HESI: Nursing Skills
Raise the head of the bed The priority is to assist breathing. Raising the head of the bed is the least invasive and first action. Assessing for diminished breath sounds and applying oxygen are important but should be done after raising the head of the bed. In addition, requesting a chest x-ray, if not already done, is appropriate, but the priority is to immediately perform nursing interventions that will promote ventilation.
A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. Which would the nurse do first? 1 Raise the head of the bed. 2 Apply oxygen. 3 Assess breath sounds. 4 Call the primary health care provider requesting a chest x-ray
Lubricating the sigmoid colon and rectum The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces.
The nurse is preparing to administer an oil-retention enema and understands that it works primarily by which action? 1 Stimulating the urge to defecate 2 Lubricating the sigmoid colon and rectum 3 Dissolving the feces 4 Softening the feces
Chest x-ray The insertion of a central venous catheter (CVC) into the subclavian vein can result in a pneumothorax, which would be seen on a chest x-ray. Indications of a pneumothorax before the chest x-ray would include shortness of breath and anxiety. If the chest x-ray is negative for pneumothorax, the CVC line may be used. The central line should not be flushed until placement is verified. Blood withdrawal is utilized once placement is verified, but is not used to verify initial placement. Fluoroscopy may be used during placement in certain settings, but not for placement verification.
Which procedure is used to verify placement of a newly inserted central venous access device (CVAD)? 1 Chest x-ray 2 Flushing the line with heparin 3 Withdrawing blood to ensure patency 4 Chest fluoroscopy
Left Sims To take advantage of the anatomical position of the sigmoid colon and the effect of gravity, the client should be placed in the left Sims or left side-lying position for the enema. Back lying, knee-chest, or mid-Fowler positions do not facilitate the flow of fluid into the sigmoid colon by gravity. Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.
A client is scheduled for a colonoscopy, and the health care provider prescribes a tap water enema. In which position should the nurse place the client during the enema? 1 Left Sims 2 Back lying 3 Knee-chest 4 Mid-Fowler
Lower the height of the enema bag. Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes and then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps. Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to identify it. This will permit you to recognize areas that need further review. It will also help you see how correct your "guessing" can be. Remember: on the licensure examination you must answer each question before moving on to the next question.
The client reports abdominal cramping while undergoing a soapsuds enema. Which action would the nurse take? 1 Immediately stop the infusion. 2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches (5-7.5 cm). 4 Clamp the tube for 2 minutes and then restart the infusion
Discuss the incident with the nurse. Discussing the incident with the nurse is the initial action. The nurse should understand that the technique is not safe and discussing the incident with the nurse provides an opportunity for the offending nurse to correct the technique being used. The dressing should be changed immediately and correctly; the priority is to protect the client. Filing an incident report depends on the policy of the institution and might be done later. Offering to demonstrate the proper technique may or may not be done by the observing nurse; if so, it should be done later. Reporting the individual to the nursing supervisor depends on the policy of the institution and might be done later. STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all exams is not realistic but scoring an 85% may be a better goal.
The nurse uses the same pair of gloves to remove a soiled dressing and to apply a new sterile dressing. Another nurse is observing the dressing change procedure. Which initial action would the observing nurse take? 1 File an incident report. 2 Discuss the incident with the nurse. 3 Offer to demonstrate the proper technique. 4 Report the individual to the nursing supervisor
Remove the IV catheter and restart the saline lock in another site The client's report of pain and burning at the site indicates that the tip of the catheter is no longer in the vein and the client needs removal of the current catheter and a new IV access site. Documenting the findings and then reassessing the site in 8 hours would leave the client with no IV access. Flushing vigorously will lead to more pain as more saline is pushed into the infiltrated site. Changing the dressing would leave the client without a patent IV access. Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just select the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question.
Which action would the nurse take when a client reports pain and burning at a peripheral intravenous (IV) site after the nurse has flushed the saline lock with normal saline? 1 Remove the IV catheter and restart the saline lock in another site. 2 Document the findings per protocol and reassess the site in 8 hours. 3 Flush the IV catheter and saline lock again vigorously with normal saline. 4 Change the dressing and apply a new clean dressing per IV care protocol
1 A paper field must remain dry to be considered sterile 3 A 1-inch (2.5 cm) border around a sterile field is considered contaminated. 4 Sterile objects in contact with clean objects are considered contaminated Once a sterile paper field becomes wet it allows microorganisms on the surface of the table to contaminate the field. A 1-inch (2.5 cm) border around the outer edge of a sterile field is considered contaminated because the edges touch the table. Once a sterile object comes into contact with any object that is not sterile, it is no longer considered sterile. Sterile objects below the waist are considered contaminated. A fenestrated drape may be considered sterile as long as it has not been contaminated.
Which basic principles of surgical asepsis must the nurse consider when changing the dressing of a child with severe burns? Select all that apply. One, some, or all responses may be correct. 1 A paper field must remain dry to be considered sterile. 2 Sterile items held below the waist are considered sterile. 3 A 1-inch (2.5 cm) border around a sterile field is considered contaminated. 4 Sterile objects in contact with clean objects are considered contaminated. 5 A fenestrated drape is not considered sterile.
Perform catheter care twice a day A biofilm made up of bacteria develops on long-term indwelling catheters. The best way to eliminate this biofilm is to perform routine perineal hygiene daily. The efficacy of cranberry tablets in decreasing the frequency of urinary tract infections has not been established. Antibiotic therapy may increase the growth of microbes within the biofilm.
Which evidenced-based nursing intervention links to reducing catheter associated urinary tract infections (CAUTIs) in clients requiring long-term indwelling catheters? 1 Perform catheter care twice a day. 2 Replace the catheter on a routine basis. 3 Administer cranberry tablets three times a day. 4 Administer prophylactic antibiotics twice a day for the duration of the catheter placement.