2020V1 Fundamentals - Notes HESI Saunders (Psych101

1. Question about air pressure mattress = those type of bed we don’t put sheets to avoid skin tearing of the patient 2. What nerves we assess when using Snellen chart = optic nerve (II) 3. Nurse assistant tells you abo ...

1. Question about air pressure mattress = those type of bed we don’t put sheets to avoid skin tearing of the patient 2. What nerves we assess when using Snellen chart = optic nerve (II) 3. Nurse assistant tells you about stool characteristics or something, and what would you prioritize = Watery stool (diarrhea) 4. There are two patients who are complaining of pain, what you would do first to assist them or something like that = assess their pain first (compare which one is more severe, by describing it) 5. There was a priority question which client do you assist first (remember ABC’s) = she chose the answer that had something to do with breathing- D 6. For adult = pull the ear up and outward 7. When you take care of a patient with Hepatitis A, what do you do? Wear gloves when giving bath 8. The patient has TB and what would you place in biohazard bag before taking it from the room = Sputum sample 9. They said when the person is agnostic (or something) what do we include in care plan = something to do with spirituality 10. Nurse observes nursing assistive personnel giving patient a bed bath and has the patients foot soaked in the basin of water. What should the nurse instruct the nursing assistive personnel to do? Dry the water between the toes (because of skin breakdown) 11. When you catheterization on circumcised patient, what to do? Advance the catheter and inflate the balloon 12. Which position do you apply enema? Left side-lying (Sims’) position with the right knee flexed 13. Elderly patient that needed to have something done, who would you ask consent = daughter in law because she has the consent or whatever 14. A patient has an order for wrist restraint, after putting them on, what do you = check capillary refill 15. When giving medication = make sure you verify the patient identification band 16. When you bathe someone with UTI or something like that, what do you do = put don gloves 17. What is the safe procedure regarding gloves = change gloves before entering another room 18. A patient with a soft bland diet reports constipation you assess the bowel sounds and they are low what do you do? Heat prune juice 19. A patient was admitted for dehydration yesterday, what are signs that the patient is getting hydrated? Pulse 20. A patient has difficulty swallowing, how would you check for the gag reflex? With the tongue depressor touch the back of their tongue/throat 21. A patient is a slight ambulatory patient and is at home and the nurse that checks on him goes and asks her how can he remove the swelling on his feet? Move his feet in bed/ instruct client to flex both of his feet daily something with “dorsiflexion” or whatever 22. Muslim patient is taking dialysis every morning, but would get anxious = Obtain an interpreter to figure out why he is upset 23. A situation where a new nurse that was cleaning a wound, and you had to decide, was he doing it wrong or right = he was right… (it’s supposed to be cleaned from the center (inside) and outwards in circular motion) 24. Patient was having leg cramping = low potassium 25. Which value needs to be reported to the health care provider? Potassium 3.1 26. Clean stream urine collection = colonies of microorganism present in the urine same indicates need for a new urine sample 27. Something about patient teaching to a patient that does not speak English. How should the nurse evaluate that he understands how to clean his wound at home? Have the patient demonstrate his understanding (return demonstration) 28. Patient is practicing diaphragmatic breathing, which is the proper way? Inhale and have the diaphragm “sink in” during exhaling (“sink in” are the main words in answer) 29. Client discharged to long term care facility with an indwelling catheter. What should the nurse do to reduce the risk of infection? Flush the catheter with sterile saline daily. 30. Three different patients are requesting pain meds from the meds at the same time. What should the nurse ask the patients? Rate your pain on a pain scale 31. Client wishes to spend time with her significant other and the deranged husband comes by to visit client and objects to the significant other being there. What should the nurse do? Instruct the multidisciplinary team of the patient’s wish. 32. Cancer patient with stage 4 lung cancer and pain management = around the clock pain med administration. 33. There is another question talking about pain management, but the answer to that one is = PCA pump 34. Some question about obstructive sleep apnea and what the nurse should do before leaving the room? Make sure the positive airway pressure machine is on 35. When you transport a patient with tuberculosis