Exit HESI Version 1, 2,3 Exam latest updated

Exit HESI Version 1 what do you screen for on a newborn baby? - ANSWER hypothyroidism check T4 level (decreased) what would the potassium level be in a pt with diabetes insipidus? - ANSWER hypokalemia what is an ...

Exit HESI Version 1 what do you screen for on a newborn baby? - ANSWER hypothyroidism check T4 level (decreased) what would the potassium level be in a pt with diabetes insipidus? - ANSWER hypokalemia what is an expected side effect of Solu-Medrol? - ANSWER bleeding, bruising what does Pilocarpine treat? - ANSWER glaucoma antidote is atropine sulfate may get a dry mouth TPN - ANSWER 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? - ANSWER phentolamine (Regitine)- it's a vasodilator and will increase blood flow to the area to prevent necrosis what diet would be chosen for a pt with CKD? - ANSWER bread & cream of wheat FIRST action for late decels? - ANSWER give O2 what do you give a premature infant with RDS? - ANSWER surfactant betamethasone (Celestone) stimulates surfactant production in alveolar space causing less tension when infant breaths- given IM to mother in preterm labor FIRST action for a newborn choking? - ANSWER aspirate what would you teach a client about getting pregnant who just received a Rubella vaccine? - ANSWER don't get pregnant for 3 months pt receiving a blood transfusion develops fluid volume excess and dyspnea, what do you do? - ANSWER increase O2 a pt returns from TURP surgery, what can the RN delegate? - ANSWER weigh daily I&O's- subtract irrigate from output kegal exercises for temporary incontinence what can be delegated to a nursing assistant or UAP? - ANSWER can discontinue suction, but cannot turn back on grooming & hygiene feeding VS ROM I&O's obtain clean urine specimen transport client transfer from bed to chair; help with bed to stretcher help with turning and repositioning ambulate what can be delegated to a LPN? - ANSWER PO meds and injections routine data collection, dressing change, catheter insertion, suctioning reinforce teaching; basic, simple teaching (turn, cough, deep breath) assist HCP in procedures when RN is unavailable (NGT insertion) can perform specific tasks in unstable situations what can the RN not delegate? - ANSWER assessment, diagnose, analyze, plan, evaluate, teach, monitor receive and give report triage invasive lines sterile technique new admissions pre-op & post-op assessment what should you be monitoring in a client who has had a nephrectomy? - ANSWER UOP it is more important than drainage what is important when caring for pt in skeletal traction? - ANSWER pin care; sterile technique; remove crust; serous drainage is ok what do you do if the pins come out of someone with skeletal traction? - ANSWER immobilize extremity do not re-insert how do you deal with a rude doctor that is avoided by the nurses? - ANSWER staff meeting what are some diet recommendations for a client with anorexia who has become hypoglycemic? - ANSWER simple sugars- milk, coke, juice, raisins once sugar is up, eat complex carbs & protein- PB and crackers low fat, high calorie, high protein what would you teach a pt taking disulfiram (Antabuse)? - ANSWER must sign consent form stating they will avoid all alcohol many preparations contain alcohol- cough syrup, mouthwash, aftershave, cologne what is confrontation? - ANSWER calling attention to inconsistent behaviors what is reflecting? - ANSWER paraphrasing or repeating what client said if a manic client is monopolizing group therapy what do you do? - ANSWER tell them to stop talking and try to listen to others tell them to take a walk with you how do you communicate with a client who has disordered thinking about food being poisoned? - ANSWER open-ended questions & silence what client would most likely be experiencing delirium? - ANSWER a client with constant pain or insomnia how would you reduce anxiety in a client who is OCD? - ANSWER allow them time to finish their ritual and then talk about it what is the priority for a depressed client who has not slept? - ANSWER sleep a client who is bipolar is going home for the weekend to adjust for discharge. what do you tell the family? - ANSWER continue normal daily activities how do you position a client with an air embolism? - ANSWER trendelenburg (HOB down) what do you do for a client with absent lung sounds? - ANSWER check pulse, if no pulse- perform CPR if they have a pulse perform rescue breaths- 1 every 6-8secs if a client has a pulse with absent breath sounds on the left side what do