspirin poisoning. Ecchymosis is a late symptom associated with a chronic aspirin overdose. Hyperventilation, not hypoventilation, is an early clinical manifestation of aspirin overdose

early alzheimers

Forgetfulness interferes with the daily routine.

goiter

In a grade 2 goiter, the mass is usually asymmetrical and is easily palpable. The goiter is invisible or impalpable in grade 0. The goiter mass moves up while swallowing and is palpable in grade 1. The goiter mass is invisible in grade 1 while the neck is in a normal position.

Temperatue

In older adults the normal temperature range is 36°C to 36.8°C orally and 36.6°C to 37.2°C rectally. In febrile conditions, the rectal temperature would be more than 37.5°C. A rectal temperature of 38.5°C would indicate a fever.

breathing

Kussmaul's respiration is an alteration in the breathing process characterized by an increased and abnormal deep and regular rate of respiration. A client suffering from hypoventilation would have an abnormally low respiratory rate and the depth of ventilation is depressed. In Biot respiration, respirations are abnormally shallow for two to three breaths, followed by irregular periods of apnea. An irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation would be observed in a client with Cheyne-Stokes respiration.

calcitonin

Lowers blood calcium levels

shock

Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid associated with the progressive stage of shock. Respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis occurs as a result of hyperventilation during early shock.

IM

No more than 1.5 mL

hypocalcemia

Prolonged ST segment Prolonged QT interval hypotension

check IV

Q hr

Dumping Syndrome

Rapid gastric emptying that occurs after a gastric resection causes rapid elevation of blood glucose followed by increased insulin secretion, resulting in reactive hypoglycemia and dumping syndrome. Diarrhea, not constipation, occurs. Steatorrhea, not clay-colored stools, may occur. Anorexia, not sensations of hunger, occurs.

Hyperphosphatemia

Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome

respiratory alkalosis

Resp- lethargy, lightheadedness, confusion, All- tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities, tetany

hypercalcemia

Shortened ST segment Widened T wave

Inhalation Anthrax

The manifestations include low-grade fever; fatigue; mild chest pain; and a dry, harsh cough. Inhalation anthrax is a two-stage illness, prodromal and fulminant. The prodromal stage is the early stage and is difficult to distinguish from influenza or pneumonia. A special feature of inhalation anthrax is that the infection does not accompany upper respiratory tract manifestations of sore throat or rhinitis inhalation meat cut

after a meal

The nurse is caring for a client for whom segmental postural drainage treatments are prescribed. The nurse would avoid scheduling a treatment for which time?

Abduction

The nurse is caring for a client with a fractured hip. Which is the nurse trying to prevent by placing pillows around the injured area?

occult blood test

The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age of 40 years. Age, family history of polyps, and a positive finding after a digital rectal examination are factors related to colon cancer and secondary reasons for the occult blood test (guaiac test).

iron injection

Ventrogluteal muscle using Z-track technique

indium

WBC tagged in bone

damaged tissue and obstructed airway

Which condition(s) in the client indicate(s) need of nursing care that supports homeostatic regulation? Select all that apply. One, some, or all responses may be correct.

hyperkalemia

absent p T waves ? widened QRS

low albumin

acute infection, ascites, alcoholism, burns, and cirrhosis 3.5-5

hyperkalemia

addisons hyperuricemia tissue damage

hypernatremia

anabolic steroids oral contraceptives NSAIDs heart failure

TPN

aspirate stomach contents assess bowel sounds position in high fowlers irrigate only if obstruction warm feeding to room temp assess pH of stomach contents prolonged- hyponatremia stop feeding during bed change should not exceed 24 hours should not be cloudy do not need second line for meds

restraints

assess every 15 min

Swanson's Theory of Caring

avoid assumptions assess thoroughly check for other signs of breast cancer

increase K+

blood transfusions bleeding potassium medications diet

clear liquid

broth coffee gelatin, apple juice, popsicles

hyperkalemia

burns trauma sepsis Addison's acidosis Widened QRS

aPTT

checked 1 hr before scheduled dose normal- 28-35 1.5-2x- good

proper cane fit

client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane

hypokalemia

constipation

hypokalemia

depressed ST U waves inverted T

bone scan

drink extra water

TB

droplet nuclei or airborne The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy Venting to the outside, 6 air exchanges per hour, and ultraviolet light

Hypermagnesemia

drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia neurological depression depressed deep tendon reflexes

