Hesi Study Materials (Autosaved).
LEGEND
HESI NCLEX RN 4th Ed. book
HESI MED SURG practice
exam
Delegation
If giving to LVN/LPN or other nurse that is floating or not critical care- give nurse the most
STABLE client.
Center of Gravity-
Older individuals center of gravity is the upper torso.
Adults- hips
ABC’s
▪ Airway, Breathing, Circulation
▪ (CAB)- compression, airway, breathing
▪ Provide if unwitnessed cardiac arrest occurs.
▪ If unconscious- begin with circulation, airway, breathing; begin CPR.
▪ 30:2 with partner
▪ 15:2 alone
▪ Place hands at lower half of sternum; above xiphoid process
▪ Reposition head to validate proper position to open airway if chest is not
moving
▪ When carotid pulse is felt, there is return of cardiac function, with return of
breathing
• Signs of effective tissue perfusion should be noticed
Preoperative-
• Nurses role is to educate/advocate, reduce anxiety, Ensure consent has been signed
within past 24 hours (valid for 45 days)
• Teaching/Learning- outcome is best when demonstrated and not only verbalized; returned
demonstration is best method.
• KNOW ALLERGIES, OTC, herbal meds
• Know any issues with previous surgical experiences
• Know about person’s culture
• Often no blood transfusions for Jehovah’s Witness
• Often NPO after midnight; clear liquids sometimes allowed up to 6 hrs before surgery
o If client does not follow, surgery will be rescheduled
• Ensure client is both emotionally and physically prepared for surgery
Surgical Risk Factors-
• Age-young and old
• Nutrition- obese and malnutrition
• Fluid/Electrolyte-dehydration/hypovolemia
• Infection
,Hesi Study Materials (Autosaved).
• Cardiac conditions
• Blood coagulation disorders
• URI/COPD- exacerbated by general anesthesia
• Renal disease- impairs F/E balance
• Uncontrolled DM- infection & delayed healing
• Liver disease- inability to detoxify meds
Meds that increase risk:
• Anticoagulants- increases bleeding
• Tranquilizers- hypotension
• Heroin- decreased CNS response
• Antibiotics- may be incompatible with anesthesia
• Diuretics- may cause electrolyte imbalance
• Steroids
• OTC herbal meds-
o THINK THREE G’s: ginseng, garlic, gingko- increase bleeding
o Fish oil, dong quai, feverfew- increase bleeding
o Prolong anesthesia- kava, Valerian, St. John’s (also interacts with
EVERYTHING)
Postoperative-
Immediate Care:
▪ VS- BP, pulse, respirations
o Especially if client has slurred speech- may indicate neuro deficits
o If SOB, may need to intubate
▪ LOC, skin color & condition
▪ Dressing location and condition
▪ IV fluids
▪ Urine output
o Notify HCP if dark and less than 30mL/hr
▪ Drainage tubes & position
▪ O2 saturation
Monitor for S&S:
▪ Shock/hemorrhage
o Compensatory mechanism is activation of SNS that will increase RR & pulse
to restore BP; constricts arterioles and causes oliguria
o Client will show elevated BP as compensatory mechanism
▪ Narrow pulse pressure
▪ Rapid weak pulse
▪ Cold, moist skin
▪ Increased cap refill
Position client on side to prevent aspiration and to allow client to cough out airway; side rails
should be up.
N/V- suction
,Hesi Study Materials (Autosaved).
▪ When getting out of bed for first time, if client had HOB down, allow client to sit
with bed in high fowlers position.
▪ Help client sit and dangle legs on side of bed.
▪ Place chair at a right angle to bedside.
▪ Encourage deep breathing prior to standing.
Most common complications:
▪ Urinary retention- monitor hydration status and I&O; offer bedpan/commode
▪ Pulmonary problems- assist to turn, cough, deep breath Q1-2 hrs., Keep hydrated, early
ambulation, incentive spirometry.
▪ Wound-healing- teach splinting when patient coughs, monitor for S&S of infection,
malnutrition, dehydration HIGH PROTEIN DIET
▪ UTI- increase fluids, empty bladder Q4-6 hrs, monitor I&O, avoid catheterization if
possible, remove ASAP
▪ Thrombophlebitis- leg exercises, early ambulation, SCD’s, avoid pressure that may
obstruct venous flow; TO NOT PLACE PILLOWS BENEATH KNEES; avoid
crossing legs at knees; LMWH- lovenox
▪ Decreased GI peristalsis/constipation/Paralytic ileus- NG tubing to decompress GI tract;
client to limit use of narcotics (possibly use stool softeners); encourage ambulation
Wound dehiscence
▪ Patient may feel as if something “gave way”
▪ Observe for serosanguinous drainage
▪ Bowel evisceration- Apply sterile dressing
, Hesi Study Materials (Autosaved).