you do? - ANSWER prepare to reposition ETT what do you suspect in a child with an irregular pulse? - ANSWER Kawasaki disease what do you monitor for in adrenal insufficiency (no steroids)? - ANSWER shock hyperkalemia increase sodium in diet what do you monitor for in addisonian crisis? - ANSWER severe hypotension hypoglycemia if a client suddenly withdraws from steroids what do you do? - ANSWER check VS what do you teach a client taking prednisone? - ANSWER monitor for hyperglycemia take in morning what do you teach a client with DM2? - ANSWER monitor blood sugar where do you give an immunization to a peds client? - ANSWER vastus lateralis you are caring for a client with AIDS and you accidentally stick yourself with a sterile needle. what do you do? - ANSWER go get a new needle- no need to report what are s/s of hypocalcemia? - ANSWER rigid & tight muscles DTRs increase stridor trouble swallowing arrythmias + Chovestek's and Trousseau's sign seizures mental changes how do you check serum sodium? - ANSWER check osmolality what do you teach a pt taking an antipyretic for and increased temp? - ANSWER give with fluids because fever can cause dehydration what is suspected if there is an increase in serosanguineous drainage? - ANSWER dehiscence what is a client at risk for who has a fractured femur? - ANSWER fat embolism priority action- stay with client and reposition to relive dyspnea what would you expect in a client with an epidural hematoma? - ANSWER temporary loss of consciousness, followed by a lucid period, and then gradually leading to coma what would you tell a client on chemo or on a neutropenic diet? - ANSWER can't eat anything raw fruits, vegetables, honey, etc. for maximum effectiveness, what should older clients use for dry skin? - ANSWER petroleum based ointment how do you communicate with an AIDS client that is anxious and reluctant to ask questions? - ANSWER discuss common fears and questions expressed by other clients with the same diagnosis on a breast exam, what finding would you report? - ANSWER dimpling clients with multiple sex partners and STDs are at risk for what? - ANSWER prostate cancer teach them importance of early detection with screening what are signs of pain in an infant? - ANSWER grimacing tachycardia restlessness irritability difficulty feeding/sleeping increased RR diaphoresis decreased O2 levels what is priority for a client with renal lithiasis? - ANSWER address pain- these pts get pain meds immediately (don't teach important of straining urine- that's RNs job) what is suspected in a pediatric client with severe edema? - ANSWER nephrotic syndrome what do you do for a pt on Amph B? - ANSWER monitor UOP- it's nephrotoxic what is the priority assessment in a client who has lost a tooth and has an eye injury? - ANSWER check pupils what is suspected in a client who is hypoventilating? - ANSWER increased CO2 decreased O2 decreased LOC pH is acidic what is the plan of care goal for a client with COPD? - ANSWER decrease risk of infection where should the level of water be in the water seal chamber? - ANSWER at 2cm where should the level of water be in the suction control chamber? - ANSWER at 20cm how do you evaluate the knowledge of cataracts and hearing in a geriatric client with lens implants? - ANSWER simple gestures & repetition how does a client present with DM2? - ANSWER usually come back to doctor for wounds that won't heal or vaginal infections don't have enough insulin insulin doesn't work what do you do when caring for a client that is in 4 restraints? - ANSWER check every 15 minutes nutrition, hydration, elimination circulation what should a client with an h.pylori infection get screened for? - ANSWER stomach ulcers stomach cancer how would a pediatric client with asthma present? - ANSWER prolonged expiratory wheezing cough inflammation and constriction of airways resulting in obstruction a client in hypovolemic shock would present with what? - ANSWER weak thready pulse TB precautions - ANSWER negative pressure room N95 respirator mask airborne precautions MRSA precautions - ANSWER gloves gown mask and goggle if possible splashing or spraying of secretions, excretions, body fluids, blood contact & standard precautions how would you teach someone to use an inhaler? - ANSWER 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 degree burn would present with leathery eschar and slough? - ANSWER full-thickness partial thickness client with 60% burns who has a fever, increased RR and TPN infusing. what is your initial action? - ANSWER check patient