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 P...
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.
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