HESI Questions you Missed

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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


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