Exit HESI 3 160 Questions And Answers 2022

Exit HESI 3 160 Questions And Answers 2022 pt is experiencing hyperkalemia - in absence of symptoms and EKG changes it is sufficiency to - ANS- switch captopril (an ACE inhibitor that promote K retention) to another ...

Exit HESI 3 160 Questions And Answers 2022 pt is experiencing hyperkalemia - in absence of symptoms and EKG changes it is sufficiency to - ANS- switch captopril (an ACE inhibitor that promote K retention) to another (non-K sparing) htn drug such as amlodipine pt is experiencing diplopia, dysphagia, descending muscle weakness and diarrhea and is dianosed w botulism what should nurse tell pts spouse? - ANS- throw out all of your home canned foods. neurotoxin are typically found in home canned foods. premature atrial contractions - ANS- momentary interruption of atrial rhythm (can be caused by stress, caffeine, drugs) -tx if beta-blocker!!! not life-threatening, cannot change dose of prescribed med, fluxetine (prozax) - ANS- antidepressant SSRI's -> first few weeks of SSRI tx the risk of self-harm and suicide is increased. normal PR interval - ANS- 0.12-0.20 seconds a thrombocyte count of 60,000 is - ANS- severely decreased (norm 150k-400k) and could mean that the pt is developing probs w coagulation in addition to the existing pancreatitis and ARDS, MODS is the most severe manifestation of sepsis and occurs when 2 organ systems become dysfunctional and require intervention to maintain homeostasis. -elevated WBC and crackles over both lungs is expected with ARDS LaVeen Shunt - ANS- plastic tube that passes from the jugular vein to the peritoneal cavity where a valve permits absorption of ascitic fluid to be carried back to venous circulation by the way of the superior vena cava. irregular heartbeat in newborns? - ANS- common, normal finding. Frontal Lobe (glioma) - ANS- frontal lobe controls personality and speech, personality changes and expressive aphasia are expected manifestations from tumor Parkland Burn Formula - ANS- 4mL x body weight (kg) x percentage of body surface= total fluid requirement in mL for 24 hours half to be given in 1st 8 hours, 1/4 in second 8 hours and 1/4 in last 8 hours... patient's bill of rights include - ANS- - Right to the least restrictive environment - Right to treatment - Right to refuse treatment - Right to have access to medical records - Access to telephone, mail, visitors, privacy, TV type 2 DM is prescribed daily insulin injections however has limited manual dexterity - ANS- for a reduction in manual dexterity, an insulin pen would ensure that the pt is compliant w daily insulin injections bc insulin pens are easier to handle than syringes. inhaled corticosteroids are often prescribed for asthma tx. steroids reduce - ANSinflammaton and swelling in airways, thereby improving air movement in lungs. an indication of effectiveness is an improvement in peak flow meter rates on pulmonary function testing. if the pts peak flow meter rates have remained unchanged after 3 months of steroid use, the current medication does is ineffective and needs to be adjusted. WIC program - ANS- a special supplemental food program for women, infants, and children, sponsored by the USDA; directed at low income pregnant and/or breastfeeding women, infants, and children under age 5. -include supplementation of nutritious foods and education. (dental caries in children) -also screens for immunization status of the participating students PD pts are at risk for excessive - ANS- protein loss, which manifests as weight loss, decreasing muscle mass, and peripheral edema. -albumin levels should be monitored regularly to ensure that pt's protein levels remain within normal range. -PD - RISK FOR HYPERGLYCEMIA due to the dialysate contains dextrose. Enalapril Maleate (Vasotec) - ANS- has a common side effect of male impotence Enalapril MALEate (Vasotec) - ANS- has a common side effect of male impotence paint thinner (Toluene) - ANS- can cause hearing loss!!! testing done to detect any changes in hearing pt receiving tx in a mental health facility becomes agitated and begins to act inappropriately in the pt lounge. which action should nurse take? - ANS- excessive noise or sound can be viewed as a threat by pts with psychiatric conditions. when the nurse observes that one of the pt's is becoming agitated, the best first action is to turn off the stereo to reduce environmental stimuli. if the pt's agitation does not recede, the nurse should then escort the pt to a quiet room to de-escalate behavior Dawn phenomenon - ANS- is the end result of a combination of natural body changes that occur during the sleep cycle. between hours 3a-8a, the body increases the amounts of counter-regulatory hormones that stop the action of insulin to