Hesi Exit Version 3 2022 Exam with complete solutions

Cleft Lip - Feeding - ANSWER Nipples with flange to occlude cleft Large, soft nipples with large holes hold baby at 60-80 degrees molded nipple breastfeeding encourages bubble baby frequently after surgical procedu ...

Cleft Lip - Feeding - ANSWER Nipples with flange to occlude cleft Large, soft nipples with large holes hold baby at 60-80 degrees molded nipple breastfeeding encourages bubble baby frequently after surgical procedure feed from the side Myocardial Infarction (MI) - ANSWER EKG Changes ST Elevation T inversion Wider Q Wave Early Decelerations - Fetal Heart Rate - ANSWER Means Head compression mirror image of contraction Normal fetal HR 120-160 JUST OBSERVE CPR in Pregnancy - ANSWER Cephalad position L lateral uterine displacement no Sodium based drugs Mag toxicity = Calcium Gluconate to fix Hyperglycemia in elderly - ANSWER Greater than 110 if fasting Greater than 140 for 2 hour test normal is 80-125 Excessive urine output Have pt. administer their own insulin Sliding scale insulin Colorectal cancer - Surgical Care and care of Colostomy - ANSWER Monitor vital signs, stoma, Q 4 hours Should be Beefy Red (normal) Dusky appearance (necrotic) Small amount of bleeding is normal NG suctioning until bowel sounds are present No lifting greater than 10 lbs or pulling for 6 weeks wash with mild soap, warm H20, pat dry do not wash off markings KNOW! Low fat, high fiber cruciferous diet (Brussel Sprouts, cauliflower, broccoli, cabbage ) Osteoporosis plan of care - ANSWER RISK IS LOW CALCIUM INTAKE Watch for stairs, waxed floor, rugs, medicate for pain High Protein, High calcium, High iron diet Weight bearing and strengthening exercises fall prevention: Non-skid socks encourage activity of D.L. Side rails in bathrooms Ectopic Pregnancy - ANSWER HCG Elevation Transvaginal ultrasound unilateral or bilateral abd. pain medical emergency Burn Neck Contractures - ANSWER Neck stabilized and aligned Airway management Splinting, neck collars Pedicuosis (head lice) - ANSWER Direct contact No sharing personal items Nits (whitish sacs) Keeping staff separate SCHOOL NURSE - send note home to parents Date Rape - ANSWER Ask if consensual - had any conceptual sex recently DKA Labs - ANSWER ANION GAP Metabolic Acidosis - PH < 7.15 Advance Directive - ANSWER Living Will Prepared when person is still alive competent, able to make decisions about life sustaining measures Pavlik Harness - ANSWER used for hip dysplasia in infants Remove only to take baths Cystectomy / Urinary Diversion - ANSWER Bricker Ileal Conduit Proximal end of ileal is closed Distal end out through Stoma in Abdominal wall Pouch for urine collection worn continuously Stent may be in place for 3 weeks after surgery to promote Urine Flow KNOW - Clean skin with mild soap, warm water, pat dry Don't wash off ink mark outlining radiation field. UAP - ANSWER Can pick up blood from lab Cocaine Abused Baby - overdose - ANSWER Tachycardia High BP Cardiac arrhythmias Chills Nausea/Vomiting Cocaine Abused Baby - withdrawal - ANSWER Fatigue Anxiety Disturbed sleep Agitation Alcoholism - ANSWER Hypo magnesium Detox Unna Boot - ANSWER Treats Venous Stasis Ulcers Layers of Gauze and Unna Paste Near Drowning - ANSWER Can cause PTSD Pyelonephritis - Chronic - ANSWER Psychosocial part - how they deal with it. Disaster Training - Safety/priority - ANSWER Nurses own safety first Red - first priority - immediate treatment Yellow - 2nd - systemic injury - treat within 30-6- minutes Green - minor injury - can wait several hours Black - NO HOPE How to avoid Medication Errors - ANSWER Six Rights ID Check Ventilated / Intubated Patient - ANSWER Check for necrosis / erosion from bleeding and trauma related to tube insertion or balloon overinflated Medications delayed due to Procedure - ANSWER Give when PT comes back an reschedule next dose accordingly Hearing Aid - ANSWER Make sure accurate fit If it's whistling, take it out and re-insert Femur Fracture - ANSWER Monitor for Compartment syndrome and bleeding Pneumothorax - ANSWER Monitor for presence of breath sounds Chest X- Ray O2 stats improved remove air to fix collapsed lung priority is ABC/s check insertion site for redness, swelling, warmth, drainage semi-fowlers change position Q 2 hours Endo f life care? - ANSWER Dehydration Thyroid Tumor - removed - ANSWER Monitor for Thyroid storm Airway Bleeding Head of bed 35-45 degrees No talking to family Talk to nurse only for assessment Inverted Nipples - ANSWER Use nipple shield After feeding clean and dry Breaks during feeding use breast pump or other suction device immediately before feeding OB Meds - Antepartum Meds - ANSWER Antacid can't be sodium based DO NOT give sodium based drugs Don't give anything with sodium DKA infusion - ANSWER Stop insulin infusion is blood sugar is < 50 and begin sliding insulin scale Condyloma (genial warts) - ANSWER Protection Prevent spreading Inform sexual partner Stapesectomy - ANSWER Improves hearing Hearing will be muffled initially Laminectomy - ANSWER Excision of a vertebral arch looking for neuro - loss of sensation always log roll them loss of urination