Exit HESI (Actual hesi hints), EXIT HESI 2
Exit HESI (Actual hesi hints), EXIT HESI 2
what is considered a postpartum infection?
a fever on 2
... [Show More] consecutive days for the first 10 days postpartum not including the first day
wound infections
mastitis
endometritis
UTIs
respiratory tract infections
what do you suspect in a child with an irregular pulse?
Kawasaki disease
what do you screen for on a newborn baby?
hypothyroidism
check T4 level (decreased)
what is an expected side effect of Solu-Medrol?
bleeding, bruising
what does Pilocarpine treat?
glaucoma
antidote is atropine sulfate
may get a dry mouth
TPN
central venous catheter
check for cloudiness
refrigerate- warm before administration
monitor electrolytes everyday
monitor for hyperglycemia and infection
change tubing with each new bag
nothing else goes through this line
what drug would you give is extravasation has occurred?
phentolamine (Regitine)- it's a vasodilator and will increase blood flow to the area to prevent necrosis
what diet would be chosen for a pt with CKD?
bread & cream of wheat
pt receiving a blood transfusion develops fluid volume excess and dyspnea, what do you do?
increase O2
what should you be monitoring in a client who has had a nephrectomy?
UOP
it is more important than drainage
what is important when caring for pt in skeletal traction?
pin care; sterile technique; remove crust; serous drainage is ok
how do you deal with a rude doctor that is avoided by the nurses?
staff meeting
what is confrontation?
calling attention to inconsistent behaviors
what is reflecting?
paraphrasing or repeating what client said
what client would most likely be experiencing delirium?
a client with constant pain or insomnia
what is the priority for a depressed client who has not slept?
sleep
a client who is bipolar is going home for the weekend to adjust for discharge. what do you tell the family?
continue normal daily activities
if a client has a pulse with absent breath sounds on the left side what do you do?
prepare to reposition ETT
what do you monitor for in adrenal insufficiency (no steroids)?
shock
hyperkalemia
increase sodium in diet
if a client suddenly withdraws from steroids what do you do?
check VS
what do you teach a client taking prednisone?
monitor for hyperglycemia
take in morning
you are caring for a client with AIDS and you accidentally stick yourself with a sterile needle. what do you do?
go get a new needle- no need to report
what do you teach a pt taking an antipyretic for and increased temp?
give with fluids because fever can cause dehydration
what is suspected if there is an increase in serosanguineous drainage?
dehiscence
what would you expect in a client with an epidural hematoma?
temporary loss of consciousness, followed by a lucid period, and then gradually leading to coma
for maximum effectiveness, what should older clients use for dry skin?
petroleum based ointment
what are signs of pain in an infant?
grimacing
tachycardia
restlessness
irritability
difficulty feeding/sleeping
increased RR
diaphoresis
decreased O2 levels
what is priority for a client with renal lithiasis?
address pain- these pts get pain meds immediately (don't teach important of straining urine- that's RNs job)
what do you do for a pt on Amph B?
monitor UOP- it's nephrotoxic
what is the priority assessment in a client who has lost a tooth and has an eye injury?
check pupils
where should the level of water be in the water seal chamber?
at 2cm
where should the level of water be in the suction control chamber?
at 20cm
how does a client present with DM2?
usually come back to doctor for wounds that won't heal or vaginal infections
don't have enough insulin
insulin doesn't work
a client in hypovolemic shock would present with what?
weak thready pulse
how would you teach someone to use an inhaler?
shake well for 5 seconds (if MDI)
exhale completely
press canister once and inhale deeply and slowly
hold breath for 10 seconds
wait 1 min between each puff
if using MDI- rinse mouth & gargle after each use
nebulizers are better for peds and clients with severe asthma because it allows you to breath normally
what is the appropriate action for a burn client in the emergent phase whose UOP and BP are dropping?
immediately call the HCP
what do you monitor for in a client with HHS and DKA with insulin drip?
hypokalemia
U wave
what is priority discharge teaching for a client with HHS?
monitor for signs of dehydration
what activity would you choose for a person who attempting suicide?
punching bag
choose most exerting answer
what would you teach a client on peritoneal dialysis about self care?
warm fluid before administration
increase protein and fiber in diet
report any fever, abdominal pain that persists after 1-2 weeks, bloody, cloudy, urine colored outflow, outflow that is great than inflow, leakage around catheter site
what do you suspect with coffee ground emesis?
peptic ulcer
stomach cancer
what medications do you give with coffee ground emesis?
