HESI Questions you Missed
do you moisturize a illiostomy
NO
Bronchovesicular breath sounds in peripheral lung fields are
abnormal and suggest pneumonia.
A "shift to the left" is evident of
number of immature cells (bands) in the blood increases to fight an infection.
10-15 ccs urine is
oliguria
Left shift WBC
possible bacterial infections
If eye ointment and eyedrops must be instilled in the same eye, what goes first
the eyedrops should be instilled firs
Before administering any "as needed" pain medication, the nurse should ask the patient to indicate
the location of the pain.
A "shift to the right" is evident when
the number of mature cells in the blood increases, as seen in advanced liver disease and pernicious anemia
To check for petechiae in a dark-skinned patient, the nurse should assess
the oral mucosal
Primary intention healing
tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring
a pressure ulcer with any kind of necrosis is what
unstable
Four-point gait
used when both legs can bear some weight; right foot, left crutch, left crutch, right foot
When assessing a patient's eating habits, the nurse should ask
what have you eaten un 24 hours
afebrile
without fever
Secondary intention healing
wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring
can a LPN reinforce teaching from plan of care?
yes
where to insert ear drops
Administer toward the wall of the canal, rather than directly onto the eardrum
Heat is contraindicated in...
- areas of active bleeding - acute localized inflammation - if a patient has cardiovascular problems
Cold is contraindicated if...
- site of injury is edematous - presence of neuropathy - patient is shivering - patient has impaired circulation
what do we give with blood transfusion
0.9NS
The nurse is working on a medical-surgical unit. Which client would the nurse see first based on the client's risk for experiencing delirium? A client being treated for hypertension 2A client recovering from hip replacement surgery 3A client being treated for a urinary tract infection (UTI) 4A client transferred from the intensive care unit after being treated for sepsis
3A client being treated for a urinary tract infection (UTI)
Magnesium levels
1.5-2.5
Normal Serum Magnesium Level
1.5-2.5
PT therapeutic range
1.5-2x (normal or control value)
PT time
11-12.5 seconds
Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? The client with colitis 2The client with Cushing's syndrome 3The client who has been overusing laxatives 4The client who has sustained a traumatic burn
2
Phosphorus levels
3-4.5
Albumin levels
3.5-5
how long in a shift can a nurse care for a radiation PT
30 mins
Hct
35-45
how far to insert for rectal
4 inches / 1-2 cm
good sources of potassium
Bananas, citrus fruits, and potatoes
how should I PT use a cane?
Have pt hold cane on their strong side Advance cane, then advance weak foot in line with cane. Use cane to support weak side, then bring strong foot forward. Repeat
who should not get caffine
MI or cardiac pT
Does an incident report copy remain in the clients chart or record?
NO
should you inject dorsal glutealy
NO
if you see pus in a wound, do you irrigate?
NO CALL HCP
If a chest drainage system line is broken or interrupted, the nurse should
clamp the tube
how do we inject penicilin
deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn't massage the injection site
isometirc exercise
done when in a castA "shift to the left" is evident
diaphragm for
high-pitched sounds, normal heart sounds
intractable pain
severe pain that is extremely resistant to relief measures
Good sources of magnesium
spinach, black beans, soy milk, bran cereal, oysters, yogurt
Salem pump for
suction, medication administration
main codeine side effect
constipation
what should you do if PT is coughing or having a hard time breathing in NG administration?
cough- pull back hard time breathing- pull out
Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? The client with colitis 2The client with Cushing's syndrome 3The client who has been overusing laxatives 4The client who has sustained a traumatic burn
4The client who has sustained a traumatic burn
how long can you apply cold/heat for
20 mins
A hydrocolloid dressing is prescribed for a client with a leg ulcer. The home health nurse is preparing a plan of care for the client and would appropriately document which intervention? Change the hydrocolloid dressing daily. 2Change the hydrocolloid dressing every 3 to 5 days. 3Apply the hydrocolloid dressing over a dry, sterile dressing. 4Apply the hydrocolloid dressing over a normal saline-soaked dressing.
2Change the hydrocolloid dressing every 3 to 5 days.
A client is receiving outpatient radiation treatments for carcinoma of the oropharynx and is experiencing dysphagia. The nurse would include which intervention in the plan of care? Encourage the client to drink only thin liquids. 2Teach the client to examine the oral mucosa monthly. 3Teach the client to speak slowly and enunciate clearly. 4Encourage the client to use artificial saliva to manage dryness.