Gastrointestinal
TPN/Insulin-
ONLY Regular insulin may be given IV. If any other type of insulin is added to a mixture, it must
be returned to the pharmacy and should NEVER be used.
▪ The most important lab value to monitor when administering TPN is glucose.
▪ They contain high levels of glucose and sugar should be monitored as often as Q6H.
▪ Monitor fluid and electrolytes
Diabetes Mellitus
▪ Insulin- Assess willingness of client to learn injection sites when newly diagnosed
▪ Monitor clients for issues related to osmotic diuresis from elevated glucose levels
Medications
▪ Rapid – “LOG” fast acting; onset <15 mins; peak 1-2 hours
▪ Regular- Humulin/novolin- onset in 30-60 minutes; peak 2-4 hours
▪ NPH- “LIN”- onset 2-4 hours; peak 4-8 hrs
Long acting- “Lantus”; onset 1-2 no peak.
▪ Metformin- biguanide; do not administer within 48 hours of IV contrast- hard on kidneys
▪ Sulfonylureas- allergic to sulfa’s
▪ Patient will often have Hx of obesity.
▪ Patient should be counseled on nutrition and weight loss.
▪ Diabetic neuropathy- loss of feeling in lower extremities; if serum glucose is decreased
with a new diabetic numbness may improve.
▪ Increased risk for stroke.
▪ Pedal pulses can be weak or absent with decreased blood supply.
▪ Patient may experience vascular scarring r/t atherosclerotic changes in vessels causing
decreased perfusion, delaying wound healing
▪ Microalbuminuria is earliest sign of diabetic nephropathy
▪ Very important to know if patient is allergic to any sulfa drugs as they are some of
the anti-hyperglycemic agents (sulfonylurea- we generally see glyburide, glipizide,
glimepiride)
o Prescribed for type 2 diabetics
o Can cause hypersensitivity reaction- trouble breathing, swelling of lips,
tongue, face, throat- contact HCP
LEGEND
HESI NCLEX RN 4th Ed. book
HESI MED SURG practice
exam
Delegation
If giving to LVN/LPN or other nurse that is floating or not critical care- give nurse the most
STABLE client.
Center of Gravity-
Older individuals center of gravity is the upper torso.
Adults- hips
ABC’s
▪ Airway, Breathing, Circulation
▪ (CAB)- compression, airway, breathing
▪ Provide if unwitnessed cardiac arrest occurs.
▪ If unconscious- begin with circulation, airway, breathing; begin CPR.
▪ 30:2 with partner
▪ 15:2 alone
▪ Place hands at lower half of sternum; above xiphoid process
▪ Reposition head to validate proper position to open airway if chest is not
moving
▪ When carotid pulse is felt, there is return of cardiac function, with return of
breathing
• Signs of effective tissue perfusion should be noticed
Preoperative-
• Nurses role is to educate/advocate, reduce anxiety, Ensure consent has been signed
within past 24 hours (valid for 45 days)
• Teaching/Learning- outcome is best when demonstrated and not only verbalized; returned
demonstration is best method.
• KNOW ALLERGIES, OTC, herbal meds
• Know any issues with previous surgical experiences
• Know about person’s culture
• Often no blood transfusions for Jehovah’s Witness
• Often NPO after midnight; clear liquids sometimes allowed up to 6 hrs before surgery
o If client does not follow, surgery will be rescheduled
• Ensure client is both emotionally and physically prepared for surgery
Surgical Risk Factors-
• Age-young and old
• Nutrition- obese and malnutrition
• Fluid/Electrolyte-dehydration/hypovolemia
• Infection
,Hesi Study Materials (Autosaved).