'prazole (proton pump inhibitors)
'tidine (h2 antagonist)
antacids
mylanta
carafate
what is the G&D of a toddler?
toilet training
magical thinkers, egocentrism
dramatic, pretend and parallel play
learn to behave through restrictions
gender identity
let child touch and hold equipment
walks without help, creeps up stairs, kneels without support
builds tower of cubes, holds two cubes in one hand, scribbles, uses cups, but struggles with spoons
uses 4-5 words, uses 10 or more words, uses 2-3 phrases
points and ask for objects
understand simple commands
talk all the time
tolerates separation from parents
temper tantrums are normal
dependency on security items (blanket)
what is suspected in a pediatric client with croup and how do you treat?
retractions & barking cough
riding with windows down at night
steamy hot showers
cool temp therapy
nebulized epinephrine, corticosteroids
what do you assess for a femoral artery sheath?
bleeding and hemorrhage
how do you care for a hemiparesis client?
ambulate
encourage independence with ADL's
increase mobility as tolerated
what do you teach a client with asthma about taking beta agonists?
if administered with theophylline cardiac dysrythmias can occur
avoid if taking beta blockers, MAOIs or tricyclic antidepressants
observe for chest, jaw, arm pain or palpitations
report increase in pulse of 20-30bpm
how do you communicate with a client who has had a CVA has developed receptive aphasia?
picture board- they can't understand spoken or written words
left hemisphere
what does tadalafil (Cialis) treat?
erectile dysfunction
BPH
pulmonary HTN
what is the side effect of ondansetron (Zofran)?
hives, chest tightness, trouble breathing
if family refuses to discuss funeral arrangements what do you do?
remain with family member without discussing (don't show acceptance of family member's feelings)
how do you treat a client with swollen tongue, dry mouth and excessive thirst?
IV hypotonic solution
0.2% NaCl
0.45% NaCl
D5W
what do you teach a client with thrombocytopenia?
watch for bleeding gums, hematuria, black stools
use electric razor
use soft toothbrush
no IM injections
how do you care for a client with AKI?
restrict protein intake
monitor for hyperkalemia
if there is a staff conflict what do you do?
attend client assignments first
what is initially used for a co-worker who is abusing narcotics?
employee assistance program
a client is having a precipitate delivery and you are waiting for the doctor. how do you position the client?
lateral sims
a client who has a family history of malignant hyperthermia is going in to surgery and receiving general anesthesia. how do you prepare?
cooling blanket
fluids
when are febrile seizures most common?
9 months - 5 years old
triggered by ear infection or viral illness
what is the priority of a client with febrile seizure?
bring fever down
a client with pancreatic cancer should monitor for what?
hypoglycemia with high levels of insulin and c-peptide
dizziness, fatigue, uncontrolled shaking, weakness, hunger, history of fainting
what do you assess for in a client with a facial injury?
violence
abuse
what is suspected in a pediatric client with diaphoresis?
diabetes
what interventions do you implement for a client in shock?
O2 is priority- place client on high flow oxygen (100% nonrebreather)
monitor VS, skin color, temp, cap refill, LOC, UOP, cardio)
place flat with legs elevated
prepare for intubation
maintain patent IV- isotonic fluids
what is a PICC used for?
chemo
blood transfusion
antibiotics
IV fluids
liquid food
frequent blood draws
what do you teach a person about their PICC line?
can go home with- stays in 3 week to months
flush once a week
use waterproof cover when showering
clamp should always be closed when not in use
report swelling, redness, pain, discolored fluid at site or fever
how do you provide hospice care?
talk about what the client wants to talk about
listen with compassion
focus on creating a peaceful environment
touch and facial expression are important
use lotion, give back rub, offer cool towel
nutrition is less important when body is shutting down- offer liquids and soft foods
teach family that this is a normal process
how do you care for a pediatric client who is impulsive?
distract by redirecting to other activities
consequences for bad behavior
reward for good behavior
what do you assess for in a victim of partner abuse?
chronic pain
when can a venipuncture be given to a pediatric client?
2 years old
median cubital, cephalic veins
dorsal hand veins
basilic vein on pinkie side of arm only used when there is not another more prominent arm vein
foot and ankle veins used as last resort
Grave's disease treatment
-Goal: inhibit production of thyroid hormones and block effect on the body
-Radioactive iodine therapy: destroys overactive thyroid cells over time
-Propylthiouracil, methimazole
-Betablockers
-Subtotal or full thyroidectomy (risk of damaging vocal cords and parathyroid glands)
Describe Lupus and pt education
-*Autoimmune disorder
-Could have a decreased WBC count; increased risk for infection
-Avoid crowds, avoid sick people, avoid sunlight (trigger)
Assessment points for pt with constipation
-Assess current medications
-Check measures that they're currently taking (daily enemas, laxatives, etc)
-Assessment: no bowel sounds, abd distention
-Make a doctors appointment
-Assess current nutrition, diet, and exercise
-Drink more water
Osteomalacia and implications for pt teaching
-Focus on nutritional support
-Sunlight is a good source of vitamin D
-Vitamin D is important to absorb calcium and phosphorous
-Check vitamin D levels
Osteomyelitis
-Bone infection
-Treat with antibiotics
-Poor healing, injury entered the bone
UTI
-Pt doesn't always report sx!
