Fundamentals HESI (no meds) Flashcards
What is acute cellulitis?
skin infection of the DERMIS and HYPODERMIS
What characteristics are associated with psoriasis?
silvery-white scales
How is Shingles diagnosed?
lesion culture
What will the nurse find on a hand with frostbite?
white/blue skin that is INSENSITIVE TO TOUCH
What is the most reliable assessment for cardiac output and tissue perfusion?
urine output
Describe the Rule of Nines?
used to estimated burn percentage
- 5% anterior head (face)
- 5% posterior head
18% anterior torso
18% posterior torso
- 5% anterior arm
- 5% posterior arm
9% anterior leg
9% posterior leg
1% perineum
What is the expected adult urine output?
30-50 mL/hour
By which route should a burn victim recieve their pain medication?
IV (they should be NPO since the digestive system will be effed)
Who is NOT allowed to care for a client with herpes zoster?
- a nurse who never had chickenpox
- a nurse who never received the varicella-zoster vaccine
Where are the legs if they are in a “dependent” position?
dangling off the bed - the venous blood flow is now “dependent” on the heart’s workload rather than passive flow
What position should a patient with a grafted burn on the right knee be in?
the affected leg should be immobilized for 3-7 days b/c the graft crosses a joint
What is the “normal” level of carbon monoxide in the body?
1% - 10%
Most common sites of cancer metastasis?
lungs
liver
brain
bones
Where do multiple myeloma cells proliferate?
the bones
What is a Billroth procedure?
a partial gastrectomy
What organ does a Whipple procedure involve? What levels should be monitored?
pancreas
blood glucose
What needs to be monitored after a TURP procedure?
transurethral resection of the prostate
hyponatremia
What is a normal platelet count?
150,000 - 450,000
What is the priority complication for a patient with multiple myelomas? Tx?
HYPERcalcemia
tx with hydration
How long can one healthcare provider stay in a patient’s room if the patient has an internal radiation implant?
30 minutes
- NO pregnant women
- NO person younger than 16
A post-operative client is being switched from NPO to a clear liquid diet on the basis that _________.
peristalsis has resumed (check bowel sounds)
What is a hallmark sign of LATE ovarian cancer?
abdominal distention
A nurse notes bloody drainage from the nasogastric tube of a client immediately following a gastrectomy, what is the nurse’s most appropriate action?
continue to monitor
bleeding is normal for the first 24 hours following this surgery
When should a urinary stoma bag be changed?
when it is 1/3 full
What is an early sign of superior vena cava syndrome - an oncological emergency?
face edema
When should a breast self-exam be conducted?
monthly - 7 days after the onset of menstruation
What electrolyte imbalance and hallmark symptom is associated with hyperparathyroidism?
HYPERcalcemia
Polyuria
What is a pheochromocytoma?
an adrenal tumor
causes the oversecretion of catecholamines (HTN, H/A)
Murphey’s sign is indicative of:
cholecystitis
What are two signs indicative of pancreatitis?
Cullen’s - discoloration of the abdomen and umbilical area
Turner’s - blue discoloration of the flanks
What indicates the patency of a cardiac fistula/graft?
a thrill
a bruit
notify HCP is a thrill/bruit is ABSENT
Where does bladder pain radiate to?
the shoulder
Which test differentiates between a myasthenic crisis and a cholinergic crisis? What should you have during the test?
Tensilon Test - have atropine available
if strength improves - myasthenic - give more meds
if more weakness - cholinergic - give antidote (atropine)
What is autonomic dysreflexia? What causes it?
catecholamine release in response to bowel, bladder or skin irritation (sitting on a needle, distended bladder)
occurs in spinal injuries above T6 - patient can’t feel anything below the waist and the body is screaming for help
What is the limbic system responsible for?
feelings and emotions
“feeling in limbo”
Allergies to which foods may put a patient at risk for latex allergy?
banana avocado pineapple grapes hazelnuts
How should a nurse take a documented spiritual history?
FICA
Faith
Importance
Community
Address in care - as a nurse
What is Digoxin used to treat?
A-fib
Side effects of TB drugs; Rifampin, INH, ETM
Rifampin - reduces effectiveness of BC, stains secretions orange (no contacts)
INH - increases phenytoin levels
ETM - check vision before starting therapy
What is not used after a part of the lung is removed?
a chest tube - they want the remaining space to fill with fluid so the other organs do not shift
What is the priority nursing action for a chest tube that falls out?
tape the hole on three sides with gauze
What does the nurse do if a chest tube becomes disconnected?
do NOT clamp!
place the end in sterile water until a new tube can be connected
What electrolyte imbalance is common after a thyroidectomy?
hypocalcemia
