Exit HESI (Actual hesi hints), EXIT HESI 2

Exit HESI (Actual hesi hints), EXIT HESI 2 what is considered a postpartum infection? (correct ANS) - a fever on 2 consecutive days for the first 10 days postpartum not including the first day wound infections mastitis e ...

Exit HESI (Actual hesi hints), EXIT HESI 2 what is considered a postpartum infection? (correct ANS) - a fever on 2 consecutive days for the first 10 days postpartum not including the first day wound infections mastitis endometritis UTIs respiratory tract infections what do you suspect in a child with an irregular pulse? (correct ANS) - Kawasaki disease what do you screen for on a newborn baby? (correct ANS) - hypothyroidism check T4 level (decreased) what is an expected side effect of Solu-Medrol? (correct ANS) - bleeding, bruising what does Pilocarpine treat? (correct ANS) - glaucoma antidote is atropine sulfate may get a dry mouth TPN (correct ANS) - central venous catheter check for cloudiness refrigerate- warm before administration monitor electrolytes everyday monitor for hyperglycemia and infection change tubing with each new bag nothing else goes through this line what drug would you give is extravasation has occurred? (correct ANS) - phentolamine (Regitine)- it's a vasodilator and will increase blood flow to the area to prevent necrosiswhat diet would be chosen for a pt with CKD? (correct ANS) - bread & cream of wheat pt receiving a blood transfusion develops fluid volume excess and dyspnea, what do you do? (correct ANS) - increase O2 what should you be monitoring in a client who has had a nephrectomy? (correct ANS) - UOP it is more important than drainage what is important when caring for pt in skeletal traction? (correct ANS) - pin care; sterile technique; remove crust; serous drainage is ok how do you deal with a rude doctor that is avoided by the nurses? (correct ANS) - staff meeting what is confrontation? (correct ANS) - calling attention to inconsistent behaviors what is reflecting? (correct ANS) - paraphrasing or repeating what client said what client would most likely be experiencing delirium? (correct ANS) - a client with constant pain or insomnia what is the priority for a depressed client who has not slept? (correct ANS) - sleep a client who is bipolar is going home for the weekend to adjust for discharge. what do you tell the family? (correct ANS) - continue normal daily activities if a client has a pulse with absent breath sounds on the left side what do you do? (correct ANS) - prepare to reposition ETT what do you monitor for in adrenal insufficiency (no steroids)? (correct ANS) - shock hyperkalemia increase sodium in dietif a client suddenly withdraws from steroids what do you do? (correct ANS) - check VS what do you teach a client taking prednisone? (correct ANS) - monitor for hyperglycemia take in morning you are caring for a client with AIDS and you accidentally stick yourself with a sterile needle. what do you do? (correct ANS) - go get a new needle- no need to report what do you teach a pt taking an antipyretic for and increased temp? (correct ANS) - give with fluids because fever can cause dehydration what is suspected if there is an increase in serosanguineous drainage? (correct ANS) - dehiscence what would you expect in a client with an epidural hematoma? (correct ANS) - temporary loss of consciousness, followed by a lucid period, and then gradually leading to coma for maximum effectiveness, what should older clients use for dry skin? (correct ANS) - petroleum based ointment what are signs of pain in an infant? (correct ANS) - grimacing tachycardia restlessness irritability difficulty feeding/sleeping increased RR diaphoresis decreased O2 levels what is priority for a client with renal lithiasis? (correct ANS) - address pain- these pts get pain meds immediately (don't teach important of straining urine- that's RNs job) what do you do for a pt on Amph B?(correct ANS) - monitor UOP- it's nephrotoxic what is the priority assessment in a client who has lost a tooth and has an eye injury? (correct ANS) - check pupils where should the level of water be in the water seal chamber? (correct ANS) - at 2cm where should the level of water be in the suction control chamber? (correct ANS) - at 20cm how does a client present with DM2? (correct ANS) - usually come back to doctor for wounds that won't heal or vaginal infections don't have enough insulin insulin doesn't work a client in hypovolemic shock would present with what? (correct ANS) - weak thready pulse how would you teach someone to use an inhaler? (correct ANS) - shake well for 5 seconds (if MDI) exhale completely press canister once and inhale deeply and slowly hold breath for 10 seconds wait 1 min between each puff if using MDI- rinse mouth & gargle after each use nebulizers are better for peds and clients with severe asthma because it allows you to breath normally what is the appropriate action for a burn client in the emergent phase whose UOP and BP are dropping? (correct ANS) - immediately call the HCP what do you monitor for in a client with HHS and DKA with insulin drip? (correct ANS) - hypokalemia U wave what is priority discharge teaching for a client with HHS?