Hesi Hints

What is the most important indicator of increased ICP?

A change in LOC.

HESI Hint 179

ABCs of Assessment: AIRWAY BREATHING CIRCULATION

HESI Hint 176

Chlamydia is the most commonly reported communicable disease in the US.

Who is at risk for stroke?

Persons with hx of HTN, previous TIA's, A-fib or flutter, DM, oral contraceptive use and older adults

Identify pain relief interventions for clients with arthritis.

Warm, moist heat (compress, baths, showers); diversionary activities (imaging, distraction, self-hypnosis, biofeedback); and medications.

HESI Hint 35

Watch for signs of hyperkalemia: dizziness, weakness, cardiac irregularities, muscle cramps, diarrhea, and nausea.

HESI Hint 178

A client come into the clinic with a chancre on his penis. What is the usual treatment? IM dose of penicillin (such as benzathine penicillin G, 2.4 million units). Obtain a sexual history, including the names of his sex partners, so that they can receive treatment.

HESI Hint 181

Infection is a life-threatening risk for those with burns.

Identify two sites that should be assessed for infection in immunosuppressed clients.

Oral cavity and genital area.

List the common clinical manifestations of jaundice.

Scleral icterus (yellow sclera), dark urine, chalky or clay-colored stools.

What is the main side effect of lactulose, which is used to reduce ammonia levels in clients with cirrhosis?

Diarrhea

List four categories of burns.

Thermal, radiation, chemical, electrical

Describe an autograft.

Use of clients own skin for grafting

Describe the method of collecting the trough and peak blood levels of antibiotics.

*Collection of trough*: draw blood 30 minutes prior to administration of antibiotic. *Collection of peak*: draw blood 30 minutes after administration of antibiotic.

List the parameters of BP for diagnosing HTN.

>140/90

HESI Hint 117

Assess the 5 Ps for nerovascular functioning: -Pain -Paresthesia -Pulse -Pallor -Paralysis

What is often the underlying cause of an abdominal aortic aneurysm?

Atherosclerosis.

HESI Hint 151

Bed rest often relieves symptoms. Bladder and respiratory infections are often a recurring problem. There is a need for health-promoting teachings.

HESI Hint 141

CSF leakage carries the risk for meningitis and indicates a deteriorating condition. Because of CSF leakage, the usual signs of increased ICP may not occur.

What symptoms of pneumonia might the nurse expect to see in an older client?

Confusion, lethargy, anorexia, rapid respiratory rate.

List five important teaching aspects for clients who are beginning corticosteroid therapy

Continue medication until weaning plan is begun by a physician; monitor serum potassium, glucose, and sodium frequently; weigh daily and report gain or >5 pounds in one week; monitor BP and pulse closely; teach symptoms of Cushing syndrome (_______________________________________________________).

List three potential causes of anemia.

Diet lacking in iron, folate, or vitamin B12; use of salicylates, thiazides, diuretics; exposure to toxic agents such as lead or insecticides.

HESI Hint 78

Diet recommended by the American Cancer Society to prevent bowel cancer: -Eat more cruciferous veggies (from the cabage family: broccoli, cauliflower, brussels sprouts, cabbage, and kale). -Increase fiber intake -Maintain average body wt. -Eat less animal fat

List four symptoms of digitalis toxicity.

Dysrhythmias, headache, nausea, and vomiting

What are the common side effects of salicylates?

GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation.

How should the nurse administer pancreatic enzymes?

Give with meals or snacks. Powder forms should be mixed with fruit juices.

What are the symptoms of autonomic dysreflexia?

HTN, bladder and bowel distention, exaggerated autonomic responses, headache, sweating, goose bumps, and bradycardia.

Which STD is characterized by remissions and exacerbations in both males and females?

Herpes simplex type II

HESI Hint 102

If in doubt whether a client is hyperglycemic or hypoglycemic, treat for hypoglycemia.

HESI Hint 90

Nonsurgical management of a client with cholecystitis includes: -Low-fat diet -Medications for pain and clotting if required -Decompression of the stomach via NG tube

What is the only IV fluid compatible with blood products?

Normal saline

HESI Hint 74

Opiate drugs tend to depress gastric motility. However they should be given with caution, the nurse should assess for abdominal distention; abdominal pain; abdominal rigidity; signs and symptoms of shock-increased HR; decreased BP, indicating possible perforation/GI bleed.

HESI Hint 118

Orthopedic wounds have a tendency to ooze more than other wounds. A suction drainage device usually accompanies the client to the postoperative floor. Check drainage often.

HESI Hint 86

PROVIDE AN ENVIRONMENT CONDUCIVE TO EATING For clients who are anorexic or nauseated: -Remove strong odors immediately, they can be offensive and increase nausea. -Encourage client to sit up for meals; this can decrease the propensity to vomit. -Serve small, frequent meals. -Give antiemetic prior to eating.

What lab values should be monitored daily in a client with thrombophlebitis who is undergoing anticoagulant therapy?

PTT (_____________) PT (______________) Hgb (_____________) Hct (_____________) Platelets (____________)

HESI Hint 134

Paralytic ileus is common in comatose patients. A gastric tube aids in gastric decompression.

List three nursing interventions for the prevention of thromboembolism in immobilized clients with musculoskeletal problems.

Passive ROM exercises, elastic stockings, and elevation of foot of bed to 25 degrees to increased venous return.

HESI Hint 177

Pelvic inflammatory disease (PID) involves one or more of the pelvic structures. The infection can cause adhesions and eventually result in sterility. Manage the pain associated with PID with analgesics and warm sitz baths. Bed rest in a semi-fowler position may increase comfort and promote drainage. Antibiotic treatment is necessary to reduce inflammation and pain.

HESI Hint 143

Physical assessment should concentrate on respiratory status, especially in clients with injury at C3 to C5, because the cervical plexus innervates the diaphragm.

HESI Hint 160

Physical symptoms occur as a compensatory mechanism when the body is trying to make up for a deficit somewhere in the system. For instance, cardiac output increases when Hgb levels drop below 7 g/dL.

What immediate actions should the nurse implement when a client is having a mycardial infarction?

Place the client on immediate strict bed rest to lower O2 demands on the heart; administer O2 by nasal cannula at 2-5 L/min.

List 5 symptoms of hyperglycemia.

Polydipsia, polyuria, polyphagia, weakness, weight loss

HESI Hint 92

Postoperative thryoidectomy: be prepared for the possibility of laryngeal edema. Put a trach set at the bedside along with O2 and suction machine. Calcium gluconate should be easily accessible.

HESI Hint 42

Protein intake is restricted until blood chemistry shows ability to handle the protein catabolites, urea and creatinine. Ensure high calorie intake so protein is spared for its own work; give hard candy, jelly beans, or flavored carbohydrate powders.

After kidney surgery, what are the primary assessments the nurse should make?

Respiratory status (breathing is guarded because of pain); circulatory status (the kidney is very vascular and excessive bleeding can occur); pain assessment; urinary assessment (most importantly assessment of urinary output).

HESI Hint 138

Restlessness may indicate a return to consciousness but can also indicate anoxia, distended bladder, covert bleeding, or increasing cerebral anoxia. Do not oversedate, and report any symptoms of restlessness.

HESI Hint 64

Restricting sodium reduces salt and water retention, thereby reducing vascular volume and proload.

HESI Hint 175

STDs in infants and children usually indicate sexual abuse and should be reported. The nurse is legally responsibility to report suspected cases of child abuse.

Outline a teaching plan for a client with an STD.

Signs and symptoms of STD; mode of transmission; avoiding sex while infected; providing concise written instructions regarding treatment, and requesting a return verbalization to ensure that the client understands; teaching safer sex practices.

List for signs of an inhalation burn.

Singed nasal hairs, circumoral burns; sooty or bloody sputum, hoarseness, and pulmonary signs, including asymmetry of respirations, rales, or wheezing.

What is the most common risk factor associated with lung cancer?

Smoking

HESI Hint 159

Steroids are administered after a stroke to decrease cerebral edema and retard permanent disability. H2 inhibitors are administered to prevent peptic ulcers.

HESI Hint 148

Symptoms involving motor function usually begin in the upper extremities with weakness progressing to spastic paralysis. Bowel and bladder dysfunction occurs in 90% of cases. MS is more common in women. Progression is not "orderly."

What diagnostic test is used to determine thyroid activity?

T3, T4

HESI Hint 98

Teach clients to take steriods with meals to preven gastric irritation. They should never skip doses. If they have nausea or vomiting for more than 12-24 hrs, they should contact the MD.

Following transurethral resection of the prostate gland (TURP), hematuria should subside by what postoperative day?

The 4th day

HESI Hint 101

The body's response to illness and stress is to produce glucose. Therefore, any illness results in hyperglycemia.

HESI Hint 139

The forces of impact influence the type of TBI. They include acceleration injury, which is caused by the dead being in motion, and deceleration injury, which occurs when the head stops suddenly. Helmets are a great preventative measure for motorcyclists and bicyclists.

What actions should the nurse take if a hemolytic transfusion reaction occurs?

Turn off transfusion. Take temperature. Send blood being transfused to lab. Obtain urine sample. Keep vein patent with normal saline.

