HESI V2 2015 Notes.

HESI V2 Final Notes 1. Patient is receiving hospice care and become mottled:  Remove heating pad and place soft blanket 2. Patient is having suicidal thought and suddenly:  Begin to show signs of improvement 3. A young male in a motorcycle accident in a puddle of water:  Stabilize the victim’s neck and roll over to evaluate. 4. Nursing problem best for early Parkinson disease:  Impaired mobility 5. Demonstration of teaching daughter’s eye drop:  Remind the patient to close her eyes after the drop. 6. Nurse assumed care of a postoperative patient with type 2 diabetic mellitus with a glucose level of 750:  Assess for signs of fluid volume deficit. 7. Select all that apply for soft food:  Pasta with a cream sauce  Pancake with syrup  Scramble eggs  Steamed brown rice 8. Unresponsive hyperthyroidism patient:  Notify Health care provider of a positive Chvoteck’s sign 9. RN Gave medication to patient and patient had an adverse reaction. Place in order.  Stop infusion  Assess vital  Contact HCP  Document  Initiate report 10. Young boy with chronic vegetative and the mother wants to take the patient home:  Determine the mother’s basic skills 11. Patient is 41 weeks of gestation what finding should the nurse report:  Fetal heart rate located in the upper quadrant 12. Patient is 34 weeks of gestation with a slight increased level of T4 what needs to be report immediately:  Hematocrit level of 28 13. A male client is taking ferrous docusate with no bowel movement in 3 days:  The addition of a laxative to the current regimen 14. Client with PKD is receiving antibiotic is experience severe pain:  Teach the client on how to use dry heating pad on the site. 15. Diabetic patient:  If patient has someone available who can prepare food and oversee his diet. 16. UAP left the patient’s bed in the highest position and sides down: Both side rails should be raised 17. A 4 year old patient fell of a tricycle how does the RN get him to cooperate while doing the assessment?  While doing the assessment ask the child to blow of penlight to activate it 18. Diabetic insipidus:  Hypernatremia 19. Proper placement of AED pad (Picture)  Right pad which goes above the right nipple line, so the left one goes below the left nipple line 20. Picture of an adolescent taking albuterol for asthma:  Ask the patient if he has an extension 21. Confused patient took off dressing on abdomen:  Re-do the dressing first 22. New UAP:  Observed the UAP job performance 23. Who should the Nurse see first:  The child with stridor 24. Patient is in hurry to get the exam done and seems angry:  Nurse should tell the patient that “you seem angry, tell me more about it” 25. Patient with type A+ can receive blood from:  O+ 26. Patient in intermittent compression devises.  Nurse observes lower extremity redness and swelling. 27. Patient in confused and keeps trying to get out of bed but needs help ambulating. What does nurse implement?  Bed alarm. 28. Patient with heart failure HF, what does nurse do?  Assess lung fields for crackles. 29. Bipolar man too busy to eat, showers, or sleep because he is starting up a new business. He is alert to name, place, time date but not his situation.  He is at risk for imbalanced nutrition. 30. Patient on clonidine.  Nurse is concerned about BP 90/76 because it is contraindicated. 31. Toddler receiving OS via face mask and has cracked lips and nose.  Put water soluble lubricant on child. 32. The drug class that cure septic shock?  Antiinfectives 33. A sign that Dilantin is therapeutic?  Absence of seizure activity. 34. Pregnant mom in labor got Hemabate administered what RN to do? RN to give an antiemetic 35. Patient on a mechanical ventilator what indicates that they have open airways.  Bilateral breath sounds. 36. Risk of Coumadin therapy. Select all that apply:  OTC Herbs, gums bleeding, and limit food that interacts with drug. 37. A group of 18 year old with type II diabetes. How do you teach them?  Watch a video presentation and a BGM or actual demonstration. 38. Patient has a liver transplant.  The nurse needs to monitor temperature. 39. Patient with diabetes mellitus has a temp 101.6 fasting glucose of 325?  Monitor blood glucose level more frequently. 40. UAP taking care of a client with OSAS.  Nurse should confirm that UAP put the call bottom within reach. 41. Partial thickness burn on neck. What do you have patient do to prevent muscle contracture?  Have patient actively turn head 90 degrees every hour. 42. What does nurse does for a patient in hypovolemic shock and is receiving RBC’s?  Increase O2 via nasal cannula if dyspnea is present. 43. A female who smokes 2 packs a day for 50 years  Multi organ disease syndrome MODS 44. Female who is 24 weeks gestation has been coughing for 5 days.  Put her in a private room. 45. A female patient’s blood is A-positive. What type of blood can she receive?  AB, Rh positive. 46. A patient is on Haldol and begins to exhibit uncontrolled facial movements and darting eyes.  The nurse should hold the next dose and report to HCP. 47. Mom tells the nurse that her daughter does not have nearly the ear aches that her older daughter had.  The nurse explains that the HIB or Hepatitis B vaccination is responsible. 48. DIC  D-Dimer 49. Patient in with an asthma attack and ABG’s are pH 7.22 PaCO2 55, HCO3 25?  