HESI FUNDAMENTALS
1. Transdermal top or bottom- goes into bottom layer of skin
2. Patient bilateral ear pain, what to do- ask for pain relief
... [Show More] prescription such as acetaminophen
3. Low back pain due to surgery, how do you position patient- Sit with a back support (such as a rolled-up towel) at the curve of your back. Keep your hips and knees at a right angle. (Use a foot rest or stool if necessary.) Your legs should not be crossed and your feet should be flat on the floor.
4. Magnesium levels are low, symptoms?- weaken your bones, give you bad headaches, make you feel nervous, and even hurt your heart. Abnormal eye movements (nystagmus), Convulsions, Fatigue, Muscle spasms or cramps, Muscle weakness, Numbness.
5. Patient was dehydrated and now is on iv, how do u confirm they are re-hydrated- Plasma osmolality, urine osmolality and urine specific gravity are the most widely used markers of hydration.
6. Sleep apnea patients, who should nurse monitors for (copd, insomnia, etc? pt with multiple problems that has diabetes htn? )- pt with multiple problems that has diabetes htn.
7. Which needle for a well-developed patient (was it IM, yes it was?)- IM
8. Quality of pain, do you provide a scale or ask them to describe it- you describe pain quality.
9. Intact skin non-blanchable (do I turn them?)- yes, it is a sign of stage 1 pressure ulcer. remove all pressure from the area. Keep the area as dry and clean as possible to prevent bacterial infections.
10. Axillary temperature (should the arm be at heart level, put sheath over it, check when the last time they ate or drank was??)- for axillary, which is armpit, u put plastic sheath over the thermometer probe. You only check when last they ate r drank for oral temp and ask to place arm at heart level for blood pressure.
11. Muslim women C-section (bow down as respect? Focus solely on the client? Use the family members as primary source? ethnic sensitivity?)- ethnic sensitivity.
12. The patient family (they speak spanish) is crying (Do u close room or ask another nurse to see why they crying, or contact an interpreter)- close room to give them rivacy.
13. What is fidelity? What is considered fidelity- Fidelity in nursing means that nurses must be faithful to the promises they made as professionals to provide competent care. Keep their promises.
14. Patient blood pressure was 140/60 after 6 hours it became 180/90 what should the nurse do- retake the BP in 15 mins
15. Rash on the abdomen used cream and ointment - put on ppe before assessing, ask if pain was there before putting on ointment
16. Nasopharynx- skin and mucous membrane
17. Heating pad- neurosensory impairment
18. Cancer patient taking medication causing constipation they increased laxative - add more morphine
19. Activity intolerance- unsteady gait to progress to deliberately walking, do you move things out of the way for him
20. Patient watching TV and don't want to take medication you took out of the wrapper- nurse watch as u dispose of it
21. Patient with a CVA trying to get dressed- put the right side on first or tell the pt something like “it must be difficult”
22. Answer for a question : place padding under nasal cannula
23. Knowledge deficit (diet change) is part of a care of a care plan. What do you need to know and include- etiology
24. UAP fixing bed feeding tube- tube with purulent drainage
25. Brady scale reassess- urinary incontinence (Braden scale assesses pressure ulcer risk)
26. Temperature of 102- select all that apply
1. An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports are likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in the client's teaching plan?
a. The importance of using vaginal lubricants
b. Methods used to practice safe sex
c. Information about alternative ways to express sexuality
d. Intercourse positions that help prevent tears
2. While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action would the nurse take in response to this finding?
a. Reposition the pulse oximeter clip to obtain a new reading
b. Stop suctioning until the pulse oximeter reading is above 95%
c. Complete the intermittent suction of the nasopharynx
d. Apply an oxygen mask over the client's nose and mouth
3. The home health nurse is reviewing the personal care of an elderly client who lives alone. Which client assessment findings indicate the need to assign the UAP to provide routine foot care and file the client's toenails? (SATA)
a. Syncope when bending
b. Hand tremors
c. Diminished visual acuity
d. Urinary incontinence
e. Shuffling gait
4. A client who has been diagnosed with terminal cancer tells the nurse, "The doctor told me I have cancer and do not have long to live." Which response is best for the nurse to provide?
a. "That's correct. You do not have long to live."
b. "Would you like me to call your minister?"
c. "Don't give up, you still have chemotherapy to try."
d. "Yes, your condition is serious."
