Milestone 1 - Exam Study Guide – Hesi
Questions And Accurate Answers.
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.
Droplet Precautions - Answer -Flu
-Meningitis
-Mumps
,-Pneumonia
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
Nutrition Assessment Food frequency record/ questionnaire: (FFQ): - Answer Finite list of foods and
beverages that that indicate # of foods
Nutrition Assessment Diet History - Answer History of foods and information known about foods and
nutrition
Pressure ulcer-infection - Answer 1. Hemostasis
2. Inflammatory Phase
3. Proliferation Phase
4. Maturation phase
Hemostasis - Answer -Occurs immediately after initial injury
-Involved blood vessels constrict and blood clotting begins
-Exudate is formed causing swelling and pain
-Increased perfusion results in heat and redness
-Platelets stimulate other cells to migrate to the injury to participate in other phases of healing
Inflammatory Phase - Answer -Follows hemostasis and lasts 2-3 days
-Macrophages enter the wound area and remain for an extended period
-They ingest debris and release growth factors that attract fibroblasts to fill in the wound
-The patient has be generalized body response
Questions And Accurate Answers.
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.
Droplet Precautions - Answer -Flu
-Meningitis
-Mumps
,-Pneumonia
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
Nutrition Assessment Food frequency record/ questionnaire: (FFQ): - Answer Finite list of foods and
beverages that that indicate # of foods
Nutrition Assessment Diet History - Answer History of foods and information known about foods and
nutrition
Pressure ulcer-infection - Answer 1. Hemostasis
2. Inflammatory Phase
3. Proliferation Phase
4. Maturation phase
Hemostasis - Answer -Occurs immediately after initial injury
-Involved blood vessels constrict and blood clotting begins
-Exudate is formed causing swelling and pain
-Increased perfusion results in heat and redness
-Platelets stimulate other cells to migrate to the injury to participate in other phases of healing
Inflammatory Phase - Answer -Follows hemostasis and lasts 2-3 days
-Macrophages enter the wound area and remain for an extended period
-They ingest debris and release growth factors that attract fibroblasts to fill in the wound
-The patient has be generalized body response