Administer albuterol. 50. CVC central venous  Use 2nd port for n/s 51. Acute pancreatitis?  Withhold food 52. Child with cystic fibrosis?  Chest physiotherapy 2x/day before meal 53. Lupus Erythematosus?  BP 170/9854. Elderly women fell and broke hip?  Urine output related to total fluid intake. 55. Chronic pain patient?  Something about mirror therapy helps with reducing pain 56. Incentive Spirometer  Cough when finish 57. Kids want the nurse to force their mom whom is refusing her meds to take them, so the nurse should go in the room and?  Nurse will go in to find out why she don’t want meds and treatment and offer her trial drugs 58. Restraints and where and how you would tie them?  Bed frame with a quick release knot 59. Mom gives baby a dose of digoxin and baby vomits?  Don’t let mom give the next dose. (Hold Digoxin) 60. A younger patient with HYPOGLYCEMIA how do you know when the parents have an understanding of the s/s?  Diaphoresis (sweating) that is the answer! 61. Glaucoma  Eye drops are needed for the rest of their life (Take all the time) 62. Family brings patient in the ER who had multiple TIA's what should RN do?  Call the stroke team 63. Emotional status of someone with Parkinson’s  Someone who is crying frequently 64. Emphysema  Pink Puffer 65. Patient is talking about his mom dying 50 years ago, and his urine is pink and frothy. What is going on with this patient?  Patient has Delirium 66. Patient gained 4lbs in 3 days (Rapid weight gain)  RN should listen to lungs 67. HOT SPOT. Picture of a pediatric patient in a 90/90 femoral traction how would you assess for compartment syndrome?  Put hot spot on toes 68. The parents of a 6 year old recently diagnosed with Duchene muscular dystrophy tell the nurse that their child wants to continue swimming classes. How should the nurse respond?  Encourage parents to allow child to continue attending swimming lessons with supervision. 69. An elderly male client tells the nurse that he often wakes during the night. What action should the nurse implement first?  Ask the client to describe what happens when he awakens70. Before placing a client’s dentures in the sink for cleansing, what action should the nurse take?  Place a washcloth in the bottom of the sink 71. The nurse is caring for a client with dysphagia is attempting to insert an NG tube, but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus?  Flex the clients head with chin to the chest and insert 72. School nurse doing secondary prevention  Performing vision and hearing screenings 73. Hand washing is the most important to prevent spread of infection in a hospital. Which statement is true regarding hand washing?  Blocks Pathogens transmission 74. A patient is 24 weeks gestation comes in with body aches, fever, and cough, has been prescribed H1N1 influenza. Which prescription has the highest priority?  Assign patient to a private room 75. MATH. Heparin 25,000 units infusing at 500 ml/hr then order is changed to 900 ml/hr  18 76. MATH. Heparin  14 77. MATH  33 78. MATH  0.75 79. Patient has TB?  RN to question order for Isoniazid because patient has Hepatitis B. 80. Drag and Drop in order question: I’m pretty sure you only needed to swap 1 & 2 1. Place catheter set in between patient 2. Apply sterile gloves, and maintain sterile field 3. Cleanse the Meatus, using that Benodine stuff 4. Lube the catheter tip and then insert 81. The nurse is assessing a 4 year old girl with eczema. Her skin is dry and scaly, and the mother reports that she frequently scratches her skin to the point of causing bleeding. Which guideline is indicated for care of this child?  Keep her nails trimmed and short 82. Picture Questions: Patient lying in bed only shows lower half from where Jackson-Pratt Drain/tube is at and the bulb syringe is full your  You’re going to drain it 83. Indwelling catheter cleaning?  Was wrong because used the same cloth from cleaning the vagina to clean the catheter. 84. RN sees PCA remove glove from cleaning feces? RN to tell PCA her removal was incorrect and her way could spread contamination. 85. Lung Sounds  Low pitched coarse crackles 86. Peptic ulcer disease/GERD  GERD because after patient finishes eating the pain would go away. 87. Pt taking Cardura - if patient gets dizzy and tachy?  RN to monitor BP and HR cause it’s a vasodilator 88. Rn walking patient and patient falls or gets dizzy?  RN to slide patient to the ground 89. Burgers disease?  Keep warm because cold exposure causes pain 90. Chvostek sign?  Hypocalcemia 91. Patient having chest pain and pressure drops  RN to give bolus of NS 92. Patient on saline and TPN but RN have to give antibiotics?  It was to add secondary line to NS and infuse 93. Afib?  Anticoagulants 94. Osteomyelitis how does it occur?  Bone infection or infection 95. Patient neuro problems?  Ask patient to raise arm 96. Voltaren (Diclofenac) – Rash adverse reaction  RN to tell patient 97. Patient cirrhosis of the liver?  Give Lactulose 98. Thyroidectomy?  RN to have intubation kit and calcium gluconate at bedside 99. Possible over dose RN gave a dose of Narcan but still unresponsive and don't response to touch or verbal command?  RN to give another dose of Narcan 100. Patient who had ms but college student who called and said they had fever?  Tell them normal