lower blood glucose levels. the increased release of these hormones, at a time when bedtime insulin is wearing out, results in increase in blood sugars. this causes blood glucose to rise in the morning. the bedtime dose of insulin is prescribed to counter the effects of dawn phenomenon activity intolerance - ANS- pt's hr has remained elevated 15 min after physical activity is stopped. s/s: increase HR > 20 bpm from resting hr in response to activity, continued elevation of HR >5 min after stopping, cardiac rhythm changes, blood pressure changes > 15 mmHg during activity. a pt w advanced dementia becomes agitated and verbally aggressive while nurse is providing morning care - ANS- when a pt refuses morning care and becomes agitated and verbally aggressive, the best action for the nurse would be to avoid confrontation, leave the room to let the pt calm down and retry at another time. ankylosing spondylitis (AS) - ANS- the inflammatory response that causes degenerative changes in the spinal vertebrae; sacroiliac joints; connective tissues such as tendons and ligaments in the hips, shoulders, knees, feet, and ribs; and tissues of the lungs, eyes, and heart valves -see extensive kyphosis, not lordosis -pain in AS is worse at night or with inactivity and is relieved by exercise. pain that becomes worse when the day progresses is seen in pts with osteoarthritis 6 month old pt is diagnosed w intussusception. which medical intervention would nurse prep for? - ANS- first intervention would be enema or hydrostatic reduction -emergency bowel resection surgery is only if pt is experiencing manifestations of bowel perforation or peritonitis nasal packing is used - ANS- after a submucosal resection for a deviated nasal septum and is used to prevent postoperative bleeding. INITIAL SORTING FOR START TRIAGE - ANS- 1)walking wounded (green) get them off site 2)immediate (red) 3)delayed (yellow) 4)unsalvageable (black) check ABG for pt w pnuemonia - ANS- demonstrating change in level of consciousness and responsiveness which could indicate detrioration in oxygen. lacto-vegetarian diet - ANS- no eggs!! no meat, chicken, fish, eggs, adding brown rice with legumes together create a complete protein!!! can drink milk pts in renal failure can continue to have an adequate urine output but bc of damage, the kidney's may not be able to eliminate metabolic wastes and electrolytes from the body!!! (n/v/d weakness) - ANS- pt is experiencing manifestations of hyperkalemia. best action would be to remove K from IV fluids contracture formation is a common complication of burn injuries and can be prevented by proper positioning of the affected limb, range of motion exercises and physical therapy. to prevent flexion contractures of the hip and knee - ANS- , the nurse should instruct the pt to keep the hip and knee extended. as a rule of tub, joints should be placed in their position of function abruptio placentae - ANS- abdominal pain and vaginal bleeding 30 weeks pregnant. allergies and diazepam (Valium) for generalized anxiety disorder - ANS- benzos such as diazepam are a class of drugs that work on GABA receptors in the CNS. stimulation of these receptors results in anxiolysis (reduced anxiety) hyponosis (sleep induction), sedation, and muscle relaxation. because overstimulation of the GABA reeptors can cause severe CNS depression (decreased resp drive, unconsciousness, coma, death), the pt should be instructed to void concomitant use w other CNS depressants such as alc, opioids, antihistamines. anti-allergy meds contain antihistamines the nurse is preparing to admin med to a pt through a NG tube connected to suction, what should nurse do first when administering this med? - ANS- first disconnect the suction from the NG tube. measure what vitals when seeing elevated pain? - ANS- elevated HR and BP - akathisia - ANS- feeling of inner restlessness and or inability to sit still. this condition is a common side effect of antipsychotic drugs that occur within days of starting the med. -breathing and relaxation techniques should be implemented for symptomatic relief. extravasation of dopamine can cause - ANS- tissue sloughing and gangrene. the nurse would stop the infusion and begin extravasation treatment. pt just received an orthopedic surgical procedure and the surgeon has prescribed traction to be applied in the post-anesthesia care unit. what will nurse do when applying the traction? - ANS- the nurse would contact the area where the pt will be transferred after stabilization to have the bed sent down to the post anesthesia care area so that traction can be applied. normal respiratory rate for 2 year old toddler - ANS- 24-40 breaths per min. pt unable to drive home due to general anesthetic uses instead of local - ANS- ask