for signs of infection what is the appropriate action for a burn client in the emergent phase whose UOP and BP are dropping? - ANSWER immediately call the HCP what do you monitor for in a client with HHS and DKA with insulin drip? - ANSWER hypokalemia U wave what is priority discharge teaching for a client with HHS? - ANSWER monitor for signs of dehydration how would a person present who is having alcohol withdrawals? - ANSWER tremors nervous nausea hyperactive nightmares disorientation hallucinations increased pulse increased BP seizures how would you care for a patient who has attempted suicide? - ANSWER safe environment is priority- safe-proof room contract for safety and renew direct, closed ended statements re-channel anger through exercise what activity would you choose for a person who attempting suicide? - ANSWER punching bag choose most exerting answer what would you teach a client on peritoneal dialysis about self care? - ANSWER 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? - ANSWER peptic ulcer stomach cancer what medications do you give with coffee ground emesis? - ANSWER 'prazole (proton pump inhibitors) 'tidine (h2 antagonist) antacids mylanta carafate how do you prevent ICP? - ANSWER maintain oxygenation- decreased O2 can increase ICP maintain CO2 30-35- increased CO2 can increase ICP keep CSP <100 what is the G&D of a toddler? - ANSWER 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 normal dependency on security items (blanket) what is suspected in a pediatric client with croup and how do you treat? - ANSWER 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? - ANSWER bleeding and hemorrhage how do you care for a client who has had a knee arthroplasty? - ANSWER continuous passive motion- keeps knee in motion and prevents formation of scar tissue PT sets machine to gradually increase flexion and extension never hyperextend or hyper flex the knee address pain- or they will not participate in activities in a client with myasthenia gravis, how do you know if Mestinon has been effective? - ANSWER muscle strength improves take before activities such as eating and working how would a client present who has had a contact allergic reaction? - ANSWER pruritis edema erythema vesicles papules crusting and thickening of skin occurs 6-48 hours following exposure what do you instruct the client to do before obtaining a sputum specimen? - ANSWER rinse mouth out obtain in morning how do you care for a hemiparesis client? - ANSWER ambulate encourage independence with ADL's increase mobility as tolerated what do you teach a client with asthma about taking beta agonists? - ANSWER 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 what is the goal in the rehabilitation phase with a burn client? - ANSWER pt gains independence and achieves maximum function provide emotional support how do you communicate with a client who has had a CVA has developed receptive aphasia? - ANSWER picture board- they can't understand spoken or written words left hemisphere what does tadalafil (Cialis) treat? - ANSWER erectile dysfunction BPH pulmonary HTN how do you administer dobutamine IV? - ANSWER dilute in 50ml solution- can cause extravasation started at low doses (0.5-1.0 mcg/kg/min) titrated at intervals of a few minutes not to exceed 40 mcg/kg/min short term what do you monitor for in a client with MI developing cardiogenic shock? - ANSWER ventricular dysrhythmias tachycardia confusion hypotension what do you teach the client taking warfarin (Coumadin)? - ANSWER limit green leafy vegetables bleeding precautions what is a side effect of eptifibatide? - ANSWER bleeding what do you care for after chemo treatment? - ANSWER nausea and vomiting what is the side effect of ondansetron (Zofran)? - ANSWER hives, chest tightness, trouble breathing what is considered a postpartum infection? - ANSWER 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 if family refuses to discuss funeral arrangements what do you do? - ANSWER 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? - ANSWER IV hypotonic solution 0.2% NaCl 0.45% NaCl D5W what do you teach a client with thrombocytopenia? - ANSWER 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? - ANSWER restrict protein intake monitor for hyperkalemia males should get monthly testicular exams starting when? - ANSWER 15 years old to 36 years old what do you monitor for in a client with hypothyroidism? - ANSWER neuro changes slow, deliberate speech what is the peak? - ANSWER highest acting level of drug collected 30min-1hr after administration