A hospitalized pt reports to the nurse he has not had a BM in 2 days. Which intervention should the nurse implement first?
Assess the pt's medical record to determine his normal bowel pattern
A pt who has COPD is resting in a semi-Fowler's position with O2 at 2L/min NC. The pt develops dyspne...
a hospitalized pt reports to the nurse he has not had a bm in 2 days which intervention should the nurse implement first
a pt who has copd is resting i
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HESI NURSING EXIT EXAM
A hospitalized pt reports to the nurse he has not had a BM in 2 days. Which intervention
should the nurse implement first? - Answer Assess the pt's medical record to determine
his normal bowel pattern
A pt who has COPD is resting in a semi-Fowler's position with O2 at 2L/min NC. The pt
develops dyspnea. What action should the RN take first? - Answer Raise the HOB
higher
A pt who has hyperparathyroidism is scheduled to receive a prescribed dose of oral
phosphate. The RN notes that the pt's serum calcium level is 12.5 mg/dL. What action
should the nurse take? - Answer Administer the dose of oral phosphate (to counter the
hypercalcemia)
In completing a pt's preoperative routine, the RN finds that the consent has not been
signed. The pt begins to ask more questions about the medical procedure. What action
should the nurse take next? - Answer Inform the HCP that the pt has additional
questions about the surgery
Complementary and Alternative therapy (CAM) includes the use of? - Answer Culture,
herbals, yoga, acupressure, acupuncture, reiki, and aromatherapy
What OTCs can cause bleeding? - Answer ASA, ginko biloba, Vitamin E
What are the post-partum daily caloric increases? - Answer Post-partum, 300 calories
extra daily; Post-partum & breatfeeding, 500 calories extra daily
Regarding ABXs, after the 1st 2 doses, what should be done? One hour later? - Answer
Redraw blood to determine Trough; RE-draw blood to determine Peak
List of Teratogenic medications - Answer Ibuprofen, Alcohol, Nicotine, Warfarin,
Falidemide, Accutane, Tylenol
List of Vesicants - Answer Chemo, Dopamine, Dobutamine; any Med whose pH is 9 or
better is considered a Vesicant
Scope of Practice for an LPN - Answer can assess wounds, perform wound dressing
changes, administer PO, Nasal, SQ, IM & transdermal meds; SVN therapy; BUT cannot
do VANCO
The UAP reports to a staff nurse that a pt who had surgery 4 hours ago has had a dec
in BP from 150/80 to 110/70 in the past hour. The nurse advises the UAP to check the
pt's dressing for excess drainage & report the findings to the nurse. Which factor is most
,important to consider when assessing the legal ramifications of this situation? - Answer
The parameters of the State's or Province's Nurse Practice Act
An awake & alert pt with impending pulmonary edema is brought to the ED. The pt
provides the nurse with a copy of a living will stating "no invasive medical procedures
should be used to keep me alive." The healthcare team is questioning whether the pt
should be intubated. What info should guide the team's decision? - Answer The pt is
awake & alert, which makes the living will irrelevant & non-binding
A family member of a pt who is in a Posey vest restraint asks why the restraint was
applied. How should the nurse respond? - Answer The pt's previous actions place her at
a high risk for harming herself & others.
What nursing action has the highest priority when admitting a pt to a psychiatric unit on
an involuntary basis? - Answer Determine the behaviors that resulted in the need for the
pt's admission; i.e., danger to self or others
Informed consent must meet the following criteria: - Answer +pt is competent & of legal
age
+legal sexual age is 13
+the pt understands the procedure, risks & benefits, & alternative procedures
+the RN is witnessing the signature
+all questions the pt has about the procedure are the responsibility of the HCP who will
perform the procedure
The nurse enters the room of a preoperative pt to obtain the pt's signature on the
surgical consent form. Which question is most important to ask the pt? - Answer Have
you received any preoperative pain medication?
Which assignment should the nurse delegate to a UAP in an acute care setting? -
Answer Taking VS for an older pt with left humeral & left tibial fractures
The charge nurse confronts a staff nurse whose behavior has been resentful & negative
since a change in unit policy was announced. The staff nurse states, "Don't blame me;
nobody likes this idea." What is the charge nurse's priority action? - Answer Encourage
the nurse to be accountable for her own behavior
The charge nurse is making assignments for each of 4 staff members, including an RN,
an LPN, & 2 UAPs. Which task is best assigned to the LPN? - Answer Perform sterile
wound irrigation
Which situation warrants a variance (incident) report by the nurse? - Answer Pt A
received medication prescribed for Pt B
, A nurse is preparing for a change of shift. Which action by the RN is characteristic of
ineffective handoff communication? - Answer During rounds, the nurse talks about the
problem the UAP created by not performing a fingerstick blood glucose
The nurse is planning pt assignments for the shift. The care team includes an RN, an
LPN,& a UAP. Which pts could be assigned to the LPN? - Answer +A pt scheduled for a
STAT X-ray after a fall on his hip
+A pt with a pressure ulcer who was prescribed negative pressure care (wound VAC)
A charge nurse is making assignments for 5 pts; The nursing team has an RN, an LPN,
and 2 UAPs. Which pts would be assigned to the RN? - Answer +A pt from the previous
shift with unstable angina
+A cardiotomy pt who is day 2 Post-op & has chest tubes
A 72-yo pt returned from surgery 6 hours ago. The pt received hydromorphone 2 mg IV
30 minutes ago for a pain rating of 8/10. A family member requested that her father be
checked immediately. Upon arrival to the pt's room, you find the pt difficult to arouse, &
a RR = 6. What is the priority nursing action? - Answer Administer Naloxone 0.4 mg IVP
A nurse auscultates the abdomen of a pt who is 48 hours Post-op & finds hypoactive
BS. The pt states he is nauseous. The nurse knows the pt might be experiencing a
____________________ _____________ - Answer paralytic ileus
In the pt's Pre-op interview & assessment, what would the nurse be most concerned
with? - Answer +pt did not adhere to NPO orders
+pt took his OTCs that morning which included ASA and Vitamin E
+pt did not sign the surgical consent form
+pt does not know his allergies
How should a nurse assess a pt immediately Post-op? - Answer +1st PULMONARY
+2nd VTEs
+3rd Bowel Sounds
+4th CHK Foley
+5th CHK Wound for dehiscence or evisceration
+Upon awakening Assess pt's PAIN level
+Monitor for s/sx of SHOCK
The nurse's Pre-operative teaching to a pt about to undergo surgery would include? -
Answer +Pre-op checklist
+diet restrictions
+specific pre-procedure prep
+cough/deep breathe
+incentive spirometer
+turning
+SCDs
+methods of pain control
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