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Fundamentals Exit HESI


Determining the client position for insertion of indwelling catheter, Most important
Orthopnea
Nurse teaching male with multiple sclerosis (MS) how to empty bladder using creude method. When
performing return demonstration pt applies pressure to the umbilical area of his abdomen
Apply downward manual pressure at the suprapubic region
Finding a client sitting on the floor, nurse calls for help from UAP
Get a BP cuff
Correct position for patient walking with cane
30o flexion at the elbow
Teaching a patient about crutch walking
Place weight on arms and hands when using crutch
Patient has active tuberculosis. Action to prevent spread of infection
Wear mask when going to patients room
To advance NG tube while inserting what position should patient be in
High fowlers
Which profession is at greatest risk of developing Hepatitis A
Cook in a restaurant
Handwashing sequence
Palms, between fingers, dry off with paper towel, turn off faucet
Someone with wound vac how to make sure it is effective
Check seal to make sure no leaks
Chest tube becomes disconnected
Get new saline bottle to stick end into until reconnect tube
Patient in ventricular fibrillation
Defib shock once
Chest tube colume 125
Mark container between 100 and 150
Heart sounds audio
S1S2
Patient on bleed precautions
Soft bristle toothbrush
Electric razor only to shave
Avoid IM injections, use small needles when necessary and hold pressure for 5 minutes
No straining with BM

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UAP giving complete bath-which patient is more concern


Patient with dyspnea (SOB when lying flat)
Patient receiving Morphine in PCA pump
Make sure the lock is on the machine
Precautions for RSV
Do not put patient with another patient having RSV
Insulin can be kept at room temp
28 days
Drawing insulin
Clear (regular) first then cloudy (NPH)
Know the insulins and their peak/onset (there are several Qs about this in different formats)
Rapid-Lispro (Humalog) and Aspart (Novolog) Onset: 5-15 minutes Peak: .75-1.5 hours
Short acting- regular (humulin) Onset: 30-60 minutes Peak: 2-3 hours (IV ok)
Intermediate acting- NPH Onset: 1-2 hours Peak 6-12 hours
Long acting- Glargine (lantus) Onset 1.1 hour Peak: 14-20 hours (DO NOT MIX)
Assessing placement of NG tube
<4 pH gastric aspiration
Carpal spasm induced by BP cuff and seen in patient with hypocalcemia
Trousseaus sign
Trousseau's sign
(Trousseau sign of latent tetany, low calcium, holding hand like swan, seen in hypocalcemia before
hyperrelexia or tetany) Put bp cuff around arm, inflate, hold in place 3 mins, occuldes brachial, pt, will
put hands like shape of swan
Facial spasm after tapping facial nerve and seen in patients with hypocalcemia
Chvosteks sign
Patient on neutropenic precautions
No flowers or plants in room
No fresh veggies-cooked only
Avoid crowds and sick people
head of the bed positioning for post-craniotomy patient with infratentorial lesions
FLAT
Supratentorial elevated
assisting the patient to cough productively
increase fluids to loosen secretions
O2 flow rate be for a patient with COPD
No more than 2 liters by nasal cannula

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patient is vomiting and restless, diarrhea, respiration rate of 8 to 10 per minute, shows arrhythmias on
the EKG monitor
metabolic alkalosis
preventing hypoxia during suctioning
give 100% oxygen before and after endotracheal suctioning
assessing a patients sleep-rest pattern related to respiratory health
Has trouble falling asleep
Awakens abruptly during the night
Has to sleep with the head elevated
nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting
The fingernails and their base
caring for a patient with COPD and pneumonia who has an order for arterial blood gases to be drawn
5 Minutes
patient with a recent history of a dry cough has had a chest x-ray that shows presence of nodules
Positron emission tomography (PET)
patient with recurrent shortness of breath just had a bronchoscopy
Monitoring the patient for laryngeal edema
After assisting at the bedside with thoracentesis, the nurse should continue to assess the patient for
Pneumothorax
nurse notices clear nasal drainage in patient newly admitted with facial trauma and a nasal fracture
Test the drainage for the presence of glucose
patient is being discharged from the emergency department after being treated for epistaxis
Apply ice compresses to the nose
Pinch the entire soft lower portion of the nose
Partially insert a small gauze pad into the bleeding nostril
caring for a patient who is 3 hours postoperative laryngectomy, the nurses highest priority assessment
Airway patency
teaching a patient the supraglottic swallow following a radical neck dissection with
Cola
nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care
facility-allergy
Hypersensitivity to eggs
Which task can the registered nurse (RN) delegate to nursing assistive personnel (NAP) care of a stable
patient has a tracheostomy
Suctioning the patients oropharynx