Which type of diabetes always requires insulin replacement?

Type 1

List three interventions for clients with a tendency to bleed.

Use a soft toothbrush, avoid salicylates, do not use suppositories.

List problems associated with immobility.

Venous thrombosis, urinary calculi, skin integrity problems

Why is the burned client allowed no "free" water?

Water may interfere with electrolyte balance. Client needs to ingest food products with highest biologic value.

HESI Hint 99

Why do clients with diabetes have trouble with wound healing? High blood glucose contributes to damage of the smallest vessels, the capillaries. This damage causes permanent capillary scarring, which inhibits the normal activity of the capillary. This phenomenon causes disruption of capillary elasticity and promotes problems such as diabetic retinopathy, poor healing of breaks in the skin, and cardiovascular abnormalities.

HESI Hint 158

Words that describe losses in strokes: 1. Apraxia- inability to perform purposeful movements in the absence of motor problems. 2. Dysarthia- difficulty articulating 3. Dysphagia- impairment of speech and verbal comprehension 4. Aphasia- loss of the ability to speak 5. Agraphia- loss of the ability to write 6. Alexia- loss of the ability to read 7. Dysphagia- dysfunctional swallowing

Write four nursing interventions for the care of the blind person and four nursing interventions for the care of the deaf person.

*Care of blind*: announce presence clearly, call by name, orient carefully to surroundings, guide by walking in front of client with his or her hand in your elbow. *Care of deaf*: reduce distraction before beginning conversation, look and listen to client, give client full attention if he or she is a lip reader, face client directly.

What bowel sound disruptions occur with an intestinal obstruction?

*Early mechanical obstruction*: high-pitched sounds *Late mechanical obstruction*: diminished or absent bowel sounds

State three symptoms of hyperthyroidism and three symptoms of hypothyroidism.

*Hyper-* Weight Loss Heat intolerance Diarrhea *Hypo-* Fatigue Cold intolerance Weight gain

Differentiate between the symptoms of left-sided cardiac failure and right sided cardiac failure.

*Left-sided failure* results in pulmonary congestion due to the backup of circulation in the left ventricle. *Right-sided failure* results in peripheral congestion due to backup of circulation in the right ventricle.

Describe fluid management in the emergent phase, acute phase, and rehabilitation phase of the burned client.

*Stage 1 - Emergent Phase*: Replacement of fluids is titrated to urine output. *Stage 2 - Acute Phase*: Patent infusion site is maintained in case supplemental IV fluids are needed; saline lock is helpful; colliods may be used. *Stage 3 - Rehabilitative Phase*: No extra fluids are needed, but high-protein drinks are recommended.

Burn depth is a measure of severity. Describe the characteristics of superficial partial-thickness, deep partial-thickness, and full-thickness burns.

*Superficial partial-thickness, first degree*: pink to red skin (IE sunburn), slight edema, and pain relieved by cooling. *Deep partial-thickness, second degree*: destruction of epidermis and upper layers of dermis; white or red, very edematous, sensitive to touch and cold air; hair does not pull out easily. *Full-thickness, third degree*: total destruction of dermis and epidermis; reddened areas do not blanch with pressure; not painful; inelastic; waxy white skin to brown, leathery eschar.

List the symptoms and conditions associated with a cystocele.

*Symptoms*: Incontinence or stress incontinence, urinary retention, and recurrent bladder infections. *Conditions*: Multiparity, trauma in childbirth, and aging.

Describe the method of extinguishing each of the following burns: thermal, chemical, and electrical.

*Thermal* - Remove clothing, immerse in tepid water. *Chemical* - Flush with water or saline. *Electrical* - Separate client from electrical source.

List the symptoms of upper and lower GI bleeding.

*Upper GI*: melena, hematemesis, tarry stools; *Lower GI*: bloody stools, tarry stools; Common to both: tarry stools

Identify foot care interventions that should be taught to the client with diabetes.

-Check feet daily and report any breaks, sores, or blisters to health care provider -Wear well-fitting shoes -Never go barefoot or wear sandals -Never personally remove corns or calluses -Cut or file nails straight across -Wash feet daily with mild soap&water

List four topics you would cover when teaching an immunosuppressed client about infection control.

-Hand-washing technique -Avoid infected persons -Avoid crowds -Maintain daily hygiene to prevent spread of microorganisms

What are the classifications of the commonly prescribed eye drops for glaucoma?

-Parasympathomimetic for pupillary constriction -Beta-adernergic receptor-blocking agents to inhibit formation of aqueous humor -Carbonic anhydrase inhibitors to reduce aqueous humor production -Prostiglandin agonists increase aqueous humor outflow

List four nursing interventions for care of the client with Hodgkin disease.

-Protect from infection -Observe for anemia -Encourage high-nutrient foods -Provide emotional support to client and family

HESI Hint 163

A 24-year-old is admitted with large areas of ecchymosis on both upper and lower extremities. She is diagnosed with acute myelogenous leukemia. What are the expected laboratory findings for this client, and what is the expected treatment? -LAB: decreased Hgb, decreased Hct, decreased platelet count, altered WBC (usually quite high) -TREATMENT: prevention of infection; prevention and control of bleeding; high-protein, high-calorie diet; assistance with ADL; drug therapy.

HESI Hint 77

A client admitted with comlaints of constipation, thready stools, and rectal bleeding over the past few months is diagnosed with a rectal mass. What are the nursing priorities? -NPO -NG tube (or intestinal tube such as a Miller-Abbott) -IV luids -Surgical preparations of bowel -Foods & fluids are restricted for 8-10 hrs before surgery if possible -If the pt has a bowel obstruction of perforation, bowel cleansing is contraindicated -Oral erythromycin and neomycin are given to further decrease the amount of colonic and rectal bacteria. -If possible, all clients who require surgery for obstruction undergo NG intubation and suction before surgery. However, in cases of complete obstruction, surgery should proceed without delay -Teaching (preoperative nutrition, etc.)

HESI Hint 75

A client admitted with complaints of severe lower abdominal pain, cramping, and diarrhea is diagnosed as having diverticulitis. What are the nutritional needs of this client throughout recovery? -Acute phase: NPO, graduating to liquids -Recovery phase: no fiber or foods that irritate the bowel -Maintenance/Rehab phase: high-fiber diet with bulk-forming laxitives to prevent pooling of foods in the pouches where they can become inflamed; avoidance of small, poorly digested foods such as popcorn, nuts, seeds, etc...

HESI Hint 105

A client comes to the clinic complaining of morning stiffness, weight loss, and swelling of both hands and wrists. Rheumatoid arthritis is suspected. Which methods of assessment might the nurse use and which methods would not be used? Use inspection, palpation, and strength testing. Do not assess rang of motion - this activity promotes pain because ROM is limited.

HESI Hint 133

A client with an altered state of consciousness is fed via enteral routes because the likelihood of aspiration is high with oral feedings. Residual feeding is the amount of previous feeding still in the stomach. The presence of 100 mL of residual in an adult usually indicates poor gastric emptying, and the feeding should be withheld.

HESI Hint 145

A common cause of death after spinal cord injury is urinary tract infection. Bacteria grow best in alkaline media, so keeping urine dilute and acidic is prophylactic against infection. Also, keeping the bladder emptied assists in avoiding bacterial growth in urine that has stagnated in the bladder.

Define stroke.

A disruption of blood supply to a part of the brain which results in sudden loss of brain function.

A nurse discovers that a client who is in traction for a long bone fracture has a slight fever, is short of breath, and is restless. What does the client most likely have?

A fat embolism, which is characterized by hypoxemia, respiratory distress, irritability, restlessness, fever, and petechiae.

HESI Hint 70

A fowler or semi-fowler position is beneficial in reducing the amount of regurgitation as well as in preventing the encroachment of the stomach tissue upward through the opening in the diaphragm.

Tachycardia is defined as___

A heart rate above 100 bpm.

Bradycardia is defined as___

A heart rate below 60 bpm.

HESI Hint 21

A laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. Observe the client for any signs of bleeding or occlusion, which are the greatest immediate postoperative risks (first 24 hours).

What precautions are required for clients with TB when placed on respiratory isolation?

A mask for anyone entering the room; private room; client must wear mask if leaving room.

HESI Hint 157

A woman who had a stroke 2 days earlier has left-sided paralysis. She has begun to regain some movement in her left side. What can the nurse tell the family about the client's recovery period? "The quicker movement is recovered, the better the prognosis is for full or improved recovery. She will need patience and understanding from her family as she tries to cope with the stroke. Mood swings can be expected during the recovery period, and bouts of depression and tearfulness are likely."

HESI Hint 60

ANTICOAGULANTS *Heparin* Antagonist: protamine sulfate Lab: PTT or aPPT determines efficacy Keep 1.5-2.5 times normal control *Warfarin (Coumadin)* Antagonist: Vit K Lab: PT determines efficacy Keep 1.5-2.5 times normal control INR: desirable therapeutic level usually 2:3 (reflects how long it takes a blood sample to clot)

HESI Hint 39

Accumulation of wast products from protein metabolism is the primary cause of uremia. Protein must be restricted in CRF clients. However if protein intake is inadequate, a negative nitrogen balance occurs, causing muscle wasting. The glomerular filteration rate (GFR) is most often used as an indicator of the level of protein consumption.

