HESI II

You are planning to assist a pt with pneumonia from bed to a chair for the first time... you determine the patients ability to help during the transfer is limited. What is the priority?

Request assistance

You are providing supplemental O2 to a pt who is experiencing a cluster headache. What assessment is most important to make?

Measure pain level

What is included in a CKD diet?

- Fresh fish, fresh chicken, fresh vegetables

An elderly male pt is admitted to the urology clinic with acute renal failure due to a post renal obstruction. What relevant history should you obtain?

"Have you had any difficulty in starting your urinary stream?"

Lithium

- Acetazolamide, theophylline, phenothiazines, or sodium bicarb may increase renal excretion of lithium, reducing its effectiveness. - Therapeutic Dose: 0.6-1.2 mEq/L - The cause of an increase in the lithium level include decreased sodium intake, fluid and electrolyte loss associated with excessive sweating, dehydration, diarrhea, or diuretic therapy.

You are preparing a teaching plan for the hospitalized pt who was recently diagnosed with Type II diabetes. Which self-care teaching topics should the nurse provide prior to discharge? (SATA)

- Benefits of regular exercise - Finger stick blood glucose testing - Sick-day management procedure

What diet for patients who have Crohns?

- Decrease fat intake - Increase B12 - Eat more fruits and vegetables - Eliminate dairy as a trial

When assessing a pt, you should establish which findings as objective? (SATA)

- Edema - Diaphoresis - HTN - Urticaria

You are developing a plan of care for a middle-aged woman who is diagnosed with type II diabetes. She has an increase in blood glucose and HDL levels. What instructions should you provide her?

- Exercise at least 3 times weekly

A male pt who is diagnosed with an evolving MI insists on getting out of bed to use the bathroom to void. What action should you take?

- Explain the need to use a urinal at this time

Signs of Lithium Toxicity

- Mild begins at level 1.5; apathy, lethargy, diminished concentration, mild ataxia, coarse hand tremors, slight muscle weakness - Moderate begins at level 1.5-2.5; N/V, severe diarrhea, slurred speech, tinnitus, blurred vision, muscle twitching, irregular tremor - Severe begins at level above 2.5 ; nystagmus, deep tendon hyperreflexia, visual or tactile hallucinations, oliguria or anuria, impaired LOC, tonic-clonic seizures or coma, leading to death. **For toxicity, hold med and call HCP, monitor cardiac status.

A pt is admitted for exacerbation of heart failure and is being treated with diuretics for fluid volume excess. In planning care, which intervention should you include? (SATA)

- Observe for evidence of hypokalemia - Weigh the pt daily in the AM - Teach the pt how to restrict dietary NA

A pt is receiving ophthalmic drops preoperatively for a cataract extraction and ask you why he is prescribed all of these medications. Which information should you include when responding to this patient? (SATA)

- One of the medications is used to anesthetize the corneal surface - The iris must be paralyzed during surgery to prevent it from reacting to light - Pupillary dilation is necessary to access the eye chamber for lens removal

At 1615 prior to ambulating a potop pt for the first time, you review the pt's medical record. Based on the data contained in the record, what action should you take before assisting the pt with ambulation?

- Remove sequential compression devices

An older adult pt is admitted for repair of a broken hip. To reduce the risk for infection in the post-op period which care interventions should you include in this pt plan of care? (SATA)

- Remove urinary catheter asap and encourage voiding - Teach pt to use incentive spirometer q2 hours while awake

You are assessing a 3 month old infant who had pylorotomy yesterday. This child..... which finding? (SATA)

- Restlessness - Clenched fists - Increased pulse rate - Increased respiratory rate

A male pt with HIV, who is receiving saquinavir PO in combination with other antiretroviral therapy, tells the home health nurse that he is always hungry and thirsty but seems to be losing weight. What action should the nurse implement?

- Use a glucometer to determine the patients capillary glucose level

You administer an abx to a pt with a respiratory tract infection. To evaluate, what labs should you monitor? (SATA)

- WBC - Sputum culture and sensitivity

A mother just delivered her baby and did not have rubella antibodies, when do you administer the vaccine?