the pt for the name of someone to contact to drive the pt home. do not delay discharge as this can last several hours and we will not know pre-determined time bulge in the inguinal area of an infant could indicate - ANS- cryptorchidism or undescended testes. Notify HCP of finding 5 year old erikson's stage of development - ANS- initiative vs guilt vaginal wall laceration expected assessment - ANS- bleeding that spurts from the vagina CAGE questionnaire - ANS- Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves (Eyeopener)? a score of 2 or more is considered clinically significant and requires further investigation for alcoholism. hemoglobin A1c blood test measures - ANS- the average blood glucose level over the last 3-4 months. Amiodarone (Cordarone) - ANS- prescribed for the conversion of a-fib to a normal sinus rhythm. this medication should be withheld for a pulse less than 60 bpm. cluster headache - ANS- excruciating stabbing or burning sensations located in the eye or cheek migraine headache - ANS- paroxysmal (sudden, periodic) attacks of mostly unilateral headache, often accompanied by disordered vision, nausea, or vomiting, lasting hours or days and caused by dilation of arteries extensive burn injury to both legs - ANS- intra-compartmental pressure of 35mmHg indicates that the pt is developing compartment syndrome in the affected limbs. compartment syndrome can occur immediately after extensive burn injury and the subsequent development of tissue edema, or later when circumferential burns heal too tightly around a limb. MEDICAL EMERGENCY high-pitched bowel sounds over the right upper abdominal quad - ANS- obstruction of the ascending colon small bowel obstruction- heard lower in abdomen descending/sigmoid colon obstruction- heard left upper or lower abdominal quadrants in acute pancreatitis - lipase and amylase - ANS- serum lipase level will increase to over 280 U/L and remain elevated for 7-14 days. the level of 100U/L indicates pts health is improving. amylase norm - 60-160 Lichenification - ANS- Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen) seen with eczema or other itchy skin disorders. to limit skin damage r/t scratching and decrease the risk of bacterial superinfection, the nurse should provide the child w pair of hand mittens. keep nails short. -avoid hot baths as they dehydrate the skin and worsen symptoms. -distraction is needed but exercising can cause sweating which irritates the skin and worsens the eczema more. -soap dries out the skin and should be avoided if possible -keep skin moisturized anabolic steroid use - ANS- elevated BP, acne, aggression CVA experiencing right-sided hemiparesis. self care activities? - ANS- PUTTING ON CLOTHES: weak side first before dressing the strong side of body. this is to facilitate the decreased range of motion and ability to wriggle and pull the weak side. UNDRESSING: undress strong side first which allows the pt to slide off the clothing from the weak side without much extra movement needed prevents over extension of the limbs and joints on weak side c. diff - ANS- contact precautions! gown and gloves. entire room should be considered contaminated and contact w any object in the room can result in transmission. pulse deficit - ANS- the difference between the rate of an apical pulse and the rate of a radial pulse radial - apical` school-age child normal red reflex? - ANS- presence of a red-orange glow when the light of the ophthalmoscope is shined into the eyes is a normal red reflex open angle glaucoma - ANS- the most common form of glaucoma, where the trabecular meshwork gradually becomes blocked, causing a buildup of pressure Antidote for lead poisoning - ANS- Edetate calcium disodium, succimer, or dimercaprol EDTA -lead level b/w 25-69 tx w calcium disodium ethlenediamine tetraacetate for 5-7 days followed by a rest and repeated -EDTA and dimercaprol (BAL) is indicated for lead level >70 -penicillamine is used only when tx w other drugs is not effective due to multisystem SE when should you take parenteral nutrition - ANS- non-healing wound; renal failure; electrolyte imbalances; fluid restriction; serum albumin level indicating malnutrition; and serum prealbumin level indicating malnutrition and possible protein malnutrition. starting a marathon with glucose levels that are too - ANS- low is dangerous. monitor BG level immediately after the event -eat snacks rich in carbs during the race -discuss decreasing routine insulin dose before the event with the provider. ^ this can can high BG but it's fine bc glucose goes down while running so its good to start off with high BG NPH insulin - ANS- intermediate acting insulin and peaks 4-12 hrs after providing!!! 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