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Anterior Cruciate Ligament injury
crutches
priority nursing assessment in the care of a patient who has a tracheostomy
Respiratory rate and oxygen saturation
promote airway clearance in a patient with pneumonia
Maintain adequate fluid intake
Splint the chest when coughing
Instruct patient to cough at end of exhalation
Soft diet-select
yogurt, chicken soup, cottage cheese
Pneumatic compression devices
used to prevent DVT, improves venous circulation
patient admitted to the hospital with pneumonia, temperature of 101.4 F, productive cough with yellow
sputum, and respiratory rate of 20
Hyperthermia related to infectious illness
IV med incompatible
start a new line
physical assessment finding in a patient with a lower respiratory problem best supports diagnosis of
ineffective airway clearance
Basilar crackles
Ankle brachial index
ensure that you provide meticulous foot care to client
clinical manifestation expect to find during assessment of a patient admitted with pneumococcal
pneumonia
Increased vocal fremitus on palpation
priority nursing intervention in helping a patient expectorate thick lung secretions
Increase fluid intake to 3 L/day if tolerated
NGT Irrigation-assignment
RN must irrigate
discharge teaching for a 65-year-old patient with COPD and pneumonia
Pneumococcal
Vitamin K
Technique 25 gauge, 58-inch needle to administer in either the vastus lateralis

discharge teaching for a patient hospitalized with pneumonia most effective when the patient states
I should continue to do deep-breathing and coughing exercises for at least 6 weeks

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After admitting a patient to the medical unit with a diagnosis of pneumonia verify which of the following
orders have been completed before administering a dose of cefotetan (Cefotan)
Sputum culture and sensitivity
New cast-increasing pain
Tingling or parasthesia indicates neurovascular compromise)-OR-(I will put adhesive tape around the
edges of the case if they become sharp)
patient diagnosed with nonsmall cell carcinoma of the lung question the patient related to a history of
which risk factor for this type of cancer
Asbestos exposure
Cigarette smoking
Exposure to uranium
intervention most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease
Positioning patient with good lung down
Guaiac+ & vitamin K
Blood in stool after a guaiac test may be caused by vitamin k deficiency
71-year-old patient admitted with acute respiratory distress related to cor pulmonale
Perform a physical assessment of the respiratory system and ask specific questions related to this
episode of respiratory distress
Stoma Assessment
The stoma will shrink within 6 to 8 weeks after surgery. Therefore it needs to be measured at least once
weekly during this time and as needed if the patient gains or loses weight. A healthy stoma should be
reddish pink and moist and protrude
patient with metastatic lung cancer and a 60-pack-per-year history of cigarette smoking
Mucociliary clearance
Insulin admin- teaching
rotate sites of injection, no aspiration, 90* angle
While ambulating a patient with metastatic lung cancer, a drop in oxygen saturation from 93% to 86%
Obtain a physicians order for supplemental oxygen to be used during ambulation and other activity
Cred Method
Crede is a method used for those w/atonic bladders- Apply downward manual pressure at the
suprapubic region
45-year-old female with a pulmonary embolism
Obesity
Hypertension
Cigarette smoking
Recent long distance travel

