Science Medicine Nursing
BSN 225 - HESI FUNDAMENTALS EXAM
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HESI Study, HESI - Fundamentals, H... HESI RN FUNDAMENTALS EXIT EXA... Done
200 terms 125 terms Teacher 173 terms
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,The nurse is caring for a client b. offer to administer 5mg of morphine orally as prescribed for
on hospice who was started on breakthrough pain
a 25 mcg/hr Fentanyl patch
yesterday at 0800. The nurse Rationale:
completes an assessment today A fentanyl patch is effective for 72 hours before it needs to be
at 2000 and reviews the replaced. This breakthrough pain is evidenced by a decline in
following assessment data: pain rating followed by an elevated pain rating during the time
that the fentanyl patch should still be effective.
Yesterday 0800
BP 98/60
HR 110
RR 24
O2SAT 94%
PAIN 6/10
INTERVENTIONS
Fentanyl patch 25mcg/hr
applied
Yesterday 2000
100/55
100
20
95%
2/10
Reposition, visiting with family
Today 0800
92/40
104
24
92%
4/10
Ice pack applied
Today 2000
100/65
110
24
94%
7/10
Which intervention is best for
the nurse to provide?
a. explain that the fentanyl patch
takes time to become effective,
and they should experience
relief soon.
b. offer to administer 5mg of
morphine orally as prescribed
for breakthrough pain
c. reposition the client and offer
to give a back rub.
d. call the provider to provide
, an update on the client's
When changing a client's post- a. Notify the healthcare provider.
condition
op wound dressing, the nurse
notes yellow purulent drainage. Rationale:
What action should the nurse Yellow purulent drainage is an indication of an infection. This
take? finding should be reported to the healthcare provider for
assessment and intervention.
a. Notify the healthcare
provider. Choices B, C, and D are all incorrect because the priority action
b. Cover the wound with clean is to notify the healthcare provider of the status of the wound.
gauze and secure. Further wound management (cultures, irrigation, or no irrigation,
c. Irrigate the wound with sterile packing or no packing, antibiotics, etc.) should be determined
water and leave open to air. after assessment of the site by the surgical team. Irrigating the
d. Irrigate the wound with wound before assessment has been completed may interfere
normal saline and pack with with medical decision-making and hsould be avoided.
gauze.
2670 mL
The healthcare provider
Rationale:
prescribes enteral feeds of Jevity
66mL/hour x 20 hours = 1320 mL
1.2 cal at 66mL/hour over 20
hours, and free water flushes of
Then it is necessary to calculate the amount of fluid from the free
225 mL q 4 hours x 24 hr via
water flushes.
nasogastric tube. How many mL
of total fluid will the client
Free water flushes every 4 hours for 24 hours = 6 flushes
receive in 24 hours? (Enter
numerical value only. If rounding
225 mL x 65 flushes = 1350 mL
is required, round to one
decimal place.)
Finally, add the two sums together:
1320 mL + 1350 mL = 2670 mL in 24 hours
BSN 225 - HESI FUNDAMENTALS EXAM
Save
Students also studied
Flashcard sets Study guides
HESI Study, HESI - Fundamentals, H... HESI RN FUNDAMENTALS EXIT EXA... Done
200 terms 125 terms Teacher 173 terms
cd4875 Preview carmelstar0607 Preview jnganga822
,The nurse is caring for a client b. offer to administer 5mg of morphine orally as prescribed for
on hospice who was started on breakthrough pain
a 25 mcg/hr Fentanyl patch
yesterday at 0800. The nurse Rationale:
completes an assessment today A fentanyl patch is effective for 72 hours before it needs to be
at 2000 and reviews the replaced. This breakthrough pain is evidenced by a decline in
following assessment data: pain rating followed by an elevated pain rating during the time
that the fentanyl patch should still be effective.
Yesterday 0800
BP 98/60
HR 110
RR 24
O2SAT 94%
PAIN 6/10
INTERVENTIONS
Fentanyl patch 25mcg/hr
applied
Yesterday 2000
100/55
100
20
95%
2/10
Reposition, visiting with family
Today 0800
92/40
104
24
92%
4/10
Ice pack applied
Today 2000
100/65
110
24
94%
7/10
Which intervention is best for
the nurse to provide?
a. explain that the fentanyl patch
takes time to become effective,
and they should experience
relief soon.
b. offer to administer 5mg of
morphine orally as prescribed
for breakthrough pain
c. reposition the client and offer
to give a back rub.
d. call the provider to provide
, an update on the client's
When changing a client's post- a. Notify the healthcare provider.
condition
op wound dressing, the nurse
notes yellow purulent drainage. Rationale:
What action should the nurse Yellow purulent drainage is an indication of an infection. This
take? finding should be reported to the healthcare provider for
assessment and intervention.
a. Notify the healthcare
provider. Choices B, C, and D are all incorrect because the priority action
b. Cover the wound with clean is to notify the healthcare provider of the status of the wound.
gauze and secure. Further wound management (cultures, irrigation, or no irrigation,
c. Irrigate the wound with sterile packing or no packing, antibiotics, etc.) should be determined
water and leave open to air. after assessment of the site by the surgical team. Irrigating the
d. Irrigate the wound with wound before assessment has been completed may interfere
normal saline and pack with with medical decision-making and hsould be avoided.
gauze.
2670 mL
The healthcare provider
Rationale:
prescribes enteral feeds of Jevity
66mL/hour x 20 hours = 1320 mL
1.2 cal at 66mL/hour over 20
hours, and free water flushes of
Then it is necessary to calculate the amount of fluid from the free
225 mL q 4 hours x 24 hr via
water flushes.
nasogastric tube. How many mL
of total fluid will the client
Free water flushes every 4 hours for 24 hours = 6 flushes
receive in 24 hours? (Enter
numerical value only. If rounding
225 mL x 65 flushes = 1350 mL
is required, round to one
decimal place.)
Finally, add the two sums together:
1320 mL + 1350 mL = 2670 mL in 24 hours
