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Fundamentals HESI > Case Studies > Flashcards

Case Studies Flashcards

1
Q

Cannula prongs should be lubricated with…

A

water-based gel

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2
Q

1 tsp is equal to how many mL?

A

5

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3
Q

What class of medication reduces cough?

A

antitussive

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4
Q

Vesicular lung sounds are a (blank) finding in peripheral lung fields.

A

normal

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5
Q

How should the nurse perform lung auscultation?

A

Beginning at the top of the chest, comparing one side to the other, moving downward, and finishing at the lung base

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6
Q

What are three ways the nurse can prevent venous thromboembolism?

A
  • dorsal flex and plantar flex feet
  • use sequential compression devices
  • administer enoxaparin (an anticoagulant)
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7
Q

Unilateral calf edema is a possible sign of…

A

thrombophlebitis (report to HCP)

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8
Q

How does the nurse assess for orthostatic hypotension?

A

Take BP and pulse in lying, sitting, and standing positions

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9
Q

Deep breathing can help prevent…

A

atelectasis

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10
Q

The Braden Scale assesses…

A

risk for pressure sores

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11
Q

The 90-degree side lying position places pressure on the…

A

greater trochanter (high risk for skin breakdown)

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12
Q

How can the nurse prevent pressure sores?

A

Reposition the patient every 2 hours while awake

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13
Q

What class of medication increases the risk for bleeding during surgery and post-op and should be withheld prior to surgery?

A

anticoagulants

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14
Q

Method for final verification (review scheduled procedure, site, and client)

A

“time out”

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15
Q

How should the patient be positioned in the immediate post-anesthesia period?

A

On their side

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16
Q

Hypoactive bowel sounds are (blank) after anesthesia.

A

expected

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17
Q

Packed RBC are only compatible with…

A

normal saline

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18
Q

Unintentional opening of a wound is called…

A

dehiscence

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19
Q

pain or burning with urination

A

dysuria

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20
Q

bladder training: start with every (blank) hours during the day and every (blank) hours at night

A

2, 4

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21
Q

(Blank) can be used for internal organ irrigation such as bladder or stomach

A

Saline

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22
Q

Monitor skin integrity and pulse volumed of restrained extremities every (blank) minutes.

A

30

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23
Q

Restraints must be removed at least every (blank) hours.

A

2

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24
Q

Resistance to antibiotic is a risk factor for…

A

sepsis

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25
Q

Elevated creatinine indicates a problem with the…

A

kidneys

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26
Q

What position should the patient be in for an enema or suppository?

A

Sim’s

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27
Q

After catheter removal, report if the patient has not voided after (blank) hours.

A

8

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28
Q

Do not open or crush (blank) medications.

A

extended release

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29
Q

What is the order for abdominal assessment?

A

inspection, auscultation, percussion, palpation

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30
Q

What position should the patient be in for abdominal auscultation?

A

supine

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31
Q

Where should the nurse begin to auscultate for bowel sounds?

A

right lower quadrant

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32
Q

Bowel sounds are normally heard (blank) times per minute.

A

5-35

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33
Q

The most common adverse effect of opioid analgesics is…

A

constipation

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34
Q

The average adult needs how much fluid daily to prevent constipation?

A

1400-2000 mL

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35
Q

barium liquid swallow followed by x-rays of esophagus, stomach, duodenum

A

upper GI series

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36
Q

Docusate sodium is a…

A

stool softener

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37
Q

What procedures are performed to assess for presence of fecal impaction?

A

digital rectal or radiographic exam

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38
Q

Vagal nerve stimulation causes (blank) of heart rate.

A

slowing

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39
Q

Verbal prescriptions should be…

A

read back and signed within 24 hours.

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40
Q

(Blank) heightens perception of pain and impairs coping skills.

A

Fatigue

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41
Q

All (blank) products should be avoided in children unless prescribed.

A

aspirin

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42
Q

(Blank) promotes muscle relaxation and relief of pain caused by stiffness or spasm.

A

Heat

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43
Q

(Blank) occurs following the initial vasoconstricting effects of cold.

A

Reflex vasodilation

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44
Q

(Blank) sends stimulating impulses through the skin, blocking pain signals from reaching the brain.

A

Transcutaneous electrical nerve stimulator

45
Q

With an intramuscular injection, you can use the (blank) site for most people.

A

ventrogluteal

46
Q

For intramuscular injections, the nurse should follow facility policy for (blank).

A

aspiration

47
Q

method where the muscle is tensed fully and then relaxed completely

A

progressive relaxation

48
Q

Teaching is best provided (blank) surgery.

A

before

49
Q

Veracity means…

A

truthfulness

50
Q

When administering eye drops, pull the conjunctival sac (blank) and apply light pressure over the (blank).

A

down; inner canthus

51
Q

The severity of a burn is determined by…

A

depth of burn, extent of burn, location of burn, client risk factors

52
Q

What is the initial treatment of a thermal, partial thickness burn?