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GI bleeding-NGTsuction
Show the pt a nasogastric tube and explain reasons for low intermittent suction
patient had a left total knee arthroplasty. On postoperative day3 , the patient complains of shortness of
breath, slight chest pain, and that something is wrong. Temperature is 98.4o F, blood pressure 130/88,
respirations 36, and oxygen saturation 91% on room air
Pulmonary embolus from deep vein thrombosis
Decision making-impaired provider
call subordinate
Urinary catheter- Wrong placement
pain
patient with asthma, the nurse notes wheezing and dyspnea
Narrowing of the airway
Dehiscence
A 4cm area of dehiscence is observed on abdomen is highest priority
man with asthma is brought to the emergency department by automobile. He is short of breath and
appears frightened
Anxiety
patient who has anxiety and an exacerbation of asthma-primary reason for the nurse to carefully inspect
the chest wall of this patient
Evaluate the use of intercostal muscles
IM Site
deltoid 100.0% 82.0% (upper shoulder-B12, flu shot)
positions most appropriate for the nurse to place a patient experiencing an asthma exacerbation
High Fowlers
Insulin pen benefits
convenient, easy to use, travel benefits, mistake free
patient with an acute exacerbateion of asthma
Wheezing becomes louder
Coumadin-Diet recommendations
Avoid ingesting foods high in vitamin K because this vitamin reduces the drug's effect
diagnosis of activity intolerance for a patient with asthma
Work of breathing
Buck's traction
fractured femur, transporting w/traction-leave weights in place for duration of transport

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exacerbation of asthma- patient received a -adrenergic bronchodilator and supplemental oxygen
Systemic corticosteroids
Z-track Injection steps
Z-track steps: After the needle is withdrawn from the skin surface-is when nurse should release the
retracted tissue-OR-Understand the reason for Z track method, Its used for IM prevent leakage
patient with acute exacerbation of COPD needs to receive precise amounts of oxygen
Venturi mask
Transfer to chair
Use a mechanical lift to transfer a client to the chair-Delegate to UAP
appropriate use of a peak flow meter- instruct the patient
Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse
Hand hygiene-alcohol based
UAP using a hand sanitizers that is alcohol for 2 minutes- I put tell that hand sanitizer use is less >
2min
salmeterol (Serevent) for a patient with asthma
Close lips tightly around the mouthpiece and breathe in deeply and quickly
Patient on fall precautions
Room close to nurse station
Assist with ambulation
Wear non skid foot wear
Sign posted on patient door
Bed in low-locked postion
Bed alarm on
Hematuria-assess blood in the urine
When starting the urine stream or at the end of voiding
common adverse effects from the inhaled corticosteroid beclomethasone (Beclovent)
Oropharyngeal candidiasis and hoarseness
Pharyngeal rattle
palliative care
patient understood medication instructions about the use of a spacer device
More of the medication will get down into my lungs to help my breathing
Chemotherapy Thrombocytopenia
increased risk for bleeding. Bleeding precautions
Wound & protein Purulent drainage
Is pus, a protein-rich liquid product of the liquefaction of necrotic tissue. It is made up of cells and
cellular debris and is usually caused by an infection. It is thick and yellow, green, tan, or brown

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test result identify that a patient with an asthma attack is responding to treatment
A decreased exhaled nitric oxide
patient is not experiencing adverse effects of albuterol (Proventil) after which of the following vital signs
Pulse rate of 76
Protocol for Droplet Precautions
Private Room or cohort mask
Russel Traction
femur or lower leg instability
order for inhalers-asthma attack
Albuterol (Proventil)
GERD interventions
Teach the patient to limit or eliminate foods that decrease LES pressure, such as chocolate, alcohol,
fatty foods (especially fried), caffeine, and carbonated beverages. The patient should also restrict spicy
and acidic foods (e.g., orange juice, tomatoes)
Cardiac cath
Ambulate-maybe 1 hour after
administered a first dose of oral prednisone to a patient with asthma
Intake and output
Fecal occult blood test - Two methods for testing occult blood in the stool are available:
The traditional FOBT and the newer FIT (fecal immunochemical test). The traditionally used FOBT
(e.g., Hemoccult II) requires an active component of guaiac and is, therefore, more likely than the FIT
(e.g., HemeSelect or InSure) to yield false-positive results. In addition, patients having the guaiacbased test must avoid certain foods before the test, including raw fruits and vegetables and red meat.
Vitamin Crich foods, juices, and tablets must also be avoided. Anticoagulants, such as warfarin
(Coumadin), and NSAIDs have to be discontinued for 7 days before testing begins
patient with a diagnosis of asthma exacerbation, assess for which of the following potential triggers
Exercise
Allergies
Emotional stress
Upper respiratory infections
Crohn's - diet choice
low residue, low fat, high protein, high calorie, no dairy products
BP- lymphedema
inform UAP no blood pressure on that arm
Burns Parkland formula
The Parkland Formula is as follows. Fluid for first 24 hours (ml) = 4 * Patient's weight in kg * %BSA
(%burned) Afterwards, the first half of this amount is delivered in the first 8 hours, and the remaining
half is delivered in the remaining 16 hours. Example: Pt burned on 50% of BSA, Pt weighs 80kg =

