Skills - HESI

A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing.

-Close the roller clamp on the IV tubing -Spike the IV bag and half-fill the drip chamber -Open the roller clamp and fill the tubing -Uncap the distal end of the tubing. -Attach the distal end of the tubing to the client.

The nurse is inserting an indwelling catheter through the urethral opening in a female patient and notices urine beginning to flow into the clear tubing. The next step in the procedure is to:

Advance the catheter one to two inches further

The nurse assesses the stoma of a patient and finds it to be dry and gray. Which action by the nurse is most appropriate?

Document the appearance of the stoma and notify the physician

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position?

Left Sims' position

The nurse is inserting a nasogastric (NG) tube into an adult client. During the procedure, the client begins to cough and have difficulty breathing. The nurse should take which priority action?

Pull back on the tube, and wait until the client is breathing easily.

Collection of a clean catch midstream urine specimen for a urine culture has been ordered for the patient. The nurse provides instructions to the coherent, independent, female patient on how to collect the specimen. Which statement by the nurse would be best to evaluate the patient's understanding of the procedure?

"Please tell me how you will collect the specimen?"

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client?

"Take a deep breath when I tell you, and hold it while I remove the tube."

The nurse has assigned the care of a patient with a condom catheter to a nursing assistive personnel (NAP). Which statement/s made by the NAP indicates a need for further action?

"Two hours after I apply the condom, I'll inspect the penis for redness, swelling, or leakage." "If the patient is uncircumcised, I will retract the foreskin and secure the catheter in place, ensuring the foreskin remains retracted."

After removing an indwelling urinary catheter, the student nurse correctly teaches the client: (select all that apply)

"You may experience mild burning the first time you void after catheter removal. The burning will soon subside." "I would like for you to keep a record of your voiding after the catheter is removed. I will place this urine "hat" on the toilet seat so the amount of urine you void can be measured." "I want you to be aware of the signs of UTI: fever, chills, flank pain, back pain, the feeling of having to void very often, and in a hurry. Please notify me if you have any of these signs and symptoms."

The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions should the nurse take to perform this procedure?

-Place pt in a semi Fowler's -Turn on suction device and set the regulator at 80 mm Hg -Attach suction tubing to suction catheter -Hyperoxygenate pt -Insert catheter into tracheostomy until resistance is met, and then pull it back 1 cm. -Apply intermittent suction and slowly withdraw catheter while rotating it back and forth

What height would you raise an enema container above the anus to instill a high enema?

12 to 18 inches

The nurse is preparing to insert an indwelling urinary catheter into an adult female. Which size catheter is most appropriate for this procedure?

14-16 Fr

When administering an enema to an adult patient, the tip of the rectal tube should be inserted:

3 to 4 inches

The nurse is caring for a patient with a Salem sump tube. The nurse recognizes that the blue "pigtail" on the Salem sump is a/an:

Air vent

The nurse is preparing to insert a nasogastric tube (NG) into a client. What nursing measure will best facilitate insertion of the tube?

Asking the client to swallow as the tube is being advanced

A client's nasogastric feeding tube has become clogged. The nurse should take which action first?

Aspirate the tube.

The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube. Which is the priority nursing action?

Assess tube placement.

A patient has an order for placement of an indwelling urinary catheter. Preparing for the procedure includes:

Assessing allergies by checking the chart and asking the patient about the allergies Selecting a catheter size that minimizes urethral damage Premedicating with an analgesic 30 minutes prior to the procedure

The nurse is preparing to administer medication using a client's nasogastric tube. Which actions should the nurse take before administering the medication?

Check the residual volume. Aspirate the stomach contents. Turn off the suction to the nasogastric tube. Test the stomach contents for a pH indicating acidity.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube?

Checking for the presence of bowel sounds in all 4 quadrants

The nurse has a prescription to administer intermittent tube feedings via a newly inserted duo tube (feeding tube) to a patient. Prior to administering the first feeding, the nurse must confirm placement of the feeding tube by:

Checking the radiographic results

The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action?

Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication.

The nurse is assigned the care of a patient with an indwelling catheter. Which intervention is appropriate when caring for a patient with a retention catheter?

Clean the catheter with soap and water from the meatus outward

A nurse is caring for a patient who is experiencing abdominal and rectal discomfort. The nurse suspects the patient has a fecal impaction. Which findings support the suspected diagnosis?

Diarrhea Nausea and vomiting Rectal discomfort

The nurse is caring for a client with a Penrose drain from an abdominal incision. Which is an appropriate nursing intervention for this client?

Ensure that a sterile safety pin is through the drain.

The nurse is administering a bolus feeding through nasogastric (NG) tube. Which position should the nurse use for the client after the tube feeding?

Fowler's on the right side. gravity helps facilitate gastric emptying, which reduce vomiting.

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion?

High Fowler's

Three hours after an indwelling catheter is placed, the nurse is making rounds and notes there is no urine in the catheter bag. The nurse's priority action is to:

Inspect system for kinks or leaks, and palpate the patient's bladder for distention

A care provider writes the prescription, "NG to wall suction". Which suction setting is most appropriate?

Low intermittent suction

The nurse orientee is preparing to insert a nasogastric tube, and the nurse educator is observing the procedure. Which item, if obtained by the nurse orientee, would indicate a need for further teaching regarding this procedure?

Oil-soluble lubricant. Use Water-soluble lubricant instead.

Which statement/s about catheter associated urinary tract infections (CAUTIs) is/are true?

Patients are frequently catheterized for caregiver convenience rather than medical reasons, therefore contributing to CAUTI's. CAUTIs are preventable. Nurses help reduce the risk of CAUTIs by acting as advocates for the patients regarding removal of unnecessary catheters.

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions?

Percussion and vibration

The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action?

Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.

The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action?

Pull back on the tube and wait until the respiratory distress subsides.

The nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which item from the unit supply area for use in applying pressure to the site after removing the IV catheter?

Sterile 2 × 2 gauze

Obtaining a urine specimen using an intermittent catheter is a:

Sterile procedure using betadine or chlorhexidine, catheter kit, and sterile gloves

The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action?

Stop the irrigation temporarily.

The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?

Taking an oral temperature for a client with a cough and nasal congestion

A client with a colostomy has a prescription for irrigation of the colostomy. Which solution should the nurse use for the irrigation?

Tap water. If the tap water is not suitable for drinking, bottled water should be used.

The patient begins to complain of abdominal cramping while receiving a cleansing enema. Which action/s are appropriate for the nurse to take?

Temporarily stop the infusion Lower the height of the enema bag.

The nurse has an order to insert a nasogastric (NG) tube into a patient who is awake and alert. Which action/s should the nurse perform prior to the insertion of the tube?

Verify the physician order and patient identification Assess the patency of each nostril

The patient has a soap suds enema ordered. Which is an appropriate action to be performed by the RN?

Warm the tap water before adding to the bag

What type of effluent is to be expected from an ileostomy?

Watery to thick stool