rn exit hesi Exam 2022/2023 with complete solutions

normal blood pressure - ANSWER 120/80 normal spo2 - ANSWER 95-100 normal pulse - ANSWER 60-100 normal adult respirations normal children respirations - ANSWER 16-20 16-30 glucose level - ANSWER 70-110 no ...

normal blood pressure - ANSWER 120/80 normal spo2 - ANSWER 95-100 normal pulse - ANSWER 60-100 normal adult respirations normal children respirations - ANSWER 16-20 16-30 glucose level - ANSWER 70-110 normal wbc normal platelets - ANSWER 5000-10,000 150,000-4000,000 normal bun - ANSWER 10-20 creatinine - ANSWER .6-1.3 sodium - ANSWER 135-145 potassium albumin - ANSWER 3.5-5.0 calcium - ANSWER 8.6-10.0 digoxin level - ANSWER .5-2.0 magnesium - ANSWER 1.6-2.6 hematocrit - ANSWER female 35-45 male 42-52 absence seizure - ANSWER last only a few seconds tonic clonic seizure - ANSWER protect airway protect pt from injury monitor duration of seizure activity status epileptic in er - ANSWER protect airway administer valuim(diazepam) place IV protect pt from injury main seizure drugs - ANSWER carbamazepine(tegretol) avoid grapefruit phenytoin(dilantin) extra growth on gums valproic(dapakote) affects wound healing if G.I symptoms occur while on seizure meds you should advice pt to - ANSWER take with food signs of depression in children - ANSWER pretends to be sick trouble in school pessimistic attitude TREATMENT FOR DEPRESSION - ANSWER antidepressants counseling psychotherapy should not take St. johns wort while taking what meds - ANSWER antidepressants if a pt is on TPN and it runs out with no more available at the time, the nurse should - ANSWER infuse 10% dextrose with water at 54ml/hr best way to tell if ng tube is correctly in place - ANSWER chest x-ray proper use of inhaler - ANSWER during inhalation the pt should administer the medication after a procedure hispanics believe that - ANSWER they should drink hot things to restore balance blood transfusion are forbidden by - ANSWER jehovah witness when a pt has a hip replacement the nurse should - ANSWER place a pillow between legs while lying to prevent hip dislocation giving meds through the NG tube the nurse should - ANSWER mix them individually if a pt is DNR and the nurse resesitates it is called - ANSWER battery miseries mean - ANSWER pain when suction nasotracheal tube you should know what - ANSWER never suction longer then 15 seconds, if you get large amount of yellow secretions but past 15 secs, reoxygenate and then continue suctioning intramuscular injections in thin patients should be given where - ANSWER ventrogluteal landmark for ventrogluteal - ANSWER greater trochanter (hip) most effective way to use imagery sensory is - ANSWER to include as many images as possible progressive relaxation activity is accomplished by - ANSWER 1st-establish regular breathing pattern 2nd- tense muscle fully 3rd- relax muscle completely when should you teach a pt about how to use a PCA pump - ANSWER the day before surgery teleology means - ANSWER ENDS JUSTIFY THE MEANS veracity means - ANSWER truthfulness correct deep breathing exercise - ANSWER inhale through the nose, exhale slowly through mouth without pursed lips number one cause of bedsores - ANSWER prolonged bedrest what is the number 1 question t ask a pt before surgery - ANSWER have you had anything to eat since midnight when a pt gets anesthesia what is highest priority for nurse to do - ANSWER position pt due to risk of perioperative-positioning injury why does a nurse call a time out before the surgery starts - ANSWER for final verification of procedure, site and right pt. what do you expect to find after surgery - ANSWER hypoactive bowel sounds if you have a pt with lt hip replacement, p/o they have moderate sanguinous drainage nurse should - ANSWER observe area under hip (since gravity pulls) mark amount of drainage on dressing by circling it to help relieve anxiety for a pt who has never been hospitalized the nurse should - ANSWER explain room environment to help prevent venous thromboembolism - ANSWER dorsal & plantar flex of feet lovenox injections (anticoagulant) proper way to evaluate legs is - ANSWER use 2 pillows place 1 lengthwise under each calf if pt is experiencing right sided weakness - ANSWER place at 45* angle on lt side when a pt is starting to fall the nurse should - ANSWER gently try to lower to the ground atelectasis can lead to pneumonia, to prevent atelectasis the pt