72 hours after delivery

A breastfeeding patient wants to know what the best form of birth control for her to use now?

A condom or other barrier

The home health nurse is preparing to make daily visits to a group of patients. Which should she see first?

A pt with CHF who reports a 3 lb weight gain in the last 2 days

You have completed the diet teaching of a male pt who is being discharges following treatment. ....protein diet is epnoucraged to promote wound healing. What lunch choice?

A tuna fish sandwich with chips and ice cream

While conducting a mental state exam, you ask the pt to implement the....exercises provides a measure of which parameter?

Abstract thinking

While changing a pts postop dressing, you observe a red and swollen and green drainage and foul odor. Given there is a positive MRSA... What is an important action for you to take?

Administer prescribed abx

What should you do for a child who is experiencing separation anxiety while in the hospital?

Allow parents to visit as much as possible

Which intervention should you implement when beginning a physical exam of a 6 month old?

Allow the child to remain in caretakers lap

A patient receiving TENS complains of a tingling sensation, what do you do?

Ask if sensation feels uncomfortable

Post-op patient is in pain

Assess for bleeding

What do you want to do before your patient receives dialysis?

Assess vitals

You have a dementia patient who keeps wandering away from the facility, what do you do?

Assess what is triggering the wandering

The nurse who works in labor and delivery is reassigned to the cardiac care unit for delivery. Which assignment is best to give this nurse?

Assist cardiac nurses with their assignments

A pt in the ICU is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should you take first?

Auscultate bilateral breath sounds

Oxygen at 5 L/minute per nasal cannula is being administered to a 10 year old with.... what principle of O2 administration should you consider?

Avoid administration of O2 at high levels for extended periods

A pt complains of shortness of breath and abdominal pain 1 week after bariatric evaluation. Which assessment finding warrants immediate intervention?

BP 88/50

What is the treatment for aplastic anemia?

Bone marrow transplant

What do you do for a patient experiencing acute eye pain?

Call physician

A woman comes to the hospital saying that her "baby is coming"?

Check the perineum

What do you do when you walk into a patient with COPDs room and see them leaning over doing pursed lip breathing?

Check their pulse ox/O2 level

A patient is in ventricular fibrillation. What is the first action you take?

Defibrillate with one shock

A male patient with severe anxiety becomes diaphoretic and complains of chest pain, what intervention should be implemented first?

Determine pt BP and pulse

Upon auscultation of a patient with pneumonia in the upper left lobe what will you hear?

Diminished breath sounds

Which assessment is most important for you to include in the daily plan of.....

Distal pulse intensity

A patient with chronic alcoholism is admitted with decreased serum magnesium levels. What snack option is best for this pt?

Dry roasted almonds

What to monitor in patients with anorexia?

Electrolyte levels (not glucose)

You note a visible prolapse of the umbilical cord after a pt experiences spontaneous labor. What intervention should you implement immediately?

Elevate the presenting part off the cord

A pt is being treated for SIADH and has a weight gain of 4.4 lbs in 24 hours and an elevated pulse. Which intervention should you perform?

Ensure patient takes a diuretic q AM

Tricyclic Antidepressants

Examples: amoxapine, amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, protriptyline, and trimipramine. - May reduce seizure threshold, may reduce effectiveness of antihypertensives, cardiac toxicity can occur and all pts should receive an ECG before and during treatment, overdose is life-threatening. - Adverse Effects: anticholinergic effects, photosensitivity, cardiovascular disturbances such as tachycardia, seizures. - Interventions: Monitor pattern of daily bowel activity, assess for urinary retention, administer entire dose at one time at bedtime preferably

SSRI's

Examples: citalopram, escitalopram, fluoxetine, paroxetine, sertraline, vilazodone hydrochloride, venlafaxine, duloxetine, desvenlafaxine, bupropion, mirtazapine, nefazodone, and trazodone - Adverse Effects: N/V, diarrhea, photosensitivity, insomnia, somnolence, HA, dizziness, tremors, seizure activity - Interventions: Interact with numerous medications, can lower or raise BP, give with snack or meal to reduce the risk of dizziness, take bupropion and fluoxetine early in day to prevent interferences with sleep, monitor WBC and neutrophil, be aware of serotonin syndrome.