A

dry dressing

53
Q

Chronic middle ear infections are associated with…

A

hearing loss

54
Q

entry of foreign substances into the lungs

A

aspiration

55
Q

professionals that adapt fine motor movements for provision of self care

A

occupational therapists

56
Q

What measures should be taken for a client with dysphagia?

A
  • elevate to high Fowler’s when eating
  • keep elevated at least 1 hour after eating
  • all fluids at room temperature
57
Q

Pallor of any mucous membranes may indicate…

A

anemia

58
Q

Regular measurement of weight is a good indicator of…

A

nutritional status

59
Q

How many calories does the average adult need per day?

A

20-35 calories/kg

60
Q

protein lab values

A

6.4 - 8.3 mEq/L

61
Q

What is needed when a client asks not to be resuscitated?

A

identifying bracelet

62
Q

Feed client with feeding tube once…

A

bowel sounds are present (usually 24 hours after insertion)

63
Q

Before teaching, the nurse should assess…

A

readiness to learn

64
Q

Fluid volume deficit often causes what changes in vital signs?

A

orthostatic hypotension and tachycardia

65
Q

How are orthostatic vital signs measured?

A

lying, sitting, standing (both VP and pulse are typically measured in each position)

66
Q

What measure provides the most important data about fluid volume status?

A

daily weights

67
Q

Where should skin turgor be assess in the elderly?

A

over sternum

68
Q

1 kg is equal to how many lbs?

A

2.2

69
Q

A decrease in serum protein leads to and increase in…

A

free drug molecules

70
Q

What should the nurse do when there is a medication error?

A

complete incident report and primary nurse notify HCP

71
Q

Obstruction in IV tubing is often caused by…

A

patient movement

72
Q

What actions should be taken when there is an IV site complication (ex. phlebitis)?

A
  • discontinue IV
  • take action for complication
  • start IV at a different site
73
Q

Fluid volume excess leads to abnormal…

A

breath sounds

74
Q

The nurse does not need a prescription to record…

A

I&O

75
Q

Fluid volume excess leads to what changes in the pulse?

A

tachycardia (increase in rate) and bounding pulse (increase in volume)

76
Q

When should diuretics be taken?

A

in the morning (to reduce nocturia)

77
Q

What should NOT be used as a patient identifier?

A

room number

78
Q

What are signs of fluid volume deficit?

A

changes in mental status, change in urine output, tachycardia, longitudinal furrows on tongue

79
Q

What should the nurse do when the patient is unable to swallow?

A

suction oral secretions

80
Q

How should oral secretions be suctioned?

A

gently with tonsil tip or Yankauer suction device

81
Q

When the patient is dying, where do cyanosis and mottling first occur?

A

in the hands and feet and then progress centrally

82
Q

irregular or patchy discoloration of skin

A

mottling

83
Q

redness that occurs when an area is lower than the heart (most common in legs)

A

dependent rubor

84
Q

occurs when tissue is relieved of pressure; abnormal when redness lasts longer than 1 hour and surround tissue does not blanch

A

reactive hyperemia

85
Q

Pressure ulcers usually occur over…

A

bony prominences

86
Q

Spongy skin indicates that (blank) has occurred.

A

pressure damage

87
Q

What position should the patient sleep in for pressure relief?

A

30 degree lateral inclined

88
Q

dressing for stage I pressure ulcer

A

transparent film

89
Q

dressing for stage III or IV pressure ulcer

A

hydrogel covered with foam dressing

90
Q

purulent drainage

A

pus

91
Q

serous drainage

A

thin, watery

92
Q

sanguineous drainage

A

bright red

93
Q

What measures should the nurse take to reduce the effect of diarrhea on skin?

A
  • clean and dry skin

- apply moisture-repellent ointment

94
Q

precaution used for all patients

A

standard

95
Q

extension of wound under skin

A

sinus tract

96
Q

How should the nurse assess a sinus tract?

A

sterile cotton-tipped applicator

97
Q

Safe, effective pressure for irrigation is between…

A

4 and 15 PSI

98
Q

Incorrectly labeled medications are the responsibility of the…

A

pharmacist

99
Q

Assess for drug toxicity with a…

A

peak and trough test

100
Q

How many sleep cycles does an adult have?

A

4-6

101
Q

Meals should be avoided how many hours before bedtime?

A

3-4

102
Q

Lying in bed awake for more than (blank) may increase anxiety and inhibit sleep.

A

30 minutes

103
Q

effleurage massage

A

“to touch lightly”

104
Q

petrissage massage

A

“knead or rub with force”; used to break down tension in large muscles

105
Q

lack of airflow through the nose and/or mouth for periods of 10 seconds or longer during sleep

A

obstructive sleep apnea

106
Q

Where should patients with increased monitoring be placed?

A

near the nurse’s station

107
Q

A decrease of up to (blank) BPM during NREM sleep is considered normal.

A

20

108
Q

Can vital signs be delegated to the UAP?

A

Yes

Fundamentals HESI (3 decks)

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