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4ml/kg/hr = 4 x 50 x 80 = 16000ml total needed to be given 8000ml given in the first 8hrs and
remaining 16 hrs give 8000ml
self-administration of beclomethasone two puffs inhalation every 6 hours
Rinse the mouth with water following the second puff of medication
Nosocomial prevention
handwashing
Pediculosis capitis
use fine toothed comb, dont cut hair, white matter to the hair
Denture care
Rinse them
Elastic stocking-measure
If the pt needs calf-length stockings, measure calf
Crutch size
Assess check the distance between the axilla and the top of the crutch. It should be at least three finger
widths, or 1 to 2 inches (2.5 to 5 cm). If the crutches are not the correct length, the client could sustain
axillary nerve damage
Results for arterial blood gas labs came back, diagnosis is respiratory alkalosis
confusion, tingling of extremities, and deep, rapid respirations
Assess visual acuity and the uncorrected vision is 20/100 in the right eye and 20/80 in the left eye
Difficulty visualizing objects at a distance also known as myopia
Respiratory acidosis, retention of excess carbon monoxide in the blood, characterized by the following
lab finding
pH <7.35 and a PaCo2> 45 mmHg
pt understands teaching of arterial blood gas (ABG) lab test is being performed to determine
the efficiency of respiratory ventilation
organs and glands involved in the homeostatic process of controlling body fluid composition and volume
lungs, heart, kidneys, adrenal glands, parathyroid glands, and pituitary gland
process of inflammation involves all EXCEPT
tingling & itching
nurse is acing responsible when administering meds when doing all EXCEPT
administers the medication the clients has been storing at the bedside
in order to evaluate the postoperative for atelectasis
tachycardia, asymmetrical chest movements, & decreased breath sound
most important factor determining how well a pt might tolerate anesthesia and surgery is
cardiopulmonary function

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postoperative pt with an abdominal incision dressing includes which goal
to protect the incision from microorganisms & trauma
changing wound dressing that is smells and there is a lot of pus
re-dress the wound, using strict asepsis, and notify the physician immediately
Most frequent cause of hypovolemic shock postsurgical
hemorrhage
Deep vein thrombosis occurs in the
lower extremities and pelvis
most at risk of developing a deep vein thrombosis (DVT)
a fractured hip
DVTs usually develop
7 to 10 days after surgery and are always asymptomatic
clinical sign which indicates a possible deep vein thrombosis
positive Homans sign
reason for the administration of heparin with a pulmonary embolus is to
prevent embolus recurrence
earliest signs of hypoxia is
restlessness
chronic renal failure, complains of a tingling sensation around mouth and positive Chvosteks sign
Hypocalcemia
inserting a nasogastric tube for severe abdominal pain
Confirm placement of tube by auscultation
Rinne test, which is negative
Bone conduction of sound is greater than air conduction of sound
Ears-tragus (small inner part-bony lip part) pain on tragus means external otitis
TB Mantoux-interpret
Technique: Ensure that the needle is inserted into the skin w/ the bevel up, Use a 25 gauge in needle
on a 1-ml calibrated syringe??)
Sex in hospital room
Close the door
Autonomy
rights to give Informed consent is based on which ethical principle
UAP using a hand sanitzers that is alcohol for 2 minutes
tell that hand sanitizer use is less > 2min