Write two nursing diagnoses for the client suffering from anemia.

Activity intolerance Ineffective tissue perfusion

HESI Hint 88

Acute pancreatic pain is located retroperitoneally. Any enlargement of the pancreas causes the peritoneum to stretch tightly. Therefore, sitting up or leaning forward reduces the pain.

HESI Hint 97

Addison crisis is a medical emergency! It is brought on bu sudden withdrawal of steroids or a stressful event (trauma, severe infection) or exposure to cold, overexertion, or decrease in salt intake. -Vascular collapse: hypotension and tachycarida occur; administer IV fluids at a rapid rate until stabilized. -Hypoglycemia: Administer IV glucose. -Essential to reversing the crises: Administer parenteral hydrocortisone. -Aldosterone replacement: Administer fludrocortisone acetate (Florinef) PO (only available orally) with simultaneous administration of salt (sodium chloride) if client has a sodium deficit.

What is the priority nursing intervention used with clients taking NSAIDs?

Administer or teach client to take drugs with food or milk.

Describe pain management of the burned client.

Administer pain medication, especially prior to dressing wound. Teach distraction and relaxation techniques. Teach use of guided imagery.

HESI Hint 121

After hip replacement, instruct the client not to lift the leg upward from a lying postion or to elevate the knee when sitting. This upward motion can pop the prosthesis out of the socket.

HESI Hint 20

Air entering the lungs is humidified along the nasobronchial tree. This natural humidifying pathway is gone for the client who has had a laryngectomy. If the air is not humidified before entering the lungs, secretions tend to thicken and become crusty.

In fewer than 10 steps, describe the method of drawing up a mixed dose of insulin (regular with NPH).

Air in cloudy, Air in clear, Draw clear (regular), Draw cloudy (NPH)

HESI Hint 132

Almost every diagnosis in the NANDA format is applicable because severely neurologically impaired persons require total care.

Cite two nursing diagnoses for a client undergoing a hysterectomy for cervical cancer.

Altered body image related to uterine removal; pain to postoperative incision.

HESI Hint 79

American Cancer Society recommendations for early detection of colon cancer: -digital rectal exam every year after 40 -stool blood test every year after 50 -colonoscopy or sigmoidoscopy exam every 10 years after the age of 50 in average-risk clients, or more often based on the advise of a physician.

HESI Hint 170

American College of Obstertricians and Gynecologists (ACOG) 2009 recommendations: Pap smears should be screened every 2 year; women 30 and older may be screened every 3 years after they have had three consecutive negative cervical cytology tests. Women ages 65 to 70 may stop Pap smears if they have three consecutive normal tests in a row and no abnormal pap smears in the last 10 years. Women with high risk factors may need more frequently screenings.

HESI Hint 85

Ammnonia is not broken down as usual in the damaged liver; therefore, the serum ammonia level rises. The metabolism of drugs is slowed down so they remain in the system longer.

HESI Hint 80

An early sign of colon cancer is rectal bleeding. Encourage patients 50 years of age or older and those with increased risk factors to be screened yearly with fecal occult blood testing. Routine colonoscopy at 50 is also recommended.

HESI Hint 154

An important aspect of treatment for Parkinson disease is drug therapy. The pathophysiology involves an imbalance between acetylcholine and dopamine, so symptoms can be controlled by administering a dopamine precursor (levodopa).

In your own words, describe Glasgow Coma Scale.

An objective assessment of the level of consciousness based on a score of 3 to 15, with scores of 7 or less indicative of coma.

HESI Hint 51

Angina is caused by myocardial ischemia. Which cardiac medications would be appropriate for acute angina? -Digoxin: not appropriate; increases the strength and contractility of the heart muscle; the problem in angina is that the muscle is not receiving enough O2. Digoxin will not help. -Nitroglycerine: appropriate; causes dilation of the coronary arteries, allowing more O2 to get to the heart muscle. -Atropine: not appropriate; increases heart rate by blocking vagal stimulation, which suppresses the heart rate; does not address the lack of O2 tot he heart muscle. -Propranolol (Inderal): not appropriate for acute angina attack; however is appropriate for long-term management of stable angina because it acts as a beta blocker to control vasoconstriction.

List four rationales for the appearance of restlessness in the unconscious client.

Anoxia, distended bladder, covert bleeding, or a return to consciousness.

List four categories of medications used in the treatment of PUD.

Antacids H2 receptor blockers Mucosal healing agents Proton pump inhibitors

What types of drugs are used in the treatment of myastenia gravis?

Anticholinerase drugs, which inhibit the action of cholinesterase at the nerve endings to promote the accumulation of acetylcholine at receptor sites; this should improve neuronal transmission to muscles.

HESI Hint 135

Any client on bed rest or immobilized must have ROM exercises often and very frequent positionn changes. Do not leave the client in any one position for longer than 2 hours. Any position that decreases venous return, such as sitting with dependent extremities for long periods, is dangerous.

Name three priorities to include in a discharge plan for a client who has had a mastectomy.

Arrange for Reach to Recovery visit. Discuss the grief process with the client. Have physician discuss with client the reconstruction options.

HESI Hint 156

Atrial flutter and fibrillation produce a high incidence of thrombus formation following dysrhythmia caused by thrombus formation following dysrhythmia caused by turbulence of blood flow through all valves and heart chambers.

In a client with cirrhosis, it is imperative to prevent further bleeding and observe for bleeding tendencies. List six relevant nursing interventions.

Avoid injections Use small-bore needles for IV insertion Maintain pressure for 5 minutes on all venipuncture sites Use electric razor Use soft-bristle toothbrush for mouth care Check stools and emesis for occult blood

What are the most important nursing interventions for the postoperative client who has had a hysterectomy with an A&P repair?

Avoid taking rectal temperatures and rectal manipulation; manage pain; and encourage early ambulation.

HESI Hint 76

BOWEL OBSTRUCTIONS: Mechanical: Due to disorders outside the bowel (hernia, adhesions) caused by disorders within the bowel (tumors, diverticulitis) or by blockage of the lumen in the intestine (intussusception, gallstone) Nonmechanical: Due to paralytic ileus, which does not involve any actual physical obstruction but results from inability of the bowel itself to function.

When examining a client with emphysema, what physical findings is the nurse likely to see?

Barrel chest, dry or productive cough, decreased breath sounds, dyspnea, crackles in lung fields.

Describe nursing care for the client who is experiencing phantom pain after amputation.

Be aware that phantom pain is REAL and will eventually disappear. Administer pain medication; phantom pain responds to medication.

HESI Hint 146

Benign tumors continue to grow and take up space in the confined area of the cranium, causing neural and vascular compromise in the brain, increased ICP, and necrosis of brain tissue. Even benign tumors must be treated because they may have malignant effects.

HESI Hint 47

Bladder spasms frequently occur after TURP. Inform the client that the presence of the oversized ballon on the catheter (30-40 mL inflated) will cause a continuous feeling of needing to void. The client should not try to void around the catheter because this can precipitate bladder spasms. Medications to reduce or prevent spasms should be given.

HESI Hint 53

Blood pressure is creased by the difference in the pressure of the blood as it leaves the heart and the resistance it meets flowing out to the tissues. Therefore, any factor that alters cardiac output or peripheral vascular resistance will alter blood pressure. Diet and exercise, smoking cessation, wt control, and stress management can control many factors that influence the resistance blood meets as it flows from the heart.

HESI Hint 33

Body weight is a good indicator or fluid retention and renal status. Obtain accurate weights of all clients with renal failure; obtain weight on the same scale at the same time every day.

What are the three most important tools for early detection of breast cancer? How often should these tools be used?

Breast self-examination monthly; mammogram baseline at age 35, followed by exams every 1-2 years in 40s and every year after the age of 50; physical exams by professional skilled in examination of the breast.

HESI Hint 3

Bronchial breath sounds (CRACKLES) are heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue.

HESI Hint 27

CHEST TUBES If the chest tube becomes disconnected, do not clamp! Immediately place the end of the tube in a container of sterile saline or water until a new drainage system can be connected. If the chest tube is accidentally remove from the client, the nurse should cover with a dry sterile dressing. If an air leak is noted, tape the dressing on three sides only; this allows air to escape and prevents the formation of a tension pneumothorax. Notify the health care provider.

HESI Hint 81

CLINICAL MANIFESTATIONS OF JAUNDICE -Yellow skin, sclera, or mucous membranes (bilirubin in skin) -Dark-colored urine (bilirubin in urine) -Chalky or clay-colored stools (absence of bilirubin in stools)

HESI Hint 155

CNS involvement related to cause of stroke: -Hemorrhagic: Caused by a slow or fast hemorrhage into the brain tissue; often related to HTN. -Embolic: Caused by a clot that has broken away from a vessel and had lodged in one of the arteries of the brain, blocking the blood supply. It is often related to atherosclerosis (so it may occur again).

A client in renal failure asks why he is being given antacids. How should the nurse reply?

Calcium and aluminum antacids bind phosphates and help to keep phosphates from being absorbed into bloodstream.