5. A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?
a. Change coccyx dressing, perform tracheostomy care, and restart the IV
b. Perform tracheostomy care, change coccyx dressing, and restart the IV
c. Restart the IV, perform tracheostomy care, and change coccyx dressing
d. Change coccyx dressing, restart the IV, and perform tracheostomy care
6. A female nursing home resident and her family only speak Spanish. During a visit, the entire family begins to cry hysterically. When unable to determine why the family is upset, what intervention is most important for the nurse to implement?
a. Ask a Spanish-speaking staff member to talk with the family
b. Use a Spanish translation reference to interview the family
c. Close the door to the client's room to provide family privacy
d. Sit quietly with the family to offer comfort and support
7. A middle-aged male client tells the nurse that weeks ago he began exercising four times a week to lose weight and to help him sleep better. He states that it still takes an hour to fall asleep at night. What action should the nurse implement?
a. Advice the client that lifestyle changes often take several weeks to be effective
b. Determine the amount of weight the client has lost since increasing his activity
c. Encourage the client to exercise everyday to eliminate bedtime wakefulness
d. Ask the client to describe the exercise schedule that he has been following
8. The female client who has a one-day post mastectomy is crying when the nurse enters the room. What action should the nurse take?
a. Remain quietly by the door until the client stops crying
b. Stay with the client in silence while touching her forearm
c. Ask the client if she would like her clergy notified
d. Tell the client it is normal to cry after surgery
9. The nurse enters the room of a client with Clostridium difficile infection to administer an IV antibiotic. The UAP is in the room cleaning the client's buttocks and states the client has been incontinent with diarrhea. The UAP is wearing gloves but not a gown. What action should the nurse implement first?
a. Advise the UAP to put on a gown
b. Observe the appearance of the diarrhea
c. Hang the scheduled dose of antibiotic
d. Assess the client's skin integrity
10. The grandmother of a young adult male admitted to the psychiatric unit yesterday requests information about her grandson's treatment plan. Before answering the family member's questions, what action should the nurse take?
a. Ask the client if he wants this information shared with his grandmother
b. Ensure that the signed release of information includes the grandmother
c. Consult with the healthcare provider before sharing the information
d. Reassure the grandmother by providing an honest response
11. The nurse is planning care for a group of patients on a Med-Surg unit during night shift.
Which patient should be closely monitored for sleep apnea?
a. A woman with restless leg syndrome and COPD
b. A young woman taking Coumadin and has a diagnosis of insomnia
c. A male with a bleeding ulcer
d. A male with multiple problems including diabetes, HTN, and obesity
12. It is most important for a nurse to recalculate a patient's Braden score. Who develops which problem?
a. Urinary incontinence
b. Hypoactive bowel sounds
c. Weakened cough reflex
d. 2+ pitting edema to both legs
13. The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3L/minute, and the client's oxygen saturation level is 92%.
What intervention should the nurse implement?
a. Place padding around the cannula tubing.
14. While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first?
a. Raise the client's legs and feet
b. Administer 250 ml saline bolus
c. Decrease blood flow from dialyzer
d. Stop the hemodialysis procedure
15. A male client presents to the clinics stating that he has a high stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help the sleep. Which intervention should the nurse implement?
a. Determine the client's sleep and activity pattern
b. Obtain prescription for client to take when stressed
c. Refer client for a sleep study and neurological follow-up
d. Teach coping strategies to use when feeling stressed
16. A cerebrovascular accident is placed on a ventilator. The client's daughter arrives with a durable power of attorney, and a living will that indicates the...extraordinary life saving measures. What action should the nurse take?
a. Refer to the risk manager
b. Notify the healthcare provider
c. Discontinue the ventilator
d. Review the medical record
17. A patient with COPD tells the nurse that she feels better when seated upright. What should the nurse tell the UAP to do when taking care of this patient?
a. Lower the bed to working level. Prevents injury to worker and patient.
18. A client is discharged for a long-term facility w/ an indwelling urinary catheter. Which nursing action should be included in the plan of care to reduce the patient's risk for infection related to catheter?
a. Secure the drainage bag a bladder level during transport
b. Administer a pen antipyretic if a fever develops
c. Flush the catheter daily with sterile saline
d. Encourage increased intake of oral fluids
19. What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?
a. Working together can decrease the risk for back injury
b. The technique is intended to maintain straight spinal alignment
c. Using two or three people increases client safety
d. Turning instead of pulling reduces the likelihood of skin damage
20. When entering a client's room the nurses observe that the UAP has lowered the head of the bed to change the linens for a client who is bedfast. Which observation requires the most immediate intervention by the nurse? (Double Check)
a. There is a dependent loop in the client's urinary drainage tubing
b. Purulent drainage is present around the insertion site of the feeding tube
c. A feeding tube infusing at 40ml/hour through an enteral feeding tube
d. The urine meter attached to the urinary drainage bag is completely full
21. The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a TV program and requests not to take the medication.
Which action should the nurse implement?
a. Keep the medication and see if the client wants to take it later
b. Explain since the medication is a controlled substance it must be taken
c. Credit the medication back and put it in the client’s medication box
d. Have another nurse watch disposal of the medication into disposal container [Show Less]