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assessing blood pressure using an aneroid sphygmomanometer, inflate the cuff to an initial reading of 160
mm calibration. Upon release immediately hears loud Korotkoff sounds
Release the air and reinflate the cuff to 30 mm Hg above the clients previous systolic reading
Native American
Allow pts family to stay in the room
After administering a medication through a nasogastric tube connected to suction
Clamp the tube
performing a surgical hand scrub prior to entering the operating room
Scrape under the nails with a nail pick
Rinse from the fingertips to the elbow
Use a soapy brush to scrub the hands
Cleanse the arm with a lathered brush
where do u pull to give a ear drop= it is a picture so look it up online (KNOW CHILD & ADULT) (pull
the pinnae top side of ear; u can look at a picture to see exactly where pinnae is) (Mine had a picture of
ear and put it on the lobule of the pinnae it is the ear lobe)
The eye picture asked to find the macula or the fovea centralis (there are 2 prominent spots on the eye
choose the DARK spot to the left not the spot where the light is)
Know how the chest tube vac machine works there is a picture of a chest tube vac machine
this q is very easy just mark the spot on the tube for the amount of 125 ml of drainage
Know which position for a pt that had bone marrow taken out
BM aspiration site: iliac crest
Pressure Ulcer
Turning the pt n noticing no pressure, redness, and pt doesnt complain of pain
Pre bed bath assessment say to CNA
activity level of the pt
IV Line
Flush line before and after compatible IV solution
avoid any weight-bearing on the left leg using a 3-point crutch gait for ambulation
Encourage continues use of the 3-point gait by the client
wheelchair-bound with a positive Thomas test after admission to the rehabilitation unit
There may be a delay in the rehabilitation process
takes NPH insulin each morning-what reason to hold usual morning NPH insulin dose
The client is NPO for surgical debridement of a leg ulcer at 11.00am
besy way to explain the proper cleansing technique around a wound drain
Start at the drain site, to avoid bringing skin bacteria toward the wound

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Children should not receive anti-diarrheals (Immodium A-D)
Total serum cholesterol should be kept below
<200 mg/dL
ABG draw
you need to put the blood in a heparinized tube, make sure there are nobubbles, put on ice immediately
after drawing
Enema positioning
left side-lying (Sim's) with knee flexed
lumbar puncture position
lateral recumbent fetal position, keep pt flat for 2-3 hrs
afterwards, sterile dressing, frequent neuro assessments
How to itch under a cast
cool air via blow dryer, ice pack for 10- 15 minutes. NEVER use
qtip or anything to scratch area
Incentive Spirometry steps
Sit upright
Exhale
Insert mouthpiece
Inhale for 3 seconds, and then HOLD for 10 seconds
Latex allergies
Assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit,avocados, chestnuts,
tomatoes, peaches
MRSA and VRSA precautions
*MRSA - Contact precaution ONLY
*VRSA - Contact AND airborne precaution (Private room, door closed, negative pressure)
Placement of a wheelchair for transfer
parallel to the bed on the side of weakness
Protocol for Airborne Transmission
Private Room - negative pressure with 6-12 air exchanges/hr
Mask, N95 for TB
Temp conversion
from Centigrade to F. F= C+40, multiply 9/5 and substract 40
From Fahrenheit to C. C= F+40, multiply 5/9 and substract 40
VRSA
Staph infection that is resistant to Vancomycin treatement! Worse than MRSA
Venous VV and Arterial AA
eleVate Veins
dAngle Arteries for better perfusion

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What is obtained before starting any iv antibiotic
Cultures
Whats petaling
You can petal the rough edges of a plaster cast with tape to avoid skin irritation
Willam's position
Semi Fowlers with knees flexed (inc. knee gatch) to relieve lower back pain