Summary HESI PRACTICE TEST STUDY GUIDE (MED-SURG / NCLEX-RN)
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Course
Hesi med surg study
Institution
Hesi Med Surg Study
Preparing for your HESI exam? Studying for this exam can be overwhelming, especially if you do not know what you should be studying. Check out our HESI study guide to get a start on your exam preparation (MED-SURG / NCLEX-RN). Please use this guide as such, a guide however remember to utilize the b...
HESI PRACTICE TEST STUDY GUIDE
(MED-SURG / NCLEX-RN)
Delegation
If giving to LVN/LPN or other nurse that is floating or not critical care-give nurse the most
STABLE client.
Center of Gravity-
Older individuals’ center of gravity is the upper torso.
Adults- hips
ABC’s
▪ Airway, Breathing, Circulation
▪ (CAB)- compression, airway, breathing
▪ Provide if unwitnessed cardiac arrest occurs.
▪ If unconscious- begin with circulation, airway, breathing; begin CPR.
▪ 30:2 with partner
▪ 15:2 alone
▪ Place hands at lower half of sternum; above xiphoid process
▪ Reposition head to validate proper position to open airway if chest is not moving
▪ When carotid pulse is felt, there is return of cardiac function, with return of
breathing
• Signs of effective tissue perfusion should be noticed
Preoperative-
• Nurses role is to educate/advocate, reduce anxiety, Ensure consent has been signed within
past 24 hours (valid for 45 days)
• Teaching/Learning- outcome is best when demonstrated and not only verbalized; returned
demonstration is best method.
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• KNOW ALLERGIES, OTC, herbal meds
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, • Know any issues with previous surgical experiences
• Know about person’s culture
• Often no blood transfusions for Jehovah’s Witness
• Often NPO after midnight; clear liquids sometimes allowed up to 6 hrs. before surgery
o If client does not follow, surgery will be rescheduled
• Ensure client is both emotionally and physically prepared for surgery
Surgical Risk Factors-
• Age-young and old
• Nutrition- obese and malnutrition
• Fluid/Electrolyte-dehydration/hypovolemia
• Infection
• Cardiac conditions
• Blood coagulation disorders
• URI/COPD- exacerbated by general anesthesia
• Renal disease- impairs F/E balance
• Uncontrolled DM- infection & delayed healing
• Liver disease- inability to detoxify meds
Meds that increase risk:
• Anticoagulants- increases bleeding
• Tranquilizers- hypotension
• Heroin- decreased CNS response
• Antibiotics- may be incompatible with anesthesia
• Diuretics- may cause electrolyte imbalance
• Steroids
• OTC herbal meds-
o THINK THREE G’s: ginseng, garlic, gingko- increase bleeding
o Fish oil, dong quai, feverfew- increase bleeding
o Prolong anesthesia- kava, Valerian, St. John’s (also interacts with EVERYTHING)
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,Postoperative-
Immediate Care:
▪ VS- BP, pulse, respirations
o Especially if client has slurred speech- may indicate neuro deficits
o If SOB, may need to intubate
▪ LOC, skin color & condition
▪ Dressing location and condition
▪ IV fluids
▪ Urine output
o Notify HCP if dark and less than 30mL/hr.
▪ Drainage tubes & position
▪ O2 saturation
Monitor for S&S:
▪ Shock/hemorrhage
o Compensatory mechanism is activation of SNS that will increase RR & pulse to
restore BP; constricts arterioles and causes oliguria
o Client will show elevated BP as compensatory mechanism
▪ Narrow pulse pressure
▪ Rapid weak pulse
▪ Cold, moist skin
▪ Increased cap refill
Position client on side to prevent aspiration and to allow client to cough out airway; side rails
should be up.
N/V- suction
▪ When getting out of bed for first time, if client had HOB down, allow client to sit with bed
in high fowlers position.
▪ Help client sit and dangle legs on side of bed.
▪ Place chair at a right angle to bedside.
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▪ Encourage deep breathing prior to standing.
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, Most common complications:
▪ Urinary retention- monitor hydration status and I&O; offer bedpan/commode
▪ Pulmonary problems- assist to turn, cough, and deep breathe Q1-2 hrs. Keep hydrated,
early ambulation, incentive spirometry.
▪ Wound-healing- teach splinting when patient coughs, monitor for S&S of infection,
malnutrition, dehydration→ HIGH PROTEIN DIET
▪ UTI- increase fluids, empty bladder Q4-6 hrs, monitor I&O, avoid catheterization if
possible, remove ASAP
▪ Thrombophlebitis- leg exercises, early ambulation, SCD’s, avoid pressure that may
obstruct venous flow; TO NOT PLACE PILLOWS BENEATH KNEES; avoid crossing
legs at knees; LMWH- lovenox
▪ Decreased GI peristalsis/constipation/Paralytic ileus- NG tubing to decompress GI tract;
client to limit use of narcotics (possibly use stool softeners); encourage ambulation
Wound dehiscence
▪ Patient may feel as if something “gave way”
▪ Observe for serosanguinous drainage
▪ Bowel evisceration- Apply sterile dressing
Gastrointestinal
TPN/Insulin-
ONLY Regular insulin may be given IV. If any other type of insulin is added to a mixture, it must
be returned to the pharmacy and should NEVER be used.
▪ The most important lab value to monitor when administering TPN is glucose.
▪ They contain high levels of glucose and sugar should be monitored as often as Q6H.
▪ Monitor fluid and electrolytes
Diabetes Mellitus
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▪ Insulin- Assess willingness of client to learn injection sites when newly diagnosed
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▪ Monitor clients for issues related to osmotic diuresis from elevated glucose levels
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