4Encourage the client to use artificial saliva to manage dryness.
The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse needs to include which piece of information in discussions with the client? Inhale as rapidly as possible .2Keep a loose seal between the lips and the mouthpiece. 3After maximum inspiration, hold the breath for 15 seconds and exhale. 4The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.
4The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.
how far away do we place crutches
6″ (15.2 cm) in front of the patient and 6″ to the side to form a tripod arrangement
what will we do if residual is 100 or more in NG admin
Hold if greater than 100 mL and reinstill
Order of Assessment
I-inspection P-palpation P-percussion A-auscultation Except with abdomen it is IAPP-inspect, auscultate, percuss and palpate.
what should you do if enteral nutrition bag gets low
If PN bag empty, prepare 10% dextrose in water to PREVENT hypoglycemia (need the solution containing the highest amount of glucose)
where do you keep restraint key
Keep key in pt's room [so all can access as needed, especially important in emergency]
To induce sleep, the first step is to
Minimize environmental stimuli
what color snellen chart for elder adults
Orange, red, or yellow should be used as indicator for the older adult
where do we find thiamine
Pork Peanuts Asparagus Whole-grain and enriched meals
when do you put PT in low fowlers
Post
The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply.
Prolonged QT interval Prolonged ST segment
when do use semi fowlers
Promotion of lung expansion, especially with ventilator-assisted pts Used for pts receiving oral care & for gastric feedings (reduce regurgitation & risk of aspiration)
When transferring a pt with one injured leg, bed to chair, where do you put chair
Put chair to bed at 45 degrees on side of good leg
nursing interventions for infiltration
REMOVE IV Elevate extremities Warm/cold compress Do not rub Document
phlebitis nursing interventions
REMOVE IV Start in OPPOSITE EXTREMITY Document
how to move with four point crutch
Right crutch → left foot → left crutch → right foot
when do you use telenbergs
Shock/ Hyptersenive crisis (blood to head)
What to do if a transfusion reaction occurs
Stop the transfusion immediately. Initiate normal saline in a separate line, save the blood bag with the remaining blood and the blood to tubing for testing
nasal drops position
Supine position with head slightly tilted back
The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value?
Tall peaked T waves4 Widened QRS complexes
how to tell PT to behave in NG removal
Tell pt to take a deep breath, exhale and beat down (Valsalva maneuver)
hypermagnesium s/sx
Tetany, twitches, and a positive Trousseau's sign are seen in a client with hypomagnesemia
universal donor blood type
Type O
The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns would the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. U waves 2Absent P waves 3Inverted T waves 4Depressed ST segment 5Widened QRS complex
U waves 3Inverted T waves 4Depressed ST segment
NSAIDs can amplify the effects of
anticoagulants (Warfarin, Glimepride, Amlodipine)
best med for neuro pathic pain
antidepressant
post eye ointment admin
ask pt to gently close eyes for 2 minutes
If a patient can't void, the first nursing action should be
bladder palpation to assess for bladder distention
Left ear color hearing aid
blue
Nursing action for PAIN after catheter insertion
deflate balloon, remove catheter, and replace with new one
how often to asesss blood transfusion
every 15 mins
post eye drop intervention
gently press against nose (same side as eye) for 1 minute to close lacrimal duct
The diaphragm of the stethoscope is used to hear
high-pitched sounds, such as breath sounds
Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of
hyperphosphatemia
The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for what electroltye issue
hypokalemia
what filter fro blood admin
in line
When a patient expresses concern about a health-related issue, before addressing the concern, the nurse should assess the patient'
level of knowledge
deltoid ml amount
max 2 m
ventrogluteal injection amount
max 3ml
what can you clean a stoma with
mild soap and water
For the patient who abides by Jewish custom, what shouldn't be served at the same meal
milk and meat
what to expect with urinaton post catheter removal?
must go in 6-8 hours burning is normal
hypomagnesium s/sx
neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension.
is a physical assessment in the health history
no
is milk part of a cleat liquid diet
no
should a wound air dry
no, keep moist
how should a PT take aspirin
on an empty stomach, with a full glass of water, and should avoid acidic foods such as coffee, citrus fruits, and cola
why do we apply heat
promote vasodilation, which reduces pain caused by inflammation
RACE
rescue, alarm, contain, extinguish
the red hearing aid is the
right side