A neighbor calls the neighborhood nurse stating that he was knocked hard to the floor by his very hyperactive dog. He is wondering what symptoms would indicate the need to visit an emergency department. What should the nurse tell him to do?

Call his MD now and inform him/her of the fall. Symptoms needing medical attention would include vertigo, confusion or any subtle behavioral change, headache, vomiting, ataxia (imbalance), or seizure.

What lifestyle changes can the client who is at risk for HTN initiate to reduce the likelihood of becoming hypertensive?

Cease cigarette smoking, if applicable; control weight, exercise regularly, and maintain a low-fat, low-cholesterol diet.

HESI Hint 12

Cells of the body depend on O2 to carry out their functions. Inadequate arterial oxygenation is manifested by cyanosis and slow capillary refill (<3 sec). A chronic sign is clubbing of the fingernails, and a late sign is clubbing of the fingers.

What activities and situations that increase ICP should be avoided?

Change in bed position, extreme hip flexion, endotracheal suctioning, compression of jugular veins, coughing, vomiting, and straining of any kind.

What is the most common cause of nongonococcal urethritis?

Chlamydia trachomatis

HESI Hint 116

Clients with fractures, edema, or casts on the extremities need frequent neurovascular assessment distal to the injury. Skin color, temp, sensation, cap refill, mobility, pain, and pulses should be assessed.

HESI Hint 37

Clients with renal failure retain sodium. With water retention, the sodium becomes diluted and serum levels may appear near normal. With excessive water retention, the sodium levels appear decreased (dilution). Limit fluid and sodium intake in ARF clients.

HESI Hint 72

Clinical manifestations of GI bleeding: -Pallor: conjunctival, mucous membranes, nail beds -Dark, tarry stools -Bright red or coffee-ground emesis -Abdominal mass or bruit -Decreased BP, rapid pulse, cool extremities (shock), increased respirations

Identify two types of hearing loss.

Conductive (transmission of sound to inner ear is blocked) Sensorineural (damage to 8th cranial nerve).

After the urinary catheter is removed in the TURP client, what are 3 priority nursing actions?

Continued strict I&O. Continued observations for hematuria. Inform client that burning and frequency may last for a week.

List four components of teaching for the client with TB.

Cough into tissue and dispose of immediately in special bags. Long-term need for daily medication. Good hand washing technique. Report symptoms of deterioration (e.g. blood in secretions).

HESI Hint 147

Craniotomy preoperative medications: -Corticosteriods to reduce swelling -Agents and osmotic diuretics to reduce secretions (atropine, glycopyrrolate [Robinul]) -Agents to reduce seizures (phenytoin) -Prophylactic antibiotics

HESI Hint 41

DIALYSIS COVERED BY MEDICARE -All persons in the US are eligible for Medicare as of their first day of dialysis under special ESRD funding. -Medicare care will indicate ESRD. -Transplantation is covered by Medicare procedure; coverage terminates 6 months postoperative if dialysis is no longer required.

HESI Hint 56

Decreased blood flow results in diminished sensation in the lower extremities. Any heat source can cause severe burns before the client realizes the damage is being done.

How does the nurse prevent hypoxia during suctioning?

Deliver 100% O2 (hyperventilation) before and after each endotracheal suctioning.

How do clients experiencing angina describe that pain?

Described as squeezing, heavy burning, radiates to the left arm or shoulder, transient or prolonged.

HESI Hint 63

Difference in synchronous and asynchronous pacemakers: -Synchronous, or demand: Pacemaker fires only when the client's heart rate falls below a rate set on the generator -Asynchronous, or fixed: Pacemaker fires at a constant rate.

Describe the priority nursing care for a client who has had radiation implants.

Do not permit pregnant visitors or pregnant caretakers in room. Discourage visits by small children. Confine client to room. Nurse must wear radiation badge. Nurse limits time in room. Keep supplies and equipment within client's reach.

Identify two nursing interventions for the client on hemodialysis.

Do not take BP or perform venipuncture on the arm with the AV shunt, fistula, or graft. Assess access site for thrill and bruit.

What instructions should be given to a client following radiation therapy?

Do not wash off lines; wear soft cotton garments; avoid use of powders and creams on radiations site.

List three safety precautions for the administration of antineoplastic chemotherapy.

Double-check order with another nurse. Check for blood return prior to administration to ensure that medication does not go into tissue. Use a new IV site daily for peripheral chemotherapy. Wear gloves when handling the drugs, and dispose of waste in special containers to avoid contact with toxic substances.

HESI Hint 182

Dressing changes are very painful! Medicate client prior to procedure!

HESI Hint 149

Drug therapy for MS clients: ACTH, cortisone, cyclophosphamide (Cytoxan), and other immunosupressive drugs. Nursing implications for administration of these drugs should focus on the prevention of infection.

What symptoms should the nurse expect to find in a client with hypokalemia?

Dry mouth and thirst, drowsiness and lethargy, muscle weakness and aches, and tachycardia.

HESI Hint 58

During aortic aneurysm repair, the large arteries are clamped for a period of time, and kidney damage can result. Monitor daily BUN and creatinine levels. Normal BUN is 10-20 mg/dL, and *normal creatinine is 0.6-1.2 mg/dL*. The ratio of BUN to creatinine is 20:1. When this ratio increases or decreased, suspect renal problems.

HESI Hint 38

During oliguric phase, minimize protein breakdown and prevent rise in BUN by limiting protein intake. When the BUN and creatinine return to normal, ARF is determined to be resolved.

HESI Hint 31

Electroytes are profoundly affected by kidney problems (a favorite NCLEX-RN topic). There must be a balance between extracellular fluid and intracellular fluid to maintain homeostasis. A change in the number of ions or in the amount of fluid will cause a shift in one direction or the other. Sodium and chloride are the primary extracellular ions. Potassium and phosphate are the primary intracellular ions.

Describe postoperative residual limb (stump) care (after amputation) for the first 48 hours?

Elevate residual limb (stump) for first 24 hours. Do not elevate residual limb after 48 hours. Keep residual limb in extended position, and turn client to prone position three times a day to prevent flexion contractures.

State four nursing interventions for assisting the client to cough productively.

Encourage deep breathing; increase fluid intake to 3 L/day; use humidity to loosen secretions; suction airway to stimulate coughing.

HESI Hint 84

Esphogeal varices may rupture and cause hemorrhage. Immediate management includes insertion of an esophagogastric balloon tamponade (a Blakemore-Sengstaken or Minnesota tube). Other therapies include vasopressors, Vit K, coagulation factors, and blood transfusions.

Differentiate between essential and secondary HTN.

Essential HTN has no known cause; secondary HTN develops in response to an identifiable mechanism.

What is the most important principle in a bowel management program for a client with neurologic deficits?

Establishment of regularity.

HESI Hint 140

Even subtle behavior changes, such as restlessness, irritability, or confusion, may indicate increased ICP.

Develop a teaching plan for a client taking antihypertensive medications.

Explain how and when to take medication, reason for medication, necessity of compliance, need for follow-up visits while on medication, need for certain labs, and vital sign parameters while initiating therapy.

HESI Hint 7

Exposure to tobacco smoke is the primary cause of COPD in the US.

HESI Hint 125

Eye drops are used to cause pupil constriction because movement of the muscles to constrict the pupil also allow aqueous humor to flow out, thereby decreasing the pressure in the eye. Pilocarpine is commonly used. Caution client that vision may be blurred for 1-2 hours after administration of pilocarpine and that adaptation to dark environments is difficult because of pupillary constriction (the desired effect of the drug).

HESI Hint 34

FLUID VOLUME ALTERATIONS Excess Fluid: Dyspnea, tachycardia, JVD, peripheral edema, pulmonary edema, weight gain, dyspnea Fluid-Deficiency: Decreased urine output, reduction in body weight, decreased skin turgor, dry mucous membranes, hypotension, tachycardia, weight loss.

HESI Hint 22

Fear of choking is very real for laryngectomy clients. They cannot cough as they could earlier because the glottis is gone. Teach the glottal stop technique to remove secretions (take a deep breath, momentarily occlude the tracheostomy tube, cough, and simultaneously remove the finger from the tube).

HESI Hint 82

Fetor hepaticus is a distinctive breath odor or chronic liver disease. It is characterized by a fruity or musty odor that results from the damaged liver's inability to metabolize and detoxify mercaptan, which is produced by the bacterial degradation of methionine, a sulfurous amino acid.

HESI Hint 89

Following an endosocpic retrograde cholangiopancreatography (ERCP), the client may feel sick. The scope is placed in the gallbladder, and the stones are crushed and left to pass on their own. These clients may be prone to pancreatitis.

HESI Hint 83

For treatment of ascites, paracentesis and peritoneovenous shunts (LeVeen and Denver shunts) may be indicated.

HESI Hint 120

Fractures of bond predispose the client to anemia, especially if long bones are involved. Check hematocrit every 3-4 days to monitor erythropoiesis.

Complications of immobility include the potential for thrombus development. State three nursing interventions to prevent thrombi.

Frequent ROM exercises, frequent (every 2 hours) position changes, and avoidance of positions that decrease venous return.