Hypomagnesemia

dysrhythmias Tetany, twitches, and a positive Trousseau's sign are seen in a client

myelography

elevate head avoid bending avoid exercise do not expect drainage withhold food 4-8 hrs prior

cog impaired

encourage fluid intake positive support social interactions when can family assistance

hyponatremia

flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes increased urine output increased specific gravity hyperactive bowel sounds

heat stroke

giddiness nausea thirst high pulse

early DIC

give heparin

Maslow's hierarchy of needs

helps the nurse understand the interrelationships of basic human needs. These basic needs are a major factor in determining a person's level of health. The first level includes basic physiological needs such as oxygen, fluids, nutrition, body temperature, elimination, shelter, and sex. The second level is safety and security needs, which involve physical and psychological security. The third level is the need of love and belonging. The fourth level encompasses self-esteem needs. The fifth level is the need for self-actualization. It is the highest expression of one's individual potential and allows for continual discovery of self.

vesicle

herpes, herpes zoster, and dermatitis associated with poison oak or ivy

Shock S/S

high hr low bp cool and clammy skin put in reverse Trendelenburg

Apgar Scale

higher score = healthier baby

metabolic acidosis

hyperpnea with Kussmaul's respirations; headache; nausea, vomiting, and diarrhea; fruity-smelling breath resulting from improper fat metabolism; central nervous system depression, including mental dullness, drowsiness, stupor, and coma; twitching; and convulsions. Hyperkalemia

arthroscopy

ice elevate knee and avoid twisting

bone marrow

iliac crest

gallium test

injection 2-3 hrs before procedure 30-60 min

colonoscopy

left sims

thiamin

legumes

normal in older adults

less turgor decreased night vision decreased mobility of ribs

third spacing

liver and kidney disease

allergic reaction to contrast medium

low bp

barium enema

low fiber diet 1-3 days before test

thoracentesis

lying of unaffected side

initial signs of hyperkalemia

muscle weakness

hypokalemia

nasal suctioning diarrhea diabetes insipidus dumping syndrome ensuring adequate oxygenation, client safety for fall prevention and potassium administration, and monitoring for complications related to diuretic therapy and client response to therapy

MRI

no radiation

Antibiotic IV

normal saline in 10 mL syringe clear sterile bandage antiseptic swab small 250 mL bag of NS 16 guage- too large and for rapid infusions

therapeutic pt

normal- 11-12.5 x 1.5-2

therapeutic aptt

normal- 30-40 x 1.5-2.5 anything >100 and <45 is bad

clinical care coordination

nurse leader

Hypothermia

occurs when the body temperature falls below 36.2°C. Based on the severity, it is classified as mild, moderate, and severe. Mild hypothermia refers to a body temperature of 34°C to 36°C (93.2°F-96.8°F). In this case, the client's body temperature is 35°C, which indicates mild hypothermia. Moderate hypothermia refers to a body temperature of 30°C to 34°C (86°F-93°F), and severe hypothermia refers to a body temperature below 30°C (86°F). The client does not have severe hypothermia; therefore, the client does not have a body temperature of 29°C. The client does not have moderate hypothermia; therefore, the client does not have a body temperature of 30°C or 33°C.

Decreased muscle strength

occurs with aging. This can be resolved by performing isometric exercises. Suggesting the client perform push-ups in the morning would be most beneficial. Increasing carbohydrates will not improve strength or prevent fatigue. Milk is rich in calcium, which is good for the overall health and especially the bones, but it will not increase strength. Warm compresses are used to reduce pain and inflammation caused by injury.

hypocalcemia

paresthesias followed by numbness (around mouth), hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety diarrhea initially- confusion, mental status changes

WBC shift to the right

pernicious anemia increased mature neutrophils

ascites test

plain film scout film flat plate of abdomen kidneys

herpes simplex

polymerase chain reaction

Allen test

pressure patient open and close hand release pressure assess color distal

Restraints

pulse temp skin integrity behavior leading to need for restraint

Potassium rich foods

raisins potatoes cantaloupe strawberries

Nutrition for MI

reduce angina reduce cardiac workload reduce dysrhythmias

feeding tube

residual amounts greater than 100 mL require holding the feeding, but this is individualized and each agency's policy should be checked. The residual amount should be reinstilled unless it is greater than 250 mL or per agency policy. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics

Guillan-Barre Syndrome (GBS)

respiratory acidosis

atelectasis

respiratory acidosis

liver biopsy post op

right side with pillow underneath

decreased GFR

shock dehydration CHF Cirrhosis with ascites

administering ear drops

side-lying position auricle up and out dropper 1 cm above canal cotton ball in outer canal

Hypophosphatemia

starvation malnutrition

Extrapulmonary causes of resp failure

stroke; sleep apnea; myasthenia gravis; and opioid analgesics, sedatives, and anesthetics.

SOAP

subjective, objective, assessment, plan

VS for baby

temp around 97.5 pulse b/w 90-130 increased RR low bp

dehydrated

urine specific gravity >1.030

metabolic alkalosis

vomiting or gastric suctioning S/S- hypoventilation and tachy, can cause seizures cardiac, nervous, neuromuscular

hyponatremia S/S

weakness in hands and feet +1 reflexes in patella headache nausea