Inter Cranial Pressure (ICP) - ANSWER Glasgow coma scale less than 8 unequal pupils widening pulse pressure Nausea/ vomiting weakness decreased motor functioning posturing Kussmauls breathing - ANSWER Deep, repetitive gasping respiratory pattern Acidosis (DKA) Sign of impending death Hypokalemia - ANSWER Caused by vomiting and diarrhea, and prolonged nasogastric suctioning INR - ANSWER Check when giving Coumadin Levels 2.0-3.0 or 3.5 Radial Artery Catheter - ANSWER no requirements for radial - compress for 2 hours after APGAR Score - ANSWER Infants 1 minute and 5 minutes 8-10 is normal 4-6 is moderate 0-3 means aggressive resuscitation Insulin - ANSWER Upper arm, thighs, abdomen, buttocks kids 4-6 mm needles Intradermal injection - ANSWER inner forearm 27-30 g needle 1/4=3/8 10-15 degrees 0.1-0.2 mg administered Eardrops - ANSWER Adults and kids > 3 straight back kids < 3 years old - down and back Burns - ANSWER 4 mL/Kg/% TBSA burned Infuse 1/2 over first 8 hours, rest over next 16 hours BP measurement in legs - ANSWER Mid thigh - listen over popliteal artery behind knee in prone position Handwashing - ANSWER hands lower than elbows water flows from elbows to fingertips pat dry fingers to forearm Braden Scale - ANSWER Pressure ulcers lower the number, higher the risk 4-23 less than 17 = risk for pressure ulcers Pediatric DKA - ANSWER pH < 7.15 Sodium above 1.6 Thyroidectomy - ANSWER Monitor airway obstruction watch for STRIDOR if dressing is tight call HCP! watch for excessive draining and bleeding VFib - ANSWER No P waves No QRS complex Chaotic Rhythm **Intubation, rapid D-Fib, Epinephrine, Lidocaine Cirrhosis - ANSWER Turn PT and deep breath Q 2 hours Monitor for : Hypovolemia Stools/Emesis for blood Breaksin skin LOOK for behavior changes - stupor, lethargy, hallucinations, level of consciousness. TEACH - Don't strain for bowel movement, blow nose, sneeze soft toothbrush, electric razor egg grate/ air mattress apply lotion Diaper Rash - ANSWER Change diaper more frequently Croup - ANSWER Barking, seal like cough, Inspiratory Stridor Maintain patent airway - provide adequate gas exchange Pop on pillows, fowlers position. Tetanus / Lockjaw - ANSWER Airway management / suctioning ABC's - seizure precaution - quiet dark room, put into coma and maintain airway Parkinson's disease - ANSWER No Dopamine Pill rolling Benign Prostate Hypertrophy (BPH) - ANSWER Enlargement of prostate S/S Frequent urination nocturia straining to urinate weak stream incomplete emptying of bladder urinary discomfort bleeding frequency retention difficulty initiating flow Kidney Stones - Renal Calculi - ANSWER Flank pain radiating to lower abdomen and groin Keep hydrated 200 ml/Hr and 2.5 L a day PO Manage pain Hemodialysis - ANSWER Low Sodium Diet - TUREY IS OK Risk for Deficient fluid volume and excess fluid volume Heart Failure - ANSWER Monitor weight same time each day S/S Difficulty breathing, edema, orthopnea, nocturnal dyspnea NOTIFY if weight gain 3-5 lbs in 1 week Acute Renal Failure - ANSWER Report weight gain greater than 2 lbs in 24 hours End Stage liver failure - ANSWER LOC Abdominal Girth Serum Albumin Swelling / Edema Fractured Skull - ANSWER When in vault of skull bone is depressed - driven upward Must operate Spinal cord injury (SCI) - ANSWER Airway then immobilization Myelosuppression - ANSWER Inhibition of bone marrow function - immunosuppressed Lupus - ANSWER Can flare up immune system dysfunction susceptible to viruses UV radiation Drugs Genetics Pernicious Anemia (Addisons Anemia) - ANSWER Can't store B-12 Confusion and delirium and disorientation are normal especially in elderly MI - ANSWER Shows EKG changes Non-ST elevation Substantial crushing pain radiating to left arm and up into jaw for men Indigestion for women Ventricular Bigeminy - ANSWER PVC's occurring in pairs Stroke - ANSWER Goal of rehab is to achieve optimal functional outcome that will allow pt. to be discharged to least restrictive environment Have pt. assist with and perform personal hygiene themselves Bucks Traction - ANSWER Adhesive tape to skin - perform lots of skin care and monitor closely Circular bandaging Align long axis of gone arm or leg weights applied by rope for free motion *** Fractured Hip*** Bowel Surgery - ANSWER Provide comfort prevent complications promote return of bowel function low continuous suction until bowel sounds return note color and amount of drainage abdominal distention Muscular Dystrophy - ANSWER Facilitate ambulation have family help with ROM exercise Urinary Catheters - ANSWER To remove clots by a triple lumen 3 way catheter Irrigate and flush Burns - ANSWER Prevent contractures splint pt, neck collars, 3/4 mattress (extension) Wound Care - ANSWER Sterile, room temp normal saline 3x day sterile dressing paper tape diet of 2400 plus calories a day to promote healing Insulin intermediate - ANSWER onset 2-4 hours peak 6-12 hours duration18-24 hours humulin roll to mix Diabetes Mellitus - ANSWER type 1 usually under age 20 type 2 usually over 30 years old excessive thirst, urination, hunger, fatigue, blurred vision, infections, numbness, tingling Polydipsia - ANSWER Increased thirst