What are common food intolerances for clients with cholelithiasis?

Fried, spicy, and fatty foods.

Name three food sources of vitamin B12.

Glandular meats (liver), milk, green leafy vegetables.

HESI Hint 124

Glaucoma is often painless and symptomfree. It is usually picked up as part of a regular eye examination.

HESI Hint 100

Glycosylated Hgb (HbA1C): -Indivates glucose control over previous 90-120 days (life of red blood cells) -Is a valuable measurement of diabetes control -Informs diagnosis of diabetes and prediabetes.

Headache and vomiting are symptoms of many disorders. What characteristics of these symptoms would alert the nurse to refer a client to a neurologist?

Headache that is more severe upon awakening, and vomiting not associated with nausea are symptoms of a brain tumor.

HESI Hint 59

Heparin prevents conversion of fibrogen to fibrin and prothrombin to thrombin, thereby inhibiting clot formation. Because the clotting mechanism is prolonged, do not cause tissue trauma, which may lead to bleeding when giving heparin subcutaneously. Do not massage area or aspirate; give in the abdomen between pelvic bones, 2 inches from umbilicus; rotate sites.

Nutritional status is a major concern when caring for a burned client. List three specific dietary interventions used with burned clients.

High-calorie, high-protein, high-carbohydrate diet; medications with juice or milk; no "free" water; tube feeding at night. Maintain accurate, daily calorie counts. Weigh client daily.

List 3 of the most common joints that are replaced?

Hip, knee, finger

HESI Hint 166

Hodgkin disease is one of the most curable of all adult malignancies. Emotional support is vital. Career development is often interrupted for treatment. Chemotherapy render many male clients sterile. May bank sperm prior to treatment, if desired.

List four groups who have a high risk for contracting hepatitis.

Homosexual males IV drug users Those with recent piercing or tattooing Health care workers

List 5 symptoms of hypoglycemia.

Hunger, lethargy, confusion, tremors or shakes, sweating

When making rounds at night, the nurse notes that a client prescribed insulin is complaining of headache, slight nausea, and minimal trembling. The clients hand is cool and moist. What is the client most likely experiencing?

Hypoglycemic/insulin reaction "Cold and clammy, give me candy"

What condition increases the likelihood that digitalis toxicity will occur?

Hypokalemia ( which is more common when taking diuretics and digitalis preparations are not given together)

What are the symptoms of spinal shock?

Hypotension, bladder and bowel distention, total paralysis, lack of sensation below lesion.

What condition results from all treatments for hyperthyroidism?

Hypothyroidism, requiring thyroid replacement

HESI Hint 94

IF two or more parathyroid glands have been removed, the chance of tetany increases dramatically: -Monitor serum calcium levels (9.0 to 10.5 mg/dL is normal range). -Check for tingling of toes and fingers and around the mouth. -Check Chvostek sign (twitching of lip after a tap over the parotid gland means it is positive) -Check Trousseau sign (carpopedal spasm after BP cuff is inflated above systolic pressure means it is positive.

HESI Hint 136

If temperature elevates, take quick measures to decrease it, because fever increases cerebral metabolism and can increase cerebral edema.

HESI Hint 122

Immobile clients are prone to complications: skin integrity problems, formation of urinary calculi (client's milk intake may be limited), and venous thrombosis (client may be on prophylactic anticoagulants).

HESI Hint 115

In clients with hip fractures, thromboembolism is the most common complication. Prevention includes passive ROM exercises, use of elastic stocking, elevation of the foot of the bed 25 degrees to increase venous return, and low-dose heparin therapy.

HESI Hint 150

In clients with myasthenia gravis, be alert for changes in respiratory status; the most severe involvement may result in respiratory failure.

HESI Hint 106

In the joint, the normal cartilage becomes soft, fissures and pitting occur, and the cartilage thins. Spurs form and inflammation sets in. The result is deformity marked by immobility, pain , and muscle spasm. The prescribed treatment regimen is corticosteriods for the inflammation; splinting; immobilization, and rest for the joint deformity; and NSAIDs for the pain.

What vital sign changes are indicative of increased ICP?

Increased BP, widening pulse pressure, increased or decreased pulse, respiratory irregularities, and temperature increase. Think Cushing's Triad: Increase SBP, decreased pulse, decreased respiration

List four nursing diagnoses for the comatose client in order of priority. (Remember Maslow's for help with priority).

Ineffective breathing pattern, ineffective airway clearance, impaired gas exchange, and decreased cardiac output.

HESI Hint 66

Ineffective endocarditis damage to the heart valves occurs with the growth of vegetative lesions on valve leaflets. These lesions pose a risk for embolization, erosion, or perforation of the valve leaflets or abscesses within adjacent myocardial tissue. Valvular stenosis or regurgitation (insufficiency), most commonly of the mitral valve, can occur, depending on the type of damage inflicted by the lesions, and can lead to symptoms of left or right-sided heart failure.

HESI Hint 164

Infection is the immunosuppressed person may not be manifested with an elevated temperature. Therefore, it is imperative that the nurse perform a total and thorough assessment of the client frequently.

HESI Hint 49

Inform the client prior to discharge that some bleeding is expected after TURP. Large amounts of blood or frank bright bleeding should be reported. However, it is normal for the client to pass small amounts of blood as well as small clots during the healing process. He should rest quietly and continue drinking large amounts of fluid.

HESI Hint 48

Instillation of hypertonic or hypotonic solution into a body cavity will cause a shift in cellular fluid. Use only sterile saline for bladder irrigation after TURP because the irrigation must be isotonic to prevent fluid and electorlyte imbalance. Clients with foley catheters require perineal care and foley care twice per day.

HESI Hint 104

Insulin is prescribed in basal/bolus and correction factor therapy. The goal of insulin therapy is to mimic the body's normal basal/bolus secretion of insulin. *Basal insulin* (long acting/intermediate acting) suppresses glucose production between meals and overnight. *Bolus insulin* or mealtime limits hyperglycemia after meals. *Correction factor* is the amount of insulin needed to correct hyperglycemia, usually given pre-meal.

Describe preoperative nursing care for a client undergoing a laryngectomy.

Involve family and client in manipulation of tracheostomy equipment before surgery; plan acceptable communication methods; refer to speech pathologist; discuss rehabilitation program.

List four nursing interventions for postoperative care of a client with a colostomy.

Irrigate daily at same time; use warm water for irrigations; wash around stoma with mild soap and water after each ostomy bag change; ensure that pouch opening extends at least 1/8 inch around the stoma.

What nursing interventions prevent corneal drying in a comatose client?

Irrigation of the eyes PRN with sterile prescribed solution, applications of ophthalmic ointment every 8 hours, close assessment for corneal ulceration or drying.

HESI Hint 5

Irritability and restlessness are early signs of cerebral hypoxia; the client's brain is not receiving enough O2.

HESI Hint 144

It is imperative to reverse spinal shock as quickly as possible. Permanent paralysis can occur if a spinal cord is compressed for 12 to 24 hours.

Describe the nurse's discharge instructions to a client with venous PVD.

Keep extremities elevated when sitting, rest at first sign of pain, keep extremities warm (but do not use heating pad), change position often, avoid crossing legs, wear nonrestrictive clothing.

HESI Hint 169

Laser therapy or cryosurgery is used to treat cervical cancer when the lesion is small and localized. Invasive cancer is treated with radiation, conization, hysterectomy, or pelvic exenteration (a drastic surgical procedure where the uterus, ovaries, fallopian tubes, vagina, rectum, and bladder are removed in an attempt to stop metastasis). Chemotherapy is not useful for this type of cancer.

A client with a diagnosis of stroke presents with symptoms of aphasia and right hemiparesis but no memory or hearing deficit. In what hemisphere has the client suffered a lesion?

Left

Describe the use of leucovorin.

Leucovorin is used as an antidote with methotrexate to prevent toxic reactions.

HESI Hint 87

Live tissue is destroyed by hepatitis. Rest and adequate nutrition are necessary for regeneration of the liver tissue being destroyed by the disease Many drugs are metabolized in the liver, so drug therapy must be scrutinized carefully. Caution the client that recovery takes many months, and previously taken medications and/or OTC drugs should not be resumed without the health care provider's directions.

HESI Hint 15

Look and listen! If breath sounds are clear but the client is cyanotic and lethargic, adequate oxygenation is not occurring.

List five nursing interventions after chest tube insertion.

Maintain a dry occlusive dressing on chest tube. Keep all tubing connections tight and taped. Monitor client's clinical status. Encourage the client to breathe deeply periodically. Monitor the fluid drainage, and mark the time of measurement and the fluid level.

HESI Hint 162

Many health care delivery systems require the nurse to be credentialed in order to administer parental chemotherapy. The practical nurse (PN) should recognize complications of chemotherapy related to administration, safety, side effects, and nursing assessment parameters and should report there to the registered nurse and health care provider.

HESI Hint 96

Many people take steroids for a variety of conditions. NCLEX-RN questions often focus on the need to teach clients the importance of following the prescribed regimen precisely. They should be cautioned against stopping the medications suddenly and should be informed that it is necessary to taper off the dosage when taking steroids.

