HESI Foundations Exam Complete Verified Solution 2023
Rectal Temp
Insert lubricated thermometer probe(w/cover) into rectum 1-1.5in toward umbilicus; reading is usually 0.9F greater than oral temp
Axillary Temp
Place thermometer probe in center of axilla; have pt place arm across chest; readin...
HESI Foundations Exam Complete Verified
Solution 2023
Rectal Temp
Insert lubricated thermometer probe(w/cover) into rectum 1-1.5in toward umbilicus;
reading is usually 0.9F greater than oral temp
Axillary Temp
Place thermometer probe in center of axilla; have pt place arm across chest; reading is
usually 0.9F lower than oral temp
Orthostatic BP readings
Orthostatic hypotension aka postural hypotension; obtain supine, sitting, & standing(1-3
min between each); observe pt for dizziness, fainting, lightheadedness; record pts
position with each reading; DO NOT DELEGATE
Exercise & Sleep
Exercise 2hrs before bedtime; allows cool down period and fatigue that promotes
relaxation
Soaking Feet
Part of routine pt hygiene; DO NOT soak feet of pts with diabetes or other peripheral
vascular disorders. Can delegate to NAP, but NAP CANNOT trim nails; Soak feet for
10-20 min in warm water, rewarm water after 10min; Nurse can trim nails using clippers,
straight across and even with fingertips; DO NOT trim in pts with circulatory problems;
Dry thoroughly, apply lotion.
Indwelling Catheter
Ambulation; never raise drainage bag above level of bladder; prior to ambulation, drain
all urine from tubing into drainage bag
False-low readings on BP cuff
cuff to wide, arm above heart level
False-high readings on BP cuff
cuff to narrow/short, cuff to loose or uneven, arm not supported
False-high diastolic readings on BP cuff
deflating cuff to slowly, inflating to slowly
Normal vitals
RR: 12-20
BP:<120/<80
HR: 60-100
Temp: 98.6F or 37C
Pulse Defecit
Assess radial and apical pulses simultaneously. The pulse defecit is the difference
between the two due to an inefficient contraction of the heart that fails to transmit a
pulse wave to peripheral pulse sites
Hygiene-self care defecit
results from side effects of medication, lack of knowledge, immobilization, an inability to
perform hygiene,, or physical condition that potentially injures the skin, mouth, feet, nails
or hair.
Hygiene Assessment
, include patient's muscle strength, flexibility, balance, visual acuity, and ability to detect
thermal and tactile stimuli, metal status, activity tolerance(RR, skin color, pulse)
Applying TED hose(antiembolitic stockings)
1. Obtain order from MD
2. Measure leg
3. Explain to patient
4. Hand hygiene
5. Supine position
6.Turn elastic inside out up to heal, pull over feet, pull all the way up calf, making sure
there are no wrinkles.
7. Remove them at least once per shift
8. Observe circulatory status of lower extremities; color temperature, and condition of
skin, palpate pedal pulses.
Ostomy Care Patient Teaching
Provide pt with supplies to last 1-2 weeks, with info on closet supply company; show
them step by step for changing pouch; provide at lease one chance for pt to change
pouch while in hospital; arrange visits from community stoma care nurse; provide
detailed discharge instructions for skin care, clothing, driving, lifting, resuming exercise,
when to contact MD
Bowel Training
Assess normal elimination patter; choose a time in t patients pattern to initiate
defecation control measures; give stool softeners every day at least 30 min prior to
selected time; offer a hot drink( hot tea) or juice (prune juice) or whatever fluid that
stimulates peristalsis for pt; help pt to toilet at time; avoid meds that can constipate;
provide privacy and set time frame for 15-20 mins for defecation; have pt lean forward
at thips while sitting on toilet, apply manual pressure with hands over abdomen, and
bear down but not strain to stimulate emptying; do not criticize or convey frustration if pt
can't defecate; maintain normal exercise within pt ability
Bowel Retraining in Elderly
Coarse bran rather than refined fiber is more effective in increasing stool weight; a
minimum of 1500mL of fluid per day reduces risk of constipation; if holding a cup is to
much, give smaller lighter cup, fill frequently; fruit juices increase fiber content and
fluids; encourage regular exercise; pt needs to feel at ease during elimination(give
privacy); review all meds, look for alternatives to constipating meds; behavioral
interventions such as habit training provide relief of constipation. Have patient sit on
toilet about 30 min after a meal, whether they have to defecate or not.
Risk for Falls
Assessment should be done during admission, following a change in patient condition,
after a fall, and when transferred; if pt is found to be risk, regular assessment always
continues; Age, fall history, bowel and urine elimination, meds, patient care
equipment(IV's, catheters, chest tubes), mobility, cognition MODERATE RISK: 6-13
points, HIGH RISK: >13 points
Ambulation
Assess pts activity tolerance, strength, VS, balance, orientation and need for
assistance, grimacing while ambulating; Assess for orthostaticVS(have pt dangle legs
on side of bed 1-2 min prior to rising if needed) to promote safety; evaluate
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller LectDan. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $11.49. You're not tied to anything after your purchase.