should - ANSWER take 10 deep breaths per hour what is atelectasis - ANSWER complete or partial collapse of the lung how would a nurse explain to a pt the correct way to deep breath - ANSWER place hands on abdomen above umbilicus, try to make your hands rise (shoulders should not rise) what does braden scale assess - ANSWER pressure ulcers way to prevent pressure ulcer - ANSWER reposition q2h , 60* side lying before giving a pt a new med what is most important question to ask - ANSWER if you are allergic to it what helps to increase normal body flora - ANSWER buttermilk and yogurt what should you teach a pt with limited ambulation - ANSWER isometric exercise of gluteal and quadriceps 5x Q2h while awake when a nurse is concern with the pt getting constipation due to lack of activity and poor diet what should the nurse do - ANSWER offer bedside commode, which allows pt independence and correct positioning for bowel action to improve spiritual needs of patient the nurse should - ANSWER place a sign on door to allow quiet time in A.M for prayer lack of sleep causes - ANSWER fatigue and pain how is quality of pain described - ANSWER dull, sharp, achy, stabbing pain intensity is measured by - ANSWER scale 1-10 and faces for children guarding is known as - ANSWER common response to an injured area if a pt is having pain and anxiety , it is important to determine what - ANSWER what is causing the anxiety before implimenting interventions the nurse should - ANSWER discuss it with the pt. aspirin should be avoid in children, why - ANSWER it causes Raynards Syndrome for a sprained ankle the treatment should be - ANSWER place heating pad on, heat promotes muscle relation and relief of pain what is important to remember about cold packs - ANSWER excessive direct exposure to skin can damage skin what causes the skin to become reddened from prolong exposure to ice - ANSWER reflex vasodilation cold causes vasoconstriction control meds are called - ANSWER schedule IV analgesics and high potential for abuse after an incorrect med is given the nurse must - ANSWER notify Dr. of error in treatment purpose of an incident report is to - ANSWER find ways to prevent future errors IV obstruction is most often caused by - ANSWER pt movement , occluding line if nurse checks IV site and it is inflammed, tender, and dated 36 hrs ago the nurse should - ANSWER remove and start in a different location phelebitis at IV site puts pt at risk for - ANSWER thrombus formation when a pts fluid intake is greater then their output, this make a concern for fluid volume excess the nurse should - ANSWER ausculate for breath sounds if a pt has swollen ankles with 4mm indention the nurse should document it as - ANSWER 2+ pitting edema present at feet and ankles if pt has abnormal breath sounds, bilateral pitting edema and jugular vein distention will cause the - ANSWER pt pulse to increase in rate and volume potassium should never be - ANSWER IV push foods high in potassium include - ANSWER baked potato, chicken, grapefruit when should dieurtics be taken - ANSWER in A.M. with breakfast due to nocturia if pt has difficulty swallowing the nurse should - ANSWER assess for adventitous breath sounds, since pt at risk for aspiration pneumonia if pt gives copy of living will it should - ANSWER be placed in medical record and document its presence when a pt is deteriorating and disoriented it is important for nurse to - ANSWER determine from family if pt has a living will and power of attorney dying process begins the following is done - ANSWER clean mouth with oral swabs 2 staff members provide care see cyanosis, motting of hands and feet signs of denial - ANSWER shock, numbness, disbelief why is transmucosal route of oxycodone used - ANSWER rapid absorption decrease chance aspiration chest tubes have 2 chambers what are they - ANSWER water seal chamber (no bubbling) suction control chamber (bubbling) keep canister on ground what is GERD - ANSWER heartburn how do you prevent GERD - ANSWER medication avoid chocolate avoid tobacco smaller portion meals chew gum after meals important info about histamine 2 blocker meds for Gerd & peptic ulcers - ANSWER may cause confusion dont smoke take with meals may cause black tongue what should you never give a pt in heart failure - ANSWER sodium bicarbonate (alka selzer) What does sucralfate (carafate ) due for a pt with ulcers - ANSWER coats to protect from