(correct ANS) - monitor for signs of dehydration what activity would you choose for a person who attempting suicide? (correct ANS) - punching bag choose most exerting answer what would you teach a client on peritoneal dialysis about self care? (correct ANS) - warm fluid before administration increase protein and fiber in diet report any fever, abdominal pain that persists after 1-2 weeks, bloody, cloudy, urine colored outflow, outflow that is great than inflow, leakage around catheter site what do you suspect with coffee ground emesis? (correct ANS) - peptic ulcer stomach cancer what medications do you give with coffee ground emesis? (correct ANS) - 'prazole (proton pump inhibitors) 'tidine (h2 antagonist) antacids mylanta carafate what is the G&D of a toddler? (correct ANS) - toilet training magical thinkers, egocentrism dramatic, pretend and parallel play learn to behave through restrictions gender identity let child touch and hold equipment walks without help, creeps up stairs, kneels without support builds tower of cubes, holds two cubes in one hand, scribbles, uses cups, but struggles with spoons uses 4-5 words, uses 10 or more words, uses 2-3 phrases points and ask for objects understand simple commands talk all the time tolerates separation from parents temper tantrums are normaldependency on security items (blanket) what is suspected in a pediatric client with croup and how do you treat?(correct ANS) - retractions & barking cough riding with windows down at night steamy hot showers cool temp therapy nebulized epinephrine, corticosteroids what do you assess for a femoral artery sheath?(correct ANS) - bleeding and hemorrhage how do you care for a hemiparesis client?(correct ANS) - ambulate encourage independence with ADL's increase mobility as tolerated what do you teach a client with asthma about taking beta agonists?(correct ANS) - if administered with theophylline cardiac dysrythmias can occur avoid if taking beta blockers, MAOIs or tricyclic antidepressants observe for chest, jaw, arm pain or palpitations report increase in pulse of 20-30bpm how do you communicate with a client who has had a CVA has developed receptive aphasia?(correct ANS) - picture board- they can't understand spoken or written words left hemisphere what does tadalafil (Cialis) treat?(correct ANS) - erectile dysfunction BPH pulmonary HTN what is the side effect of ondansetron (Zofran)?(correct ANS) - hives, chest tightness, trouble breathing if family refuses to discuss funeral arrangements what do you do?(correct ANS) - remain with family member without discussing (don't show acceptance of family member's feelings) how do you treat a client with swollen tongue, dry mouth and excessive thirst?(correct ANS) - IV hypotonic solution0.2% NaCl 0.45% NaCl D5W what do you teach a client with thrombocytopenia?(correct ANS) - watch for bleeding gums, hematuria, black stools use electric razor use soft toothbrush no IM injections how do you care for a client with AKI?(correct ANS) - restrict protein intake monitor for hyperkalemia if there is a staff conflict what do you do?(correct ANS) - attend client assignments first what is initially used for a co-worker who is abusing narcotics?(correct ANS) - employee assistance program a client is having a precipitate delivery and you are waiting for the doctor. how do you position the client?(correct ANS) - lateral sims a client who has a family history of malignant hyperthermia is going in to surgery and receiving general anesthesia. how do you prepare?(correct ANS) - cooling blanket fluids when are febrile seizures most common?(correct ANS) - 9 months - 5 years old triggered by ear infection or viral illness what is the priority of a client with febrile seizure?(correct ANS) - bring fever down a client with pancreatic cancer should monitor for what?(correct ANS) - hypoglycemia with high levels of insulin and c-peptide dizziness, fatigue, uncontrolled shaking, weakness, hunger, history of fainting what do you assess for in a client with a facial injury?(correct ANS) - violence abusewhat is suspected in a pediatric client with diaphoresis?(correct ANS) - diabetes what interventions do you implement for a client in shock?(correct ANS) - O2 is priority- place client on high flow oxygen (100% nonrebreather) monitor VS, skin color, temp, cap refill, LOC, UOP, cardio) place flat with legs elevated prepare for intubation maintain patent IV- isotonic fluids what is a PICC used for?