Mood Stabilizers

Examples: lithium, aripiprazole, carbamezapine, gabapentin, lamotrigine, olanzapine, oxcarbazepine, quetiapine, risperidone, valproate sodium, and ziprasidone. - Adverse Effects: polyuria, polydipsia, anorexia, nausea, dry mouth, fine hand tremors, inability to concentrate, lethargy, fatigue, HA, hair loss and hypothyroidism. - Interventions: give with food to minimize GI upset, instruct to avoid excessive amounts of coffee, tea, or cola (diuretic effects), monitor ECG, renal function tests, and thyroid tests (before and during treatment)

MAOI's

Examples: phenelzine, tranylcypromine, isocarboxazid, selegiline Adverse Effects: orthostatic hypotension, insomnia, weakness, lethargy, GI upset, dry mouth, hypertensive crisis (HTN, occipital HA radiating frontally, neck stiffness and soreness, N/V, sweating, fever and chills, clammy skin, dilated pupils, constricting chest pain.) - Antidote for hypertensive crisis is phentolamine by IV injection - Interventions: monitor BP frequently, if palpitations or frequent HA occur, hold med and notify HCP, avoid giving in evening to prevent insomnia, avoid foods requiring bacteria or molds for their prep and foods that contain tyramine.

An adult female asks about getting Herpes vaccination... How should you respond?

Explain the use of the vaccination to reduce the risk for Herpes Zoster

A young adult female with chronic kidney disease, peripheral edema, complaining of severe nausea and PVCs. Her BP is 200/110 what should you do first?

Furosemide

A patient comes in with vaginitis, what do you instruct her?

Her partner should be treated too

An older pt is admitted to the ICU unconscious after several days.... Urinary catheter and obtains a scant amount of dark amber output. Which intervention?

Give a bolus of 0.9% NaCl 1,000 mL over 30 minutes

What do you do for a patient with pancreatitis who is in pain?

Give them a side table to lean over

Cancer patient has lost 10 pounds and complains that food tastes bitter. What do you do?

Give them an alternate source of protein

What do you do for a patient with type AB blood who needs blood asap but there is none of their type?

Give type A until AB becomes available

The HCP prescribes methylergonovine maleate for a postpartum pt with uterine atony. What finding should indicate that the next dose should be held?

Hypertension

What is the main side effect of methergine?

Hypertension

An adolescent, whose mother recently died, comes to the school nurse complaining of a ..... student should warrant further exploration by the nurse?

I miss my mom and would like to go see her

A pt presents to the ED with right-sided facial asymmetry/ The nurse....movements that require use the facial muscles. What symptoms suggests that the pt has bells palsy rather than a stroke?

Inability to close the affected eye, raise brow, or smile

A patient has a urine specific gravity of 1.035, what do you need to do?

Increase fluids

The urinary drainage of a pt with continuous bladder irrigation is becoming increasingly red. What do you do?

Increase the irrigation rate

What do you do for a patient with diverticulitis?

Keep pt NPO because you don't want bowel motility

A pt with a new diagnosis of Raynaud's disease lives alone. Which instructions should you include in the teaching plan?

Keep room temperature at 80 degrees F.

A patient comes into the ED because she slit her wrists, what do you assess first?

LOC

A patient with pneumonia and COPD comes in, what do you assess first?

LOC and vital signs

Compression stockings are ordered for a patient that did not want to walk, what do you instruct the pt about the compression stockings?

Leave them on during the day and remove them at night

Mom on Mag Sulfate is at risk for...?

Loss of patellar reflexes (DTRs)

A pt is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema. Pt complains that anti embolic stockings are too constricting. What should you do?

Maintain both lower extremities elevated on pillows

You are planning discharge teaching for a pt with pneumonia and COPD, what do you instruct patient?

Maintain proper nutrition

A pt arrives to the ED with a BAC of 500mg/dL. The pt becomes demanding, aggressive, and shout at the staff. Which assessment finding... identify in the first 24 hours?