gastric juices (acid) pepto should not be given to children why - ANSWER contains aspirin what must be monitored when given Reglan - ANSWER temperature cause it raises it causes lip smacking complications of peptic ulcers are - ANSWER bleeding ulcer perforation gastric obstruction when a pt has a seizure disorder what brings them on - ANSWER stress lack of sleep pregnancy infection/flu what is aura, name an example of it - ANSWER when having a seizure it effects smell, taste and vision. Example: seeing floating lights epileptic cry is - ANSWER forced exhalation (tonic clonic) goiters are seen in what diseases - ANSWER hyperthyroidism hypothyroidism Graves dx when a pt is on thyroid replacement what two drugs do you have to adjust - ANSWER increase insulin decrease anticoagulants (always check vitals after given thyroid replacement drugs pt on thyroid replacement when should the nurse notify the dr. - ANSWER increase pulse 20 bpm from last week vomitting irregular pulse rate thyroid storm/crisis happens when - ANSWER pregnancy infection trauma how long does it take to see improvement when started on thyroid suppressing drugs and what can they cause - ANSWER 3 weeks risk for infection hormones changes are caused by - ANSWER gonadrotropin releasing hormone cause of hot flashes is what hormone - ANSWER follicle stimulating hormone (FSH) what is a great risk for pt on hormone replacement therapy when pt smokes - ANSWER blood clots what is Euglycemia - ANSWER normal fasting glucose 70-110 when is glucagon active - ANSWER in the morning what usually causes DM II - ANSWER obesity sedentary lifestyles when is short acting insulin given, what color is it - ANSWER before meals- clear intermediate acing insulin is what color - ANSWER cloudy (always draw up clear before cloudy) instructions when injecting insulin - ANSWER dont aspirate dont message after usually in abdomen signs of diabetic ketoacidosis - ANSWER fruity breath nausea abdomen pain remember children receiving glucophage should be given what type of doses - ANSWER adult how long should a pt not receive glucophage(Metformin) after an angiogram - ANSWER 48 hrs if a nurse notices a hemovac drain full of sanguinous (bloody) drainage the nurse should - ANSWER empty drain measure amount notify surgeon check hemoglobin/hematocrit level what is important about giving packed red blood cells - ANSWER only compatible with normal saline infuse within 2 hours infuse with NS when changing a dressing what should the nurse do first - ANSWER don sterile gloves before cleansing incision dehiscence is - ANSWER unintentional opening of a wound prior to healing (pop a stitch) when a nurse notices a pt over or under reaching it is due to - ANSWER visual defect in depth perception snellen chart for vision , numbers mean - ANSWER 20 # feet from chart 40 larger the number = poorer vision how do you define characteristics of a problem - ANSWER cluster data and compare it when speaking with hard of hearing nurse should - ANSWER make eye contact low pitch voice when a pt is being sent home but is at risk for falls the nurse should - ANSWER consult with family about assessing pt home for risk of injury like throw rugs(even if they dont slide you can trip over edges active listening means - ANSWER giving your full attention when a pt becomes dependent on others it causes - ANSWER disturbed situational low self esteem when older adults lose ability to distinguish color which colors should you use to mark things - ANSWER red,orange and yellow to assess pt ability to discriminate sensation the nurse should - ANSWER touch extremities with different objects and ask pt to describe what they are filling if pt comes out of surgery and is confused the nurse should - ANSWER address pt by name, they them where they are and the time ( keep bathroom light on to help ID surroundings) chronic middle ear infections can cause - ANSWER hearing loss paraplegia means - ANSWER paralysis of lower half of body when nurse notices reddish area on sacrum the nurse should evaluate it by - ANSWER document length time of redness apply light pressure to check for blanching measure diameter What is rubor and where is it usually seen - ANSWER redness (usually seen area lower then heart mainly legs) reactive hyperemia is - ANSWER when tissue is relieved of pressure to relief pressure on sacrum the pt should be positioned - ANSWER 30* lateral inclined position