(correct ANS) - chemo blood transfusion antibiotics IV fluids liquid food frequent blood draws what do you teach a person about their PICC line?(correct ANS) - can go home with- stays in 3 week to months flush once a week use waterproof cover when showering clamp should always be closed when not in use report swelling, redness, pain, discolored fluid at site or fever how do you provide hospice care?(correct ANS) - talk about what the client wants to talk about listen with compassion focus on creating a peaceful environment touch and facial expression are important use lotion, give back rub, offer cool towel nutrition is less important when body is shutting down- offer liquids and soft foods teach family that this is a normal process how do you care for a pediatric client who is impulsive?(correct ANS) - distract by redirecting to other activities consequences for bad behavior reward for good behavior what do you assess for in a victim of partner abuse?(correct ANS) - chronic pain when can a venipuncture be given to a pediatric client?(correct ANS) - 2 years oldmedian cubital, cephalic veins dorsal hand veins basilic vein on pinkie side of arm only used when there is not another more prominent arm vein foot and ankle veins used as last resort Grave's disease treatment(correct ANS) - -Goal: inhibit production of thyroid hormones and block effect on the body -Radioactive iodine therapy: destroys overactive thyroid cells over time -Propylthiouracil, methimazole -Betablockers -Subtotal or full thyroidectomy (risk of damaging vocal cords and parathyroid glands) Describe Lupus and pt education(correct ANS) - -*Autoimmune disorder -Could have a decreased WBC count; increased risk for infection -Avoid crowds, avoid sick people, avoid sunlight (trigger) Assessment points for pt with constipation(correct ANS) - -Assess current medications -Check measures that they're currently taking (daily enemas, laxatives, etc) -Assessment: no bowel sounds, abd distention -Make a doctors appointment -Assess current nutrition, diet, and exercise -Drink more water Osteomalacia and implications for pt teaching(correct ANS) - -Focus on nutritional support -Sunlight is a good source of vitamin D -Vitamin D is important to absorb calcium and phosphorous -Check vitamin D levels Osteomyelitis(correct ANS) - -Bone infection -Treat with antibiotics -Poor healing, injury entered the bone UTI(correct ANS) - -Pt doesn't always report sx! -Urine sample is foul smelling and cloudy -Send sample to lab for urinalysis -Order a secondary test (culture and sensitivity) to choose the correct txAssessment and nursing interventions for hip fx(correct ANS) - -Assess for pain -Hip fracture sometimes shortens the leg/rotates it -Treat like its a hip fracture even if no testing done yet -Assess circulation (pulse, cap refill, feeling, movement, wiggle toes, color) -Don't elevate the leg -No extra motion until hip is stabilized -Assess skin and circulation if in traction Care and assessment for adrenalectomy(correct ANS) - -Pt at risk for electrolyte abnormalities -Put on telemetry -Daily serum electrolytes -Monitor VS -Watch for dysrhythmias Tracheostomy pt teaching(correct ANS) - -Maintain airway: suctioning -Communicate with white boards -Cough and suction on the way out -No more than 10 seconds Steps of the chain of infection(correct ANS) - -Causative agent -Reservoir -Portal of exit: ex: wound, dressing change -Mode of transmission: nurse could be mode if they wear a gown in the hallway -Portal of entry -Susceptible host: decreased immune system, also have wounds (entry site) *Ways to block transmission: precautions, wash hands Aseptic handwashing(correct ANS) - -Wash clean to dirty -Point arms down so dirty water runs from clean to dirty Chrones Diet(correct ANS) - -Low fat -High-calorie: dried fruit increases calories and nutrients -High nutrient foods -Ex: eggs w/o yolk, lean meat, fish, seafood, chicken Heart Failure Diet(correct ANS) - -No canned/processed food -No cheese or salami -Limit sodium (fluid retention)-Vegetables and fruits Mormon Diet(correct ANS) - -No alcohol -No caffeine -Give milk, juice, or water -If diabetic, no juice -Church = latter day saints Enema administration and nursing considerations(correct ANS) - -Monitor pt for cramping and abd pain -Coach and support pt through this pain -Need to get procedure done, take break, deep breaths, then continue Trapeze bar and considerations(correct ANS) - -Need upper body strength/upper extremities -Get history from pt: make sure they don't have any problems with dislocated shoulder -Allows more independence and participation with repositioning Manual bladder irrigation