Nausea and elevated BP

You observe that a post-op pt with continuous bladder irrigation has a large ..... tubing. What action should you perform first?

Observe the amount of urine in pt urinary drainage bag

Where is lead commonly found?

Old homes and playgrounds

You walk in and see your patient is having trouble breathing, what do you do FIRST?

Sit patient up/High Fowlers

An adult male who fell from a roof and fractured his left femur is admitted for surgical stabilization after having a soft cast applied in the ED. Which assessment finding warrants immediate intervention?

Onset of mild confusion

In a sickle cell child, what is the first thing you treat?

Pain

How do you first assess a patient suspected of having appendicitis?

Palpate, NOT look

You are working an endocrinology unit what patient should you see first?

Patient taking corticosteroids that is disoriented.

You are preparing to gavage feed a premature infant through an orogastric tube...heart rate drops to 60 BPM. What action should you take?

Pause and monitor for a continued drop in HR

The pt who is receiving ahminoglycosides for an infection appears dizzy when ambulating. What should you review?

Peak and trough levels.

You work in the nursery and are attending the vaginal delivery of a term infant. What action should you complete prior to leaving the delivery room?

Place ID bands on the infant and mother

After 5 days of high fever, chills, headache, and muscle aches, an adult woman is diagnosed with severe acute respiratory syndrome. She is admitted to the hospital and placed in a negative pressure isolation room. Which assessment finding should you obtain?

Progressive productive cough

There was a medication to be given at 9, and the PCA did vitals earlier, what should the RN do?

Reassess vitals

The charge nurse observes that a primary nurse has administered 10 units of regular insulin.. 450 mg.dL. What action should the charge nurse take?

Remind the nurse to monitor the patient for signs of hypoglycemia

You notice that a patient has 4 morphine patches on, what do you do first?

Remove all of the patches

What do you do if a patient refuses to take meds when you come in to give them?

Schedule a time to come back and give

Parents of a patient newly diagnosed with sickle cell are wondering why it wasn't diagnosed before?

Screenings are only done with S/S are present, it is not a mandatory screening (one more answer for select all)

Prior to giving antibiotics, what should you do?

Take a blood culture

Patient newly diagnosed with asthmas lives in the mountains, what do you tell them?

Take meds and carry rescue inhaler everywhere

You have a patient with PTSD in the waiting room, what should you do?

Take them to a secluded area

You are caring for a 17 y/o male who fell 20 feet 5 months ago while climbing a cliff and sustained vegetative state since the accident. Which intervention should you implement?

Talk directly to the adolescent while providing care

Which intervention should you include in the preoperative prep for a patient who is scheduled for surgery?

Teach pt how to prepare small meals that are low in fat and sugar

You have an experienced LPN who is lazy and says that she is not comfortable with doing a complex dressing change, what do you do?

Tell her to do it anyway and let her know that there is help if she needs it

A patient who has an MI insists on using the bathroom, what do you do?

Tell them to use urinal for now

At a dead children support group and a man keeps talking about his child who was murdered what do you suggest to him?

That he attend a murdered children support group

A child with encephalitis needs their tube changed, what is the reason behind this?

The child is growing

Following a GSW, an adult male has an Hgb level of 4. An order for an emergency unit of blood is placed. Pt is AB negative and the blood bank reports that there is no Type AB available. What do you do?

Transfer type A negative blood until AB is available.

You plan to collect a 24-hour urine specimen for a creatine clearance test. Which instructions should you provide to the adult male patient?

Urinate at a specified time, discard the urine, and collect all subsequent urine during the next 24 hours.

What should you monitor after administering dopamine?

Urine output

How do you give an infant oral medications?

Use a syringe and place on back of tongue

Patient with asthma was having problems breathing when exercising, what do you tell them?

Use their inhaler before exercise

If you notice dehiscence of a wound, what would you do first?

Visualize the wound first

Pt complaining of IV site tenderness, when do you need to intervene?

When you notice a red streak tracking the vein

A patient with delusions tells the nurse "you aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the best response?

You seem quite rightened right now