HESI Hint 180

Massive volumes of IV fluids are given. It is not uncommon to give over 1000 mL/hr during various phases of burn care. Hemodynamic monitoring must be closely observed to be sure the client is supported with fluids but not overloaded.

HESI Hint 165

May oncologic drugs cause immunosuppression. Prevention of secondary infections is vital! Advise clent to stay away from persons with known infections such as colds. In the hospital, place client in a private room, and maintain an environment as sterile and as clean as possible. These persons should not eat raw vegetables or fruits - only cooked foods - so as to destroy any bacteria.

HESI Hint 174

Men whose testes have not descended into the scrotum or whose testes descended after age 6 are at high risk for developing testicular cancer. The most common symptom is the appearance of a small, hard lump about the size of a pea on the front or side of the testicle. Testicular self-examination (TSE) should be done regularly at the same time every month by all males after age 14. It should be done after a shower be gently palpating the testes and cord to look for a small lump. Swelling may also be a sign of testicular cancer.

HESI Hint 167

Menorrhagia (profuse or prolonged menstrual bleeding) in the most important factor relating to benign uterine tumors. Assess for signs of anemia.

During mechanical ventilation, what are three major nursing interventions?

Monitor client's respiratory status and secure connections; establish a communication mechanism with the client; keep airway clear by coughing and suctioning.

Describe the physical appearance of clients who have Cushing syndrome.

Moon face, obesity in trunk, buffalo hump in back, muscle atrophy, and thin skin.

HESI Hint 152

Myastenic crisis is associated with a positive edrophonium (Tensilon) test, whereas a cholinergic crisis is associated with negative test.

HESI Hint 95

Myxedema coma can be precipitated by acute illness, withdrawal of thyroid medication, anesthesia, use of sedatives, or hypoventilation (with the potential for respiratory acidosis and CO2 narcosis). The airway must be kept patent and ventilator support used as indicated.

HESI Hint 153

NCEX-RN questions often focus on the features of Parkinson disease: tremors (a coarse tremor of fingers and thumb on one hand that disappears during sleep and purposeful activity (pill rolling), rigidity, hypertonicity, and stooped posture. Focus: Safety!

HESI Hint 130

NCLEC-RN questions often focus on communicating with older adults who are hearing impaired. -Speak in a low-pitched voice, slowly and distinctly -Stand in front of the person, with the light source behind the client. -Use visual aids if available.

HESI Hint 119

NCLEX-RN questions about joint replacement focus on complications. A big problem after joint replacement is infection.

HESI Hint 113

NCLEX-RN questions focus on safety precautions. Improper use of assistive devices can be very risky. When using a nonwheeled walker, the client should lift and move the walker forward and then take a step into it. The client should avoid scooting the walker or shuffling forward into it; these movements take more energy and provide less stability than does a single movement.

HESI Hint 109

NCLEX-RN questions often focus on the fact that avoiding sunlight is key in the management of lupus erythematosus; this is what differentiates it from other connective-tissue diseases.

Identify the categories of drugs commonly used to treat arthritis.

NSAIDs, of which salicylates are the cornerstone of treatment, and corticosteriods (used when arthritic symptoms are severe)

HESI Hint 28

NXCLEX-RN CONTENT ON CHEST TUBES Fluctuations (tidaling) in the fluid will occur if there is not external suction. There fluctuating movements are a good indicator that the suction system is intact; they should move upward with each inspiration and downward with each expiration. If fluctuations cease, check for kinked tubing, accumulation of fluid in the tubing, occlusions, or change in the client's position, because expanding lung tissues may be occluding the tube opening. Remember, when external suction is applied, the fluctuations cease.

Why should narcotics be avoided in clients with neurologic impairment?

Narcotics mask the level of responsiveness and pupillary responses.

Is paralysis always a consequence of spinal cord injury?

No

HESI Hint 93

Normal serum calcium is 9.0 to 10.5 mEq/L. The best indicator of parathyroid problems is a decrease in the client's calcium compared to the preoperative value.

HESI Hint 30

Normally, kidneys excrete approximately 1 mL of urine per kg of body weight per hour. For adults, total daily urine output ranges between 1500-2000 mL depending on the amount and type of fluid intake, amount of perspiration, environmental or ambient temperature, and the presence of vomiting or diarrhea.

What are the immediate nursing actions if fat embolization is suspected in a client with a fracture or other orthopedic condition?

Notify MD STAT, draw blood gases, administer O2 according to blood gas results, assist with endotracheal intubation and treatment for respiratory failure.

HESI Hint 67

PERICARDITIS The presence of a friction rub is an indication of pericarditis (inflammation of the lining of the heart). ST-segment elevation and T-wave inversion are also signs of pericarditis.

HESI Hint 6

PNEUMONIA PREVENTATIVES: -Older adults: flu shots, pnu immz, avoiding sources of infection and indoor pollutants (dust, smoke, and aerosols); no smoking -Immunosuppressed and debilitated persons: flu shots, pnu immz, infection avoidance, sensible nutrition, adequate intake, balance of rest and activity -Comatose and immobile persons: Elevation of head of the bed to feed and for 1 hour after, frequent turning -Pts with functional or anatomic asplenia: Flu and pnu immz

What screening tool is used to detect cervical cancer? What are the American Cancer Society's recommendations for women ages 30-70 with three consecutive normal results?

Pap smear. Women ages 30 to 70 with three consecutive normal results may have pap smears every 2-3 years (screening for HPV).

Describe three nursing interventions to help decreased edema post-mastectomy.

Position arm on operative side pillow. Avoid BP measurements and venipunctures in operative arm. Encourage hand activities and use.

State four independent nursing interventions to maintain adequate respiration, airway, and oxygenation in the unconscious client.

Position for maximum ventilation (prone or semi-prone and slightly to one side); insert airway if tongue is obstructing; suction airway effectively, monitor arterial PO2 and PCO2; and hyperventilate with 100% O2 before suctioning.

What measures should the nurse encourage female clients to take to prevent osteoporosis?

Possible estrogen replacement after menopause, high-calcium and vit D intake beginning in early adulthood, calcium supplements post-menopause, and weight bearing exercise.

HESI Hint 110

Postmenopausal, thin white women are at highest risk for development of osteoporosis. Encourage exercise, a diet high in calcium, and supplemental calcium. Tums are an excellent source of calcium, but they are also high in sodium, so hypertensive or edematous individuals should seek another source of supplemental calcium.

HESI Hint 183

Preexisting conditions that might influence burn recovery are age, chronic illness (diabetes, cardiac problems, etc..), physical disabilities, disease, medications used routinely, and drug or alcohol abuse.

Outline admission care of the burned client.

Provide a patent airway because intubation may be necessary. Determine baseline data. Initiate fluid and electrolyte therapy. Administer pain medication. Determine depth and extent of burn. Administer tetanus toxoid. Insert NG tube.

Identify the peak action time of the following types of insulin; rapid-acting regular insulin; intermediate-acting insulin; long- acting insulin.

Rapid-acting regular insulin: 2-4 hours Intermediate-acting insulin: 6-12 hours Long-acting insulin: 14-20 hours

List five symptoms indicative of colon cancer.

Rectal bleeding, change in bowel habits, sense of incomplete evacuation, abdominal pain with nausea, weight loss.

HESI Hint 54

Remember the risk factors for HTN: -heredity -race -age -alcohol abuse -increased salt intake -obesity -use of contraceptives

HESI Hint 52

Remember: MONA when andministering medication and treatments in the pt with myocardial infarction. M-Morphine O-Oxygen N-Nitroglycerin A-Asprin

Differentiate between rheumatoid arthritis and OA in terms of joint involvement.

Rheumatoid arthritis occurs bilaterally. OA occurs asymmetrically.

What is the highest priority nursing diagnosis for clients in any type of renal failure?

Risk for imbalanced fluid volume.

HESI Hint 137

Saftey features for immobilized clients: -Prevent skin breakdown by frequent turning. -Maintain adequate nutrition. -Prevent aspirations with slow, small feedings or NG feedings. -Monitor neurologic signs to detect the first signs that ICP may be increasing. -Provide ROM exercises to prevent deformities. -Prevent respiratory complications; frequent turning and positioning provide optimal drainage.

HESI Hint 103

Self-monitoring of blood glucose (SMBG): -Uses techniques that are specific to each meter -Frequency of monitoring based on treatment regimen, change in meals, illness, and exercise regimen. -Requires recording results and reporting results to health care provider at time of visit. -Results of monitoring used to assess the efficacy of therapy and to guide adjustments in medical nutrition therapy, exercise, and medications to achieve the best possible blood glucose control.

What are the indications for a hysterectomy in a client who has fibromas?

Severe menorrhagia leading to anemia, severe dysmenorrhea requiring narcotic analgesics, severe uterine enlargement causing pressure on other organs, severe low back and pelvic pain.

List four nursing interventions for the client with a hiatal hernia.

Sit up while eating and for 1 hour after eating. Eat frequent small meals. Eliminate foods that are problematic.