and CBI(correct ANS) - -CBI: 3 way catheter -Check for kinks if not flowing properly -Manually irrigate CBI if there's a clot -If a clot is blocking, the pressure in the bladder could cause leakage around the catheter site AKI assessment(correct ANS) - -Decreased kidney function because of secondary condition and output decreases -Oliguria: less than 400 cc in 24 hrs -Kidneys aren't producing urine -Possibly can't produce urine sample AKI Interventions(correct ANS) - -Follow up and look at what drugs they're on -Monitor electrolytes -Monitor weight and edema -Monitor VS: HTN/HypoTN, increased HR -Aggressive fluids: watch for fluid overload, check lung sounds and vitals -Lasix or Mannitol IM Injections(correct ANS) - -If you stick yourself, fill out appropriate paper work and get pts blood sample-If you think you're in the wrong space, get a larger needle -If you aspirate and get blood return, take out and throw everything away Safety concerns with Parkinson's(correct ANS) - -Early: falls, decreased mobility, risk for aspiration -Late: wheelchair bound, ulcers, decreased muscle, decreased mobility Distracting Injury(correct ANS) - -Ex: traumatic amputation, so focused on treating that you don't realize the pt isn't breathing -ABCs -C: know the cause and how to control it 3 Middle ear bones(correct ANS) - Incus, Maleus (hammer), Stapes Hearing(correct ANS) - -Maleus (hammer) is first small bone hit from the eardrum vibrations -Sound waves go to tiny hair cells in cochlea and communicate with the brain to perceive sound Stapedectomy(correct ANS) - -Performed for otosclerosis -Incision behind inner ear, stapes removed and implant inserted -Allows sound and vibrations to pass from eardrum to inner ear fluids Stapedectomy pt teaching(correct ANS) - -Improvement of hearing isn't immediate, can initially be worse -Hearing improves in 3 weeks, maximum hearing takes 6 months -Dressing on the ear Polycystic Kidney Disease treatments(correct ANS) - -Need pain relievers -NO NSAIDS (advil, naproxin sodium, motrin) -Can have tylenol Neurogenic Diabetes Insipidus assessment(correct ANS) - -Very high urine output, very dilute -Monitor sodium *Monitor osmolarity and osmolality: abnormal means its dilute urine -Mostly from trauma to hypothalamus Emphysema treatment(correct ANS) - -Sit pt up in bed -Pursed lip breathing doesn't make the pt work less-Need to rest...might need bipap Trouble shooting for pulse ox(correct ANS) - -Warm up the extremity -Change site: nose, toes, earlobes Trouble shooting for BP machine(correct ANS) - -Get a different machine! Herpes Zoster(correct ANS) - -Rash along the nerves of the side of the body (usually one side) -Very painful Herpes Zoster treatment(correct ANS) - -Try to stop the replication of the virus; can still have symptoms -Pain meds throughout: narcotics Wernicke's syndrome(correct ANS) - -Common in alcoholics -Sx: confusion, memory loss, ataxia, nystagmus, ptosis, abnormal gait Degenerative Joint Disease(correct ANS) - -Assess kidney function before giving pain meds -Assess pain -Pain meds: NSAIDS (motrin, aspirin, naproxin sodium) are better for inflammation -Nonpharmacological measures: ice, rest, warm compresses Assessing radial and pedal pulses(correct ANS) - -If you can't find a pulse, use doppler ultrasound; keep looking! -Don't take pulse at same time as BP -Compare pulses bilaterally Influences on blood sugar levels(correct ANS) - -Illness/infection: check glucose more frequently -Check sugar levels before/after meals and at night -Exercise can decrease sugar: monitor before Palliative care patient care(correct ANS) - -Goal: improve quality of life, caring not curing -Still treat symptoms like pain/whatever impacts QOL -Still take meds for managing problemsHerniated disc(correct ANS) - -Thorough pain assessment -Assess quality of pain -Radiating pain and numbness bc the bulge is pressing on nerves Teaching points for multiple sclerosis(correct ANS) - -Need more rest periods -They will have periods of exacerbation -Be aware of triggers: infection, trauma, immunization, childbirth, stress, change in climate Neuropathic pain(correct ANS) - -Numbing, burning, shooting, stabbing, sharp pain -Caused by trauma, inflammation, infection (herpes zoster, HIV), diabetes -Get a good pain assessment Treatment for anaphylaxis(correct ANS) - -Need meds! -1st: epinepherine for emergent anaphylaxis; can be given IM, SubQ, IV -Benedryl -H2 blocker to stop histamine release Decorticate posturing(correct ANS) - -Flexing towards core -3 on GCS -Indicates brain injury Decerebrate posturing(correct ANS) - -Extension of extremities -2 on GCS (worse than decorticate) -Indicates brain injury DNR(correct ANS) - -Do not resuscitate -Need a document stating they're DNR, otherwise you're