Foundations HESI Review/Study Guide
Foundations HESI Review
Foundations HESI Study Guide
Foundations HESI Review/Study Guide
• Potassium –
... [Show More] 3.5-5
• Sodium – 135-145
• WBCS – 4-11
• Platelets 150-400
• RBCS – 3.8-5.1
• HGB – 11.7-15.5, 13.2-17.3
• HCT-35-47, 39-50
• Albumin – 3.5-5
• Calcium -8.6-10.2
• Glucose 70-99
• BUN – 6-20
• Creatinine – 0.6-1.3
• Mag – 1.5-2.5
• MASLOW
o Physiological needs: need in order to survive (basic need )
▪ ABCs - O2, fluid, nutrition, temp, elimination, shelter, rest
o Safety (basic need)
▪ Security and safety
o Love and belonging (psychosocial)
▪ Relationships, friends
o Self esteem (psychosocial)
▪ Prestige feeling of accomplishment
• Review the answers and determine if they are both physiological and psychosocial.
• Eliminate psychosocial answers, as physiological issues must be addressed first.
• Review the remaining answers and decide if they make sense in regards to the question asked.
• Apply ABCs (Airway, Breathing, Circulation)
• Always ask yourself, “what is the highest priority for this patient?”
• Infection control
o Shift to left = active infxn (>15 wbc)
o Isolations
▪ Airborne (measles, shingles, TB) – neg pressure, n95
▪ Droplet (strep, pna, flu) co rooms
▪ Contact (staph, mrsa, c diff)
o PPE
• Wheel chair
▪ Putting on = gown mask goggles gloves – go make google gloves
▪ Taking off = gloves goggles gown mask – abc order
o Wheelchair on stronger side when transferring
o Lock before moving
o Move catheter tubing, under bladder, don’t touch ground
• Transfer
o Paralysis – use swivel bar, or lift
▪ Unilateral use gait and transfer to stronger side
o Cath should be under bladder
o In wheelchair bag should be below bladder but do not touch ground
o Ambulate blind person = have them hang on to you, you walk in front
• Restraints
o Need po
o For confused, wanderers, falls, or removal of devices
o Last resort
o Dr needs to assess in person 1-4 hours after placed
o If blue, loosen restraints
o Evaluate q 15 min and remove q 2 hours
• Injections
o SQ – painful, small volume 25-27 g 3/5-5/8
o IM – longer needle, 21-23 g, less pain, more volume, z track
▪ Ventrogluteal (side of hip, next to greater trochanter)
• Fire safety
o Race = rescue, alarm, contain, extinguish
o Pass = pull, aim, squeeze, sweep
• Wounds
o Pressure ulcers
▪ 1 = intact, redness
▪ 2 = partial thickness, skin loss
▪ 3 = full thickness loss, fat
▪ 4 = full thickness, exposed bone, muscle
o Braden scale criteria
▪ Sensory perception, moisture, activity, mobility, nutrition, friction/shear
Advanced directives
• Include living wills, health care proxies, powers of attorney
o Living wills state which procedures he/she wants or does not want when terminally ill or in a
vegetative state (DNRs)
o Dpoa = financial, mpoa = medical decisions
• Legal: HESI question wants you to pick the attorney. So, it can be signed and then notarized.
• Collecting a Urinary Analysis -assess ability of pt to collect it safely and correctly; 24hr collection
o Toss first void keep last void
• Obtaining a wound culture-lightly clean surface of wound saline (never vigorously) swab, turn light, put lid on and break vial at bottom.
• NAP can do adls, ambulate, ROM, position, empty, any measurements, feed
• Interpreter: Older adult-use basic language, no slang. Right answer is to use another staff member that solves that speaks the language to do quick assessment if needed.
• Low back pain-pt should not be lying flat, bent knees or pulled up, curve in spine
• Tubes not working: Any decrease in output or lack of output
o Always look for kink in tubing first
• Cardiac Monitoring: K+levels-THINK cardiac!
o Elevated or decreased potassium levels can cause dysrhythmias and cardiac arrest
• Know clear liquid diet
o Mormon-jello, NO CAFFEINE, decaf coffee, broth
o Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles
• wash feet-no lotion between toes because of poor circulation/ diabetes patient. Diabetes patients - DO NOT soak feet in diabetics. Need healthcare providers order to trim toenails
• Confused person wandering hall-don’t close door or don’t restrain - need physician’s order for restraints
o Move closer to nurse station, bed alarm
• Orthostatic BP-lay down for 5 mins before taking 1st pressure, sit up wait 1-3 mins, stand up wait 1-3 mins. Also take pulse. Orthostatic hypotension is a drop of blood pressure greater than 20 mm Hg in systolic
pressure or 10 mm Hg in diastolic pressure and symptoms of dizziness, light-headedness, nausea, tachycardia, pallor or fainting when the patient changes from the supine to standing position.
• Using Crutches-PREVIOUS INFORMATION: 3 fingers or 2 inches to position to armpit, 6 inches in front of you, 2 inches to the side. 3 point crutch-3 things on ground 28. cane-30-degree angle with stronger arm and leg,
o Walking on stairs: Up stairs with the good/unaffected. Down stairs with bad/affected.
• Fall risk-assess around 30 mins
• At a minimum, the fall risk assessment needs to be completed on admission, after change of condition, after a fall, and when pt. Is being transferred.