-Urine sample is foul smelling and cloudy
-Send sample to lab for urinalysis
-Order a secondary test (culture and sensitivity) to choose the correct tx
Assessment and nursing interventions for hip fx
-Assess for pain
-Hip fracture sometimes shortens the leg/rotates it
-Treat like its a hip fracture even if no testing done yet
-Assess circulation (pulse, cap refill, feeling, movement, wiggle toes, color)
-Don't elevate the leg
-No extra motion until hip is stabilized
-Assess skin and circulation if in traction
Care and assessment for adrenalectomy
-Pt at risk for electrolyte abnormalities
-Put on telemetry
-Daily serum electrolytes
-Monitor VS
-Watch for dysrhythmias
Tracheostomy pt teaching
-Maintain airway: suctioning
-Communicate with white boards
-Cough and suction on the way out
-No more than 10 seconds
Steps of the chain of infection
-Causative agent
-Reservoir
-Portal of exit: ex: wound, dressing change
-Mode of transmission: nurse could be mode if they wear a gown in the hallway
-Portal of entry
-Susceptible host: decreased immune system, also have wounds (entry site)
*Ways to block transmission: precautions, wash hands
Aseptic handwashing
-Wash clean to dirty
-Point arms down so dirty water runs from clean to dirty
Chrones Diet
-Low fat
-High-calorie: dried fruit increases calories and nutrients
-High nutrient foods
-Ex: eggs w/o yolk, lean meat, fish, seafood, chicken
Heart Failure Diet
-No canned/processed food
-No cheese or salami
-Limit sodium (fluid retention)
-Vegetables and fruits
Mormon Diet
-No alcohol
-No caffeine
-Give milk, juice, or water
-If diabetic, no juice
-Church = latter day saints
Enema administration and nursing considerations
-Monitor pt for cramping and abd pain
-Coach and support pt through this pain
-Need to get procedure done, take break, deep breaths, then continue
Trapeze bar and considerations
-Need upper body strength/upper extremities
-Get history from pt: make sure they don't have any problems with dislocated shoulder
-Allows more independence and participation with repositioning
Manual bladder irrigation and CBI
-CBI: 3 way catheter
-Check for kinks if not flowing properly
-Manually irrigate CBI if there's a clot
-If a clot is blocking, the pressure in the bladder could cause leakage around the catheter site
AKI assessment
-Decreased kidney function because of secondary condition and output decreases
-Oliguria: less than 400 cc in 24 hrs
-Kidneys aren't producing urine
-Possibly can't produce urine sample
AKI Interventions
-Follow up and look at what drugs they're on
-Monitor electrolytes
-Monitor weight and edema
-Monitor VS: HTN/HypoTN, increased HR
-Aggressive fluids: watch for fluid overload, check lung sounds and vitals
-Lasix or Mannitol
IM Injections
-If you stick yourself, fill out appropriate paper work and get pts blood sample
-If you think you're in the wrong space, get a larger needle
-If you aspirate and get blood return, take out and throw everything away
Safety concerns with Parkinson's
-Early: falls, decreased mobility, risk for aspiration
-Late: wheelchair bound, ulcers, decreased muscle, decreased mobility
Distracting Injury
-Ex: traumatic amputation, so focused on treating that you don't realize the pt isn't breathing
-ABCs
-C: know the cause and how to control it
3 Middle ear bones
Incus, Maleus (hammer), Stapes
Hearing
-Maleus (hammer) is first small bone hit from the eardrum vibrations
-Sound waves go to tiny hair cells in cochlea and communicate with the brain to perceive sound
Stapedectomy
-Performed for otosclerosis
-Incision behind inner ear, stapes removed and implant inserted
-Allows sound and vibrations to pass from eardrum to inner ear fluids
Stapedectomy pt teaching
-Improvement of hearing isn't immediate, can initially be worse
-Hearing improves in 3 weeks, maximum hearing takes 6 months
-Dressing on the ear
Polycystic Kidney Disease treatments [Show Less]