lOMoARcPSD|5734770
Foundations review - HESI Fundamentals
Study Guide
mental health (Gwinnett Technical College)
, lOMoARcPSD|5734770
Foundations HESI Review
(from 9th ed. of Foundations text)
Read all of chapters 1 and 2 in HESI book!!! Study this information for ALL HESI exams!
Basic Nursing Skills – Vital Signs – Chapter 30
● BP cuff size (review what happens with wrong cuff size)
o False-high diastolic readings on BP cuf
● Deflating cuf to slowly, inflating to slowly
o False-low readings on BP
▪ Cuf to wide, arm above heart level
o False-high readings on BP
▪ Cuf to narrow/short, cuf to loose or uneven,
arm not supported
Technique for palpating systolic BP
o (When arterial pulsations too weak to detect Korotkoff sounds or to identify auscultatory
gap). Box 30-9, p. 508. Palpate radial pulse. Inflate cuff 30 mmHg above point at which you
can no longer palpate the pulse. Slowly release valve and deflate cuff… See documentation
guidelines, as well.
● Technique for taking BP in the leg –
o Popliteal artery.
▪ SBP usually 10-40 mmHg higher than using brachial.
● DBP remains same. Ch. 30, p. 508.
Orthostatic BP readings –
o orthostatic hypotension also called postural hypotension;
▪ obtain supine, sitting, and standing (1-3 minutes between each);
▪ observe pt. for dizziness, fainting, lightheadedness.
▪ Record pts. position with each reading (remember pt. safety);
▪ don’t delegate this.
● Note when you should take postural hypotension readings.
● Know normal vital signs – techniques, ranges, assessment, etc. Findings on respiratory
o RR: 12-20
o BP:<120/<80
o HR: 60-100
o Temp: 98.6F or 37C
o Pain 5th vital sign
Page 1
, lOMoARcPSD|5734770
Vital Signs – Guidelines
● Nurse ultimately responsible for vitals but can be delegated in
stable patients,
● RN to interpret their significance and make decision about
interventions;
● Determine equipment functional and appropriate;
o Know pt normal vitals;
● Know history, therapies and meds that could afect vitals;
● Control environmental factor that could afect vitals;
o Be organized and use systematic approach to ensure
accuracy;
o Use vitals to determine indications for med administration;
● Analyze measurements; communicate changes to HCP;
● Advise pt and or pt family of results.
● What is a pulse deficit? What do you do if you detect a pulse deficit during your assessment?
o See Clinical Decision (If pulse is irregular do an apical/radical pulse assessment to detect a
pulse deficit. Count apical pulse help patient to supine position or sitting position move aside
bed linen and gown to expose sternum and let side of chest. While a colleague counts radial
pulse begin apical pulse count out load to simultaneously assess pulses. If pulse differs by
more than 2 a pulse deficit exists which sometimes indicates alternation in cardiac output.).
o What if pulse deficit is in lower extremities? Pedal pulse weak on one side?
▪ Assess next pulse up, e.g., posterior tibial.
▪ If that pulse is weak, move up to popliteal, etc.
▪ Compare one extremity to the other.
● Apical pulse is taken for a full minute;
o PMI (point of maximal impulse) located at 4th or 5th intercostal space (ICS), just medial or left
of the midclavicular line (MCL).
● Elevated BP? Pt c/o headache? What may this indicate? What do you do?
o Reassess using other arm.
o Do not keep taking BP on same extremity.
o Reassess!!!
o May even need a manual cuff.
Pain and Sleep
● Exercise and Sleep –
o Exercise 2 hrs before bedtime allows cool down period and fatigue that promotes
relaxation (see Sleep Hygiene Habits, Box 43-9, p. 1006).
Summer Page 2
Foundations review - HESI Fundamentals
Study Guide
mental health (Gwinnett Technical College)
, lOMoARcPSD|5734770
Foundations HESI Review
(from 9th ed. of Foundations text)
Read all of chapters 1 and 2 in HESI book!!! Study this information for ALL HESI exams!
Basic Nursing Skills – Vital Signs – Chapter 30
● BP cuff size (review what happens with wrong cuff size)
o False-high diastolic readings on BP cuf
● Deflating cuf to slowly, inflating to slowly
o False-low readings on BP
▪ Cuf to wide, arm above heart level
o False-high readings on BP
▪ Cuf to narrow/short, cuf to loose or uneven,
arm not supported
Technique for palpating systolic BP
o (When arterial pulsations too weak to detect Korotkoff sounds or to identify auscultatory
gap). Box 30-9, p. 508. Palpate radial pulse. Inflate cuff 30 mmHg above point at which you
can no longer palpate the pulse. Slowly release valve and deflate cuff… See documentation
guidelines, as well.
● Technique for taking BP in the leg –
o Popliteal artery.
▪ SBP usually 10-40 mmHg higher than using brachial.
● DBP remains same. Ch. 30, p. 508.
Orthostatic BP readings –
o orthostatic hypotension also called postural hypotension;
▪ obtain supine, sitting, and standing (1-3 minutes between each);
▪ observe pt. for dizziness, fainting, lightheadedness.
▪ Record pts. position with each reading (remember pt. safety);
▪ don’t delegate this.
● Note when you should take postural hypotension readings.
● Know normal vital signs – techniques, ranges, assessment, etc. Findings on respiratory
o RR: 12-20
o BP:<120/<80
o HR: 60-100
o Temp: 98.6F or 37C
o Pain 5th vital sign
Page 1
, lOMoARcPSD|5734770
Vital Signs – Guidelines
● Nurse ultimately responsible for vitals but can be delegated in
stable patients,
● RN to interpret their significance and make decision about
interventions;
● Determine equipment functional and appropriate;
o Know pt normal vitals;
● Know history, therapies and meds that could afect vitals;
● Control environmental factor that could afect vitals;
o Be organized and use systematic approach to ensure
accuracy;
o Use vitals to determine indications for med administration;
● Analyze measurements; communicate changes to HCP;
● Advise pt and or pt family of results.
● What is a pulse deficit? What do you do if you detect a pulse deficit during your assessment?
o See Clinical Decision (If pulse is irregular do an apical/radical pulse assessment to detect a
pulse deficit. Count apical pulse help patient to supine position or sitting position move aside
bed linen and gown to expose sternum and let side of chest. While a colleague counts radial
pulse begin apical pulse count out load to simultaneously assess pulses. If pulse differs by
more than 2 a pulse deficit exists which sometimes indicates alternation in cardiac output.).
o What if pulse deficit is in lower extremities? Pedal pulse weak on one side?
▪ Assess next pulse up, e.g., posterior tibial.
▪ If that pulse is weak, move up to popliteal, etc.
▪ Compare one extremity to the other.
● Apical pulse is taken for a full minute;
o PMI (point of maximal impulse) located at 4th or 5th intercostal space (ICS), just medial or left
of the midclavicular line (MCL).
● Elevated BP? Pt c/o headache? What may this indicate? What do you do?
o Reassess using other arm.
o Do not keep taking BP on same extremity.
o Reassess!!!
o May even need a manual cuff.
Pain and Sleep
● Exercise and Sleep –
o Exercise 2 hrs before bedtime allows cool down period and fatigue that promotes
relaxation (see Sleep Hygiene Habits, Box 43-9, p. 1006).
Summer Page 2