HESI Hint 26

Some tumors are so large that they fill entire lobes of the lung. When removed, large spaces oar left. Chest tubes are not usually used with these clients because it is helpful if the mediastinal cavity, where the lung used to be, fills up with fluid. This fluid helps to prevent the shift of the remaining chest organs to fill the empty space.

What are the most important nursing interventions for clients with possible renal calculi?

Straining all urine is the most important intervention. Other interventions include accurate I&O documentation and administering analgesics as needed.

When preparing a client with diabetes for discharge, the nurse teaches the client the relationship between stress, exercise, bedtime snacking, and glucose balance. State the relationships among each of these.

Stress and stress hormones increase glucose production and increase insulin need. Conversely, exercise may increase the chance of an hypoglycemic reaction; therefore, the client should always carry a fast-acting source of carbohydrate, such as glucose tablets or hard candies, when exercising.

HESI Hint 71

Stress can cause or exacerbate ulcers. Teach stress-reduction methods, and encourage those with a family hx of ulcers to obtain medical surveillance for ulcer formation.

How should the head of the bed be positioned for post-craniotomy clients with infratentorial lesion?

Supratentorial: elevated Infratentorial: flat

HESI Hint 107

Synovial tissues line the bones of the joints. Inflammation of this lining causes destruction of tissue and bone. Early detection of RA can decrease the amount of bone and joint destruction. Often the disease goes into remission. Decreasing the amount of bond and joint destruction reduces the amount of disability.

HESI Hint 25

TEACHING POINTS: -Rifampin: reduces effectiveness of oral contraceptives; clients should use other birth control methods during treatments; give body fluids and orange tinge; stains soft contact lenses. -Isoniazid (INH): Increased phenytoin (Dilantin) levels. -Ethambutol: Vision check before starting therapy and monthly thereafter; may have to take for 1-2 years. Teach rationale for combination drug therapy to increase compliance. Resistance develops more slowly if several anti-TB drugs given, instead of just one drug at a time.

List four common symptoms of pneumonia the nurse might note on a physical exam.

Tachypnea, fever with chills, productive cough, bronchial breath sounds.

Develop a teaching plan for a client taking nitroglycerin.

Take at first sign of anginal pain. Take no more than 3, 5 minutes apart. Call for emergency attention if no relief in 10 minutes.

What precautions should clients with valve disease take prior to invasive procedures or dental work?

Take prophylactic antibiotics.

HESI Hint 73

The GI tract usually accounts for only 100-200 mL of fluid loss per day, although it filters up to 8 L per day. Large fluid losses can occur if vomiting or diarrhea exists.

HESI Hint 129

The ear consists of three parts: the external ear, the middle ear, and the inner ear. Inner ear disorders, or disorders of the sensory fibers going to the CNS, often are neurogenic in nature and may not be helped with a hearing aid. External and middle earprobelms (conductive) may result from infection, trauma, or wax buildup. These types of disorders are treated more successfully with hearing aids.

HESI Hint 172

The importance of teaching female clients how to conduct a breast self-examination cannot be overemphasized. Early detection is related to positive outcomes.

HESI Hint 44

The key to resolving UTIs with most antibiotics is to keep the blood level of the antibiotic constant. It is important to tell the client to take the antibiotics around the clock and not to skip doses so that a consistent blood level can be maintained for optimal effectiveness.

HESI Hint 16

The key to respiratory status is assessment of breath sounds as well as visualization of the client. Breath sounds are better described, not named' IE sounds should be described as crackles, wheezes, or high-pitched whistling sounds rather than rales, rhonchi, ect. which may not mean the same things to each clinical professional.

HESI Hint 127

The lens of the eye is responsible for projecting light onto the retina so that images can be discerned. Without the lens, which becomes opaque with cataracts, light cannot be filtered and vision is blurred.

HESI Hint 111

The main cause of fractures in older adults, especially in women, is osteoporosis. The main fracture sites seem to be hip, vertebral bodies, and Colles fracture of the forearm.

HESI Hint 171

The major emphasis is nursing management of cancers of the reproductive tract is early detection.

HESI Hint 173

The presence or absence of hormone receptors is paramount is selecting clients for adjuvant therapy.

HESI Hint 123

The residual limb (stump) should be elevated on one pillow. If the residual limb (stump) is elevated too high, the elevations can cause a contracture.

HESI Hint 114

The risk for the development of a fat embolism is greatest in the first 36 hours after a fracture. It's more common in clients with multiple fractures, fractures of the long bones, and fractures of the pelvis. The initial symptom of a fat embolism is confusion due to hypoxemia (check blood gases for PO2). Assess for resp distress, restlessness, irritability, fever, and petechiae. If an embolism is suspected: notify MD STAT, draw blood gases, administer o2, and assist with endotracheal intubation (PRN)>

Name the necessary elements to include in teaching a new diabetic:

The underlying pathophysiology of the disease; it's management and treatment; meal planning; exercise program; insulin administration; sick-day management; symptoms of hyperglycemia; symptoms of hypoglycemia; foot care.

HESI Hint 126

There is an increased incidence of glaucoma in older adult populations. Older clients are prone to problems associated with constipation. Therefore, the nurse should assess these clients for constipation and postoperative complications associated with constipation and should implement a plan of care directed at prevention of and, if necessary, treatment for constipation.

What is the action of hyperonmotic agents (osmotic diuretics) used to treat ICP?

They dehydrate the brain and reduce cerebral edema by holding water in the renal tubules to prevent reabsorption, and by drawing fluid from the extravascular spaces into the plasma.

HESI Hint 91

Thyroid storm is a life-threatening event that occurs with uncontrolled hyperthyroidism due to Graves disease. Other causes include childbirth, CHF, diabetic ketoacidosis, infection, pulmonary embolism, emotional distress, trauma, and surgery. Symptoms: fever, tachycardia, agitation, anxiety, and HTN Primary nursing interventions are to maintain and airway and adequate aeration. Propylthiouracil (PTU) and methimazole (Tapazole) are antithyroid drugs used to treat thyroid storm. Propranolol (Inderal) may be given to decrease excessive sympathetic stimulation.

What is the causative organism of syphilis?

Treponema pallidum (spirochete bacteria)

Malodorus, frothy, greenish-yellow vaginal discharge is characteristic of which STD?

Trichomonas vaginalis

HESI Hint 142

Try not to use restraints; the only increase restlessness. Avoid narcotics because they mask the level of responsiveness.

Which type of diabetes sometimes requires no medication?

Type 2

HESI Hint 131

Use of the Glasgow Coma Scale eliminates ambiguous terms to describe neurologic status, such as lethargic, stuporous, or obtuned. Best response: 15 Comatosed client: 8 and below Totally unresponsive: 3

HESI Hint 161

Use only normal saline to flush IV tubing or to run with blood. Never add medications to blood products. Two registered nurses should simultaneously check the physician's prescription, the client's identity, and the blood bag label.

Describe care of invasive catheters and lines.

Use strict aseptic technique. Change dressings two or three times per week or when soiled. Use caution when piggybacking drugs; check purpose of line and drug to be infused. When possible, use lines to obtain blood samples to avoid "sticking" client.

HESI Hint 29

Various pathophysiologic conditions can be realted to the nursing dx "ineffective breathing patterns" 1. Inability of air sacs to fill and empty properly (emphysema, cystic fibrosis). 2. Obstruction of the air passages (carcinoma, asthma, chronic bronchitis) 3. Accumulation of fluid in the air sacs (pneumonia) 4. Respiratory muscle fatigue (COPD, pneumonia)

HESI Hint 108

What activity recommendations should the nurse provide a client with rheumatoid arthritis? -Do not exercise painful, swollen joints -Do not exercise any joint to the point of pain -Perform exercises slowly and smoothly; avoid jerky movements (swimming is good - low impact on the joints)

HESI Hint 168

What is anatomic significance of a prolapsed uterus? When the uterus is displaced, it impinges on other structures in the lower abdomen. The bladder, rectum, and small intestine can protrude through the vaginal wall.

HESI Hint 112

What type of fracture is more difficult to heal: an extracapsular fracture (below neck of femur) or intracapsular (in the neck of femur)? The blood supply enters the femur below the neck of the femur. Therefore, an intracapsular fracture heals with greater difficulty, and there is a greater likelihood that necrosis will occur because the fracture is cut off from the blood supply.

When can a comatose client on IV hyperalimentation begin to receive tube feedings instead?

When peristalsis resumes as evidenced by active bowel sounds, passage of flatus or bowel movement

HESI Hint 128

When the cataract is removed, the lens is gone, making prevention of falls important. When the lens is replaced with an implant, vision is better.

When do PVCs present a grave danger?

When they begin to occur more often than once in 10 beats, occur in twos or threes, land near the T wave, or take on multiple configurations

Is multiple sclerosis thought to occur because of an autoimmune process?

Yes

Differentiate between acute renal failure and chronic renal failure.

*Acute renal failure*- abrupt deterioration of kidney fucntion; often reversible. *Chronic renal failure*- slow deterioration of kidney function characterized by increasing BUN and creatinine; irreverisble; eventually dialysis is required.

HESI Hint 11

*PINK PUFFER*: barrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe. The person works harder to breathe, but the amount of O2 taken in is adequate to oxygenate the issues. *BLUE BLOATER*: insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right-sided heart failure.

