Milestone 1 - Exam Study Guide - Hesi questions and answers(already passed)
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Course
HESI MILESTONE
Institution
HESI MILESTONE
Eye drop admin
-Administer medication safely and appropriately,
-Avoid cornea,
-Never touch eye or eye lid with administration device,
-Pressure to lacrimal duct after giving medications,
-Inner to outer canthus
Enema Patient Preparation
-Explain the purpose
-A reclining position for ...
Milestone 1 - Exam Study Guide -
Hesi questions and
answers(already passed)
Eye drop admin - answer -Administer medication safely and
appropriately,
-Avoid cornea,
-Never touch eye or eye lid with administration device,
-Pressure to lacrimal duct after giving medications,
-Inner to outer canthus
Enema Patient Preparation - answer -Explain the purpose
-A reclining position for enema administration
-Specifically left side-lying with the upper thigh pulled toward the
abdomen if possible, or the knee-chest position
-If the patient has a respiratory disorder or is having difficulty
breathing, elevate the head of the bed slightly.
-Avoid Fowler's position because the solution will remain in the
rectum and expulsion will occur rapidly, resulting in minimal
cleansing.
-Some patients think the solution should be expelled as soon as
possible. Reinforce the need to retain the solution to achieve the
desired results.
Residual Urine - answer urine that remains in the bladder after
voiding
Ambulation Tolerance - answer The ability to the act, action, or an
instance of moving about or walking
Wheelchair Transfer CVA - answer Bedside to Wheelchair
,1) Support pt.'s weakest side
2) Turn pt. to a decubitus position
3) Place one arm under neck & other over the legs
4) "Swoop" pt. into sitting position
5) Straddle pt.'s legs
6) Put hands on pt.'s hips
7) Lift & pivot into the wheelchair
Wheelchair Safety - answer -Check wheel locks;
-Check for flat or loose tires; Check wheel spokes;
-Be sure casters point forward for balance and stability;
- Be sure person's feet are on footplates before pushing or
repositioning (feet cannot touch or drag on floor);
-Push chair forward when transporting person, going backward
ONLY through a doorway;
-Lock both wheels before you transfer person to or from the
wheelchair;
- Follow care plan for keeping wheels locked when not mving
wheelchair (locking would keep person from moving or getting out
of chair is so desired);
-DO NOT let person stand on footplates;
-DO NOT let footplates fall back onto person's legs;
-Make sure person has needed safety belt, pouch, tray, lapboard or
cushions;
-Remove armrests (if able) when transferring person to bed, toilet,
commode, tub, or car;
-Swing front rigging out of way to transfer to & from wheelchair
(some detach);
- Clean wheelchair according to agency policy;
,-Ask nurse or PT to show you how to propel wheelchair up steps,
ramps, and over curbs; ---Follow measure to prevent equipment
accidents
Droplet precautions - answer -Use a private room, if available. Door
may remain open.
-Wear PPE upon entry into the room for all interactions that may
involve contact with the patient and potentially contaminated areas
in the patient's environment.
-Transport patient out of room only when necessary and place a
surgical mask on the patient if possible.
-Keep visitors three ft from the infected person.
Restraints - answer -are devices that limit the patient's movement
and are used to prevent the client from injury
-RN is to protect and promote the patient's rights while in them
-Need MD order and frequent monitoring by RN
-Every 15 minutes (q15m) for the first hour, then every 30 minutes
(q30m) to ensure proper circulation.
-Removed every 2 hours (q2h) for range of motion, toileting, and
offer of fluids.
-Written order by provider based on exam before applied, no PRN
orders, minimum q4 hour assessment for adults, MD assessment
face-to-face q 24 hours, Reportable if death during use w/I 24 hours
Side Rails Restraints - answer -not considered a restraint if the
patient requests that it be raised to be able to get in and out of bed.
, -They have to be able to demonstrate that they can raise and lower
the side rail by themselves
-Usually in the hospital setting 4 side rails is considered a restraint
-can pose serious risks for a confused or agitated patient.
Entanglement or injury, asphyxiation and can be fatal.
Saline Flush - answer prefilled syringe with 10 mL 0.9% sodium
chloride (NS)
Braden Scale - answer -Sensory perception, moisture, activity,
mobility, nutrition, friction and shear
-The higher the number the greater the risk
Fats - answer 9 cals per gram
Alchohol - answer 7 cals per gram
Protein - answer 4 cals per gram
Carbs/Starch - answer 4 cals per gram
Sugars - answer 4 cals per gram
Nutrition Assessment Calorie counts - answer Records portion size
patient consumes - RN; Does not rely on memory
Nutrition Assessment 24 hr call method - answer structured
interview where patient recalls food and drink in last 24 hours, can
be self administered
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