• Cardiac conditions
• Blood coagulation disorders
• URI/COPD- exacerbated by general anesthesia
• Renal disease- impairs F/E balance
• Uncontrolled DM- infection & delayed healing
• Liver disease- inability to detoxify meds
Meds that increase risk:
• Anticoagulants- increases bleeding
• Tranquilizers- hypotension
• Heroin- decreased CNS response
• Antibiotics- may be incompatible with anesthesia
• Diuretics- may cause electrolyte imbalance
• Steroids
• OTC herbal meds-
o THINK THREE G’s: ginseng, garlic, gingko- increase bleeding
o Fish oil, dong quai, feverfew- increase bleeding
o Prolong anesthesia- kava, Valerian, St. John’s (also interacts with
EVERYTHING)
Postoperative-
Immediate Care:
▪ VS- BP, pulse, respirations
o Especially if client has slurred speech- may indicate neuro deficits
o If SOB, may need to intubate
▪ LOC, skin color & condition
▪ Dressing location and condition
▪ IV fluids
▪ Urine output
o Notify HCP if dark and less than 30mL/hr
▪ Drainage tubes & position
▪ O2 saturation
Monitor for S&S:
▪ Shock/hemorrhage
o Compensatory mechanism is activation of SNS that will increase RR & pulse
to restore BP; constricts arterioles and causes oliguria
o Client will show elevated BP as compensatory mechanism
▪ Narrow pulse pressure
▪ Rapid weak pulse
▪ Cold, moist skin
▪ Increased cap refill
Position client on side to prevent aspiration and to allow client to cough out airway; side rails
should be up.
N/V- suction
,Hesi Study Materials (Autosaved).
▪ When getting out of bed for first time, if client had HOB down, allow client to sit
with bed in high fowlers position.
▪ Help client sit and dangle legs on side of bed.
▪ Place chair at a right angle to bedside.
▪ Encourage deep breathing prior to standing.
Most common complications:
▪ Urinary retention- monitor hydration status and I&O; offer bedpan/commode
▪ Pulmonary problems- assist to turn, cough, deep breath Q1-2 hrs., Keep hydrated, early
ambulation, incentive spirometry.
▪ Wound-healing- teach splinting when patient coughs, monitor for S&S of infection,
malnutrition, dehydration HIGH PROTEIN DIET
▪ UTI- increase fluids, empty bladder Q4-6 hrs, monitor I&O, avoid catheterization if
possible, remove ASAP
▪ Thrombophlebitis- leg exercises, early ambulation, SCD’s, avoid pressure that may
obstruct venous flow; TO NOT PLACE PILLOWS BENEATH KNEES; avoid
crossing legs at knees; LMWH- lovenox
▪ Decreased GI peristalsis/constipation/Paralytic ileus- NG tubing to decompress GI tract;
client to limit use of narcotics (possibly use stool softeners); encourage ambulation
Wound dehiscence
▪ Patient may feel as if something “gave way”
▪ Observe for serosanguinous drainage
▪ Bowel evisceration- Apply sterile dressing
, Hesi Study Materials (Autosaved).
Gastrointestinal
TPN/Insulin-
ONLY Regular insulin may be given IV. If any other type of insulin is added to a mixture, it must
be returned to the pharmacy and should NEVER be used.
▪ The most important lab value to monitor when administering TPN is glucose.
▪ They contain high levels of glucose and sugar should be monitored as often as Q6H.
▪ Monitor fluid and electrolytes
Diabetes Mellitus
▪ Insulin- Assess willingness of client to learn injection sites when newly diagnosed
▪ Monitor clients for issues related to osmotic diuresis from elevated glucose levels
Medications
▪ Rapid – “LOG” fast acting; onset <15 mins; peak 1-2 hours
▪ Regular- Humulin/novolin- onset in 30-60 minutes; peak 2-4 hours
▪ NPH- “LIN”- onset 2-4 hours; peak 4-8 hrs
Long acting- “Lantus”; onset 1-2 no peak.
▪ Metformin- biguanide; do not administer within 48 hours of IV contrast- hard on kidneys
▪ Sulfonylureas- allergic to sulfa’s
▪ Patient will often have Hx of obesity.
▪ Patient should be counseled on nutrition and weight loss.
▪ Diabetic neuropathy- loss of feeling in lower extremities; if serum glucose is decreased
with a new diabetic numbness may improve.
▪ Increased risk for stroke.
▪ Pedal pulses can be weak or absent with decreased blood supply.
▪ Patient may experience vascular scarring r/t atherosclerotic changes in vessels causing
decreased perfusion, delaying wound healing
▪ Microalbuminuria is earliest sign of diabetic nephropathy
▪ Very important to know if patient is allergic to any sulfa drugs as they are some of
the anti-hyperglycemic agents (sulfonylurea- we generally see glyburide, glipizide,
glimepiride)
o Prescribed for type 2 diabetics
o Can cause hypersensitivity reaction- trouble breathing, swelling of lips,
tongue, face, throat- contact HCP