HESI Hint 8

-Compensation occurs over time in client with chronic lung disease, and ABGs are altered. -As COPD worsens, the amount of O2 in the blood decreases (hypoxemia) and the amount of carbon dioxide (CO2) in the blood increases (hypercapnia), causing chronic respiratory acidosis (increased PaCO2), which results in metabolic alkalosis (increased bicarb) as compensation. -Not all clients with COPD are CO2 retainers, even when hypoxemia is present, because CO2 diffuses more easily across lung membranes than O2 -In advanced emphysema, due to the alveoli being affected, hypercarbia is a problem, rather than in bronchitis, where the airways are affected. -It is imperative that baseline data be obtained for the client.

HESI Hint 61

A Holter monitor offers continuous observation of the client's heart rate. To make assessment of the rhythm, strips most meaningful, teach the clients to keep a record of: -Medication time and doses -Chest pain episodes: type and duration -Valsalva maneuver (straining at stool, sneezing, coughing) -Sexual activity -Exercise and other activities

HESI Hint 57

A client is admitted with severe chest pain and states that he feels a terrible tearing sensation in his chest. He is diagnosed with a dissecting aortic aneurysm. What assessments should the nurse obtain in the first few hours? -vital signs every hour -neurologic vital signs -respiratory status -urinary output -peripheral pulses

HESI Hint 68

ACUTE AND SUBACUTE INEFFECTIVE ENDOCARDITIS Ineffective: acute, usually normal hearts/valves, high mortality rate Subacute: typically affects those with preexisting conditions -IV users high risk for both; usually effects right side of the heart bc of introduction of common pathogens of the skin (staph and candida) into the venous system.

HESI Hint 43

As kidneys fail, medications must often be adjusted. Of particular importance in digoxin toxicity because digitalis preparations are excreted by the kidneys. Signs of toxicty in adults include nausea, vomiting, anorexia, visual disurbances, restlessness, headache, cardiac dysrhythmias, and puls <60 bpm.

HESI Hint 2

CLIENTS AT HIGH RISK FOR PNEUMONIA: -Altered LOC -Depressed or absent gag reflex -Susceptible to aspirating oropharyngeal secretions, including alcoholics, anesthetized individuals -Brain injury -Drug overdose -Stroke vicitms -Immunocompromised

HESI Hint 62

Cardioversion is the delivery of synchronized electrical shocks to the myocardium.

HESI Hint 65

DIGITALIS -Side effects of digitalis are increased when the client is hypokalemic -Digitalis has a negative chronotropic effect (IE It slows the HR). Hold the digitalis if the pulse rate is <60 or >120 bpm (<90 bpm in an infant) or has markedly changed rhythm. -Bradycardia, tachycardia, and dysrhythmias may be signs of digitalis toxicity; these signs include nausea, vomiting, and HA in adults. -If withheld, consult with physician.

HESI Hint 1

Fever can cause dehydration because of excessive fluid loss due to diaphoresis. Increased temperature also increases metabolism and the demand for O2.

List four essential elements of a teaching plan for clients with frequent urinary tract infections.

Fluid intake 3 L/day; good handwashing; void every 2-3 hours during waking hours; take all prescribed medication; wear cotton undergarments.

HESI Hint 13

HEALTH PROMOTION: -Eating consumes energy needed for breathing. Offer mechanically soft diets, which do not require as much chewing and digestion. Assist with feeding if needed. -Prevent secondary infections; avoid crowds, contact with persons who have infectious diseases. and respiratory irritants (tobacco smoke). -Teach client to report any change in characteristics of sputum. -Encourage client to hydrate well (3 L/day) and decrease caffeine due to diuretic effect. -Obtain immz when needed (flu, pnu)

HESI Hint 4

HYDRATION: -Thins out the mucus trapped in the bronchioles and alveoli, facilitating expectoration -Is essential for client experiencing fever -Is important because 300-400 mL of fluid is lost daily by the lungs through evaporation.

HESI Hint 69

In mitral valve stenosis, blood is regurgitated back into the left atrium from the left ventricle. In the early period, there may be no symptoms, but as the disease progresses, the client will exhibit excessive fatigue, dyspnea on exertion, orthopnea, dry cough, hemoptysis, or pulmonary edema. There will be a rumbling apicle diastolic murmur, and atrial fibrillation is common.

HESI Hint 32

In some cases, persons in ARF may not experience the oliguric phase but may progress directly to the diuretic phase, during which the urinary output may be as much as 10 L per day.

HESI Hint 45

Location of the pain can help to determine the location of the stone. -Flank pain usually means the stone is in the kidney or upper ureter. If the pain radiates to the abdomen or scrotum, the stone is likely to be in the ureter or bladder. -Excruciating spastic-type pain is called colic. -During kidney stone attacks, it is preferable to administer pain medications at regularly scheduled intervals rather that PRN to prevent spasm and optimize comfort.

What discharge instructions should be given to a client who has had urinary calculi?

Maintain high fluid intake of 3-4 L/day. Pursue follow-up care (stones tend to recur). Follow prescribed diet based on calculi content. Avoid supine position.

HESI Hint 10

NORMAL ABG VALUES: *Blood Gas* *Adult* *Child* Blood Gas (pH) 7.35-7.45 7.36-7.44 PCO2 35-45 same as adult PO2 80-100 same as adult HCO3 21-28 same as adult

Describe intermittent claudication.

Pain related to PVD; the pain occurs with exercise and disappears with rest.

HESI Hint 46

Percutaneous nephrostomy: A needle or catheter is inserted through the skin into the calyx of the kidney. The stone may be dissolved by percutaneous irrigation with a liquid that dissolves the stone or by ultrasonic sound waves (lithrotripsy) that can be directed through the needle or catheter to break up the stone, which then can be eliminated through the urinary tract.

What immediate action should the nurse take when a chest tube becomes disconnected from a bottle or suction apparatus? What should the nurse do if a chest tube is accidentally removed from the client?

Place the end of the tube in a sterile water container at a 2 cm level. Apply an occlusive dressing, and notify health care provider STAT.

HESI Hint 36

Potassium has a critical safe range (3.5-5.0 mEq/L) because it affects the heart, and any imbalance must be corrected by medications or dietary modification. Limit high-potassium foods (bananas, orange juice, cantaloupe, strawberries, avocados, spinach, fish) and salt substitutes, which are high in potassium.

HESI Hint 9

Productive cough and comfort can be facilitated by semi-fowler or high-fowler position, which lessens pressure on the diaphragm by abdominal organs. Gastric distention becomes a priority in these clients because it elevates the diaphragm and inhibits full lung expansion.

HESI Hint 14

When asked to prioritize nursing actions, use the ABC rule: -Airway -Breathing -Circulation In CPR circumstances, follow CAB guidelines.

HESI Hint 24

Teaching is very important with the client with TB. Drug therapy is usually long term (6 mo or longer). It is essential that the client take the medications as prescribed for the entire time. Skipping doses or prematurely terminating drug therapy can result in public health hazard.

HESI Hint 40

The major difference between dialysis and perioteal dialysis is the amount of glucose. Peritoneal dialysis dialysate is much higher in glucose. For this reason, if the dialysate is left in the peritoneal cavity too long, hyperglycemia may occur.

HESI Hint 55

The number one cause of a stroke in hypertensive clients is noncompliance with medication regimen. HTN is often symptomless, and antihypertensive medications are expensive and have side effects. Studies have shown that the more clients know about their hypertensive medications, the more likely they are to take them; teaching is important.

During the oliguric phase of renal failure, protein should be severely restricted. What is the rationale for this restriction?

Toxic metabolites that accumulate in the blood (urea, creatinine) are derived mainly from protein catabolism.

HESI Hint 19

Tracheostomy care involves cleaning the inner cannula, suctioning, and applying clean dressing.

HESI Hint 23

Tuberculosis (TB) Skin Test: A possitive TB skin test in a healthy client is exhibited by an induration 10mm or greater in diameter 48 to 72 hours after the skin test. Anyone who has received a bacillus Calmette-Guerin (BCG) vaccine will have a positive skin test and must be evaluated with an initial chest x-ray. A health hx with s/s form may be filled out annually until s/s arise; then another x-ray is required. Chest x-rays are required on new employment; employer may require an x-ray every 5 years.

HESI Hint 17

Watch for NCLEX-RN questions that deal with O2 delivery. In adults, O2 must bubble through the same type of water solution so it can be humidified is given at >4 L/min or delivered directly tot he trachea. If given at 1 - 4 L/min or by mask or nasal pongs, the oropharynx and nasal pharynx provide adequate humidification.

HESI Hint 50

What is the relationship of the kidneys to the cardiovascular system? - The kidneys filter about 1 L of blood per minute. -If cardiac output is decreased, the amount of blood going through the kidneys is decreased; urinary output may be a sign of cardiac problems. -When the kidneys produce and excrete 0.5 mL of urine/kg of body weight or average 30 ml/hr output, the blood supply is considered to be minimally adequate to perfuse the vital organs.

HESI Hint 18

With cancer of the larynx, the tongue and mouth often appear white, gray, dark brown, or black and may appear patchy.