• Sleep disturbances-do I do ADPIE or past that point? Think (no alcohol, sleep apnea)
o Promote good sleep hygiene (limit caffeine, limit alcohol, create a routine, try to do things to
decrease stress before bed)
o Assess for issues which may cause sleep disturbances such as apnea, insomnia, pain or physical illness. Pts with apnea will get better sleep with a bipap machine. (pg 995)
NG tube care: Picture with Guy with NG-give oral care, keep airway clear
• Trach first then whatever after
• Aspiration-pt was on continuous feeding, CAN put bed flat. Answer: turn off feeding before lying pt flat. THINK ABOUT SAFETY!
• Wash hands, ask if pt has a deviated septum, evaluate nares and position of tubing (tubing can cause pressure ulcers)
• evaluate for throat and pharynx soreness, maintain good oral care (can still brush teeth) pg 1179
• Aspiration risk, HOB 30 degrees for feeding, oral care important
• Hand hygiene-using alcohol and if it’s alcohol she used a paper towel, WRONG!
Hand hygiene practices are the most important techniques to use in the prevention and control of infection.
Restraints: Family took off wrist restraint- Nurse needs to Assess pt first 3 Med Priority - med admin-nurse had 3 meds at one time which one is first- antibiotic first because it’s time sensitive keep Trough level up.
For example, if a pt is in pain, it is important to provide pain medication as soon as possible. If the patients’ blood pressure is elevated, administer the blood pressure medication before other medications.
• Metabolic syndrome risk - know waist measurements and what they indicate
o Bigger hips = lower risk
o Apple shape/ bigger abdomen = higher risk
• Stasis ulcer on lower leg = circulation and inflammation issue
o Diabetes = poor circulation = skin integrity
• Documentation: if given wrong med, assess pt first!
• Report all medication errors.
• Patient safety is top priority.
• Documentation is required.
• Nurse writes incident report: an accurate, factual description of what occurred and what was done (don’t mention in notes or put in chart).
• End of life pain-take care of pain even if Respirations are decreased to keep them out of pain.
o For acute pain use pain scale
• Agnostic beliefs = there is nothing
• Atheist beliefs = there is no higher being
• Old ppl sex - you assess safety and then leave them alone
• Consensual bleeding sex - use water soluble lube
• Ambulating - always assess ability to do so before
• For wheezing - check pulse ox, breathing pattern, breath sounds
• NC care - make sure nares aren’t dry
• Assess dehydration - skin turgor, color in mouth and gums
• Infection in urine = other flora/bacteria in colonies - sample other colonies
• MRSA in wound = IV, suction, wound care - work clean to dirty
• Enemas: enema question- put in left sims position
• (stool all over-UAP not properly gowned-answer=take CNA out of situation and get proper PPE)
▪ Foot impulse devices: foot inflation devices simulate natural walking by compressing the
• Catheter care: can wear non-sterile gloves to clean
• Important considerations include when cleaning: the skill can be delegated to NAPs but proper assessment needs to be done by the nurse
Prevention of pressure ulcers:
• Mobilization
• Reposition patient every 2 hours. Air mattress reduces pressure on same spots all the time.
• Nutrition is important, should be 1500 kcal/day: vit. A and C, and calories are needed to heal.
• Measure with Braden Scale (table 48-3 in text). Lower scores indicate a higher risk for.
• Factors influencing pressure ulcers: smoking, obesity, diabetes mellitus, poor health, anemia, and corticosteroids.
Suctioning
• NG question-feeding=stop volume. Suction don’t use if giving med NG tube
• Risk for aspiration hob 30 degrees
• X-ray placement first! Also can check with ph or air
• Always check 02 or give o2 after suction
• Clean between meds
• Using O2: flow meter-nurse can adjust with orders
O2
• Should be a gentle bubbling in chamber, not constant bubbling -call provider
• When a pt states that they no longer want to live, begin by asking open ended questions about why they feel that way. Nurses are not allowed to help that pt decide, they must have a lawyer.
• A doctor's permission is recommended before acupuncture because it can cause infection and fainting. It is contraindicated in patients who have seizure disorders, bleeding disorders, and skin infections.
• confused-orient to time and place first, think safety
o If a pt is confused, they may try to get out of bed or do things that are out of their limits. Pt injury
can occur in these situations which is why it is important to do frequent checks on patients who are not alert and oriented times 4. Ensure the confused patient has a safe environment and minimize and safety hazards that may exist. -check 02, resp
▪ Sudden confusion = give 02
o Don’t touch patient without permission – but touch lightly on the arm/shoulder for comfort
• Pneumonia discharge planning-keep drinking fluids, finish antibiotic instruct pt to cough and use spirometer. Remind to get flu and pneumonia shot
• DNR & ventilator-HESI question: consult with dr. or wait for family to bring back DNR?
o all patients will be resuscitated unless there is a written DNR order in the medical record
o without actual document, pt is full code
• Cyanotic-pulse ox
o Cyanosis - bluish discoloration in the lips, nail beds, palpebral conjunctivae and palms.
o When cyanosis is present, test oxygen saturation to determine the severity of the problem, report any lower than 90% immediately.
• Fluid/electrolyte measurement: HESI ?: patient will check weight at home
• Vegetarians-HESI wants you to pick eggs
• mode of transmission=hand hygiene
• Lower leg edema = elevate
• Low sodium q = ask how much water and ice chips (low sodium = too much fluid in blood)
o High sodium = losing too much water (dehydrated)
o Low potass = losing too much fluids – diabetic drugs
o high potass = too much fluid
• math question about how many ml of analgesic to admin, find ml for each and add
• transfer pt to wheelchair, put wheel chair on strong side
• visible breakdown = turn them
• clean catch urine with diff low colony bacteria = contaminated
• med error = assess pt first for adverse effects
• pt family member requests 2 hours to let pts spirit ascend – close blinds and come back in 2 hours
• lots of call provider qs- usually the answer [Show Less]