HESI review

Question 1

POC - incentive spirometer

Answer 1

An essential post-operative pulmonary exercise that helps mobilize and expel secretions and decrease pulmonary infection risk. The use of incentive spirometer is important for post-surgery patients to decrease the risk of a pulmonary infections

Question 2

Delegate - applying abdominal binder

Answer 2

This can be delegated to the UAP because it is non-invasive and non-sterile procedure

Question 3

What is the case managers role when working with a client experiencing a debilitating CVA?

Answer 3

A client experiencing a debilitating CVA will need to be evaluated for discharge needs such as rehabilitation. The case manager nurse will work with the interprofessional team to evaluate the client’s needs throughout hospitalization and discharge to the rehabilitation facility or home

Question 4

What should the nurses first action be when a patient with DVT is given both warfarin and heparin? What do these meds used together cause?

Answer 4

A client with DVT was mistakenly given heparin in addition to the prescribed warfarin. since both heparin and warfarin are anticoagulants, this error causes an additive blood thinning effect, the the nurse’s first action should be to monitor for signs of bleeding

Question 5

Delegation/priority. Three things are happening at once. 1 - vital signs of a newly admitted client with HF must be taken. 2 - another client has pulled out a central venous catheter, and 3 the new client also needs a stat dose of an oral anti-anxiety medication. The client who removed the central venous catheter is the least stable, is at high risk for hemorrhage and air embolism, and requires the RN’s care expertise.

How should the RN delegate these clients?

Answer 5

The ensure the the newly admitted client also receives care, the RN should assign the stat on oral medication administration to the PN and have the UAP take the vital signs

Question 6

What are things to keep in mind in regard to kidney transplant?

Answer 6

Kidney transplant patients are at high risk for fluid electrolyte imbalances
Transplant patients are immunosuppressed because of the concurrent steroid administration

a low grade fever after transplant could indicate a blunted response to a serious infection or could be early sign of rejection

Question 7

What should the nurse do when a client refuses care, such as being weighed?

Answer 7

Determine the reason why provides an opportunity to teach the client about the importance of obtaining daily weight when fluid volume alteration is a problem. It is important to keep a nonjudgemental attitude while inquiring why the patient does not want the care done.

Question 8

What should the nurse do if a prescription has been missed

Answer 8

once a missed prescription has been ID, the nurse needs to carry out the prescription that is still appropriate and follow the protocol for completing an incident report.

Question 9

Staffing criteria - what is client acuity?

Answer 9

Provides data used to determine the actual client care needs on the unit at a given point in time and is useful in anticipating the number of nurses on a unit to provide safe care.

Question 10

What should a nurse prioritize when a client is restrained?

Answer 10

ABC’s - the reassessing blood circulation should be a priority.

Question 11

What should nurse do if a client complains of pain 1 hour after receiving a strong opioid

Answer 11

The nurse should reevaluate to determine if a change in plan of care is needed.

Question 12

When should mandatory pre-certification be completed?

Answer 12

before paying for complex diagnostic procedures

Question 13

What if a nurse documents someone before actual assessment or intervention has taken place?

Answer 13

This is considered falsification and requires disciplinary action. the nurse can be reported to the Peer Review Committee

Question 14

Can a UAP obtain an indwelling catheter urine sample and fecal drainage sample?

Answer 14

yes - remember these are non-invasive and non-sterile procedures.

Question 15

What should happen if a patient’s O2 is reading less than 90%

Answer 15

this indicates poor o2 saturation and they should be assessed

Question 16

SBAR needs to include?

Answer 16

Situation
Background
Assessment (pre, intra and post op., etc.)
Recommendation

Question 17

What nurse gets information on the client’s end of life choices of the client is going to palliative care?

Answer 17

The receiving nurse

Question 18

A client has meningitis. Can a UAP care for this client? If so, how should they protect themselves?

Answer 18

A UAP can still provide care. The UAP must wear face mask to prevent transmission. The UAP should wear a mask, because Neisseria meningitis is spread through droplets.

Question 19

How often should UOP be measure for a client who has a nephrectomy and why?

Answer 19

UOP monitored hourly to assess the functioning of the remaining kidney

Question 20

Describe the prescription of Isophane insuling and regular insulin 70/30

Answer 20

Combination of 70% intermediate-acting insulin and 30% short-acting insulin.

Question 21

What should the nurse do if a prescription sent up by pharmacy is incorrect? – say the prescription called for was 70/30 of 2 different insulins

Answer 21

The best solution is to call the pharmacy and get the new medication as soon as possible. The pharmacy should be notified since the prescribed dose was not delivered.

Question 22

What should take place if a nurse is consistently coming in late to shifts and is not providing reason to why they are late?

Answer 22

a. should be reminded of the expectation of the duties
b. the tardy nurse should take responsibility for solving the problem and should be talked to in an assertive tone with the objective information being presented.

Question 23

Out of Cefltriaxone, Heparin, insulin and magnesium, what is the safest to give through an IV without a pump

Answer 23

Cefltriaxone - it is a cephalosporin anti-infective and is the safest option

Question 24

What should the UAP keep in mind when her client has sequential compression devices on?

Answer 24

Assess the condition of the skin underneath

If she notices bruising or any color changes in the legs or feet, she should report to appropriate RN

The UAP needs clear instructions from the nurse on when and how to report a change in circulation caused by the sequential compression devices

Question 25

Acute changes - AAA

Answer 25

Acute changes take priority over chronic changes. A client with acute back pain who is dx with AAA should be assessed immediately because this is a sign that the aneurysm has ruptured.

Question 26

What are the qualification for sudden inflammatory response syndrome (SIRS)?

Answer 26

temp: below 96.8 or above 100.4
HR: above 90
WBC count: greater than 12,000

Question 27

What dx might someone have if they have pitting edema and “moon face”

Answer 27

Cushing’s syndrome

Question 28

What should the RN do if a client has sepsis or suspects that someone has sepsis?

Answer 28

Monitor for early signs such as fever or chills can save their life. Sepsis protocol is centered around therapy and administering fluids, vasopressors and transfusion. The nurse should maintain strict intake and output to stay on top of vascular volume shifts. in this case, the patient in the ICU who went through an abdominoperineal resection and is not experiencing chills needs to be evaluated immidiately.

Question 29

What should happen if a fire take place?

Answer 29

All personnel should the the correct steps to take

When speaking of evacuation, the patients who are able to ambulate are moves to the fire exits first. Then, those who need assistance should be met with wheelchairs to move towards the exits

Question 30

Palliative care outline

Answer 30

Palliative team can be contacts for management of patients that will soon be transitions into that kind of care. Palliative care is a structured system for individuals who have a serious illness but do not meet criteria for hospice. the goals in palliative care include meeting the client’s wishes to prevent and relieve suffering and supporting them and their family.

Question 31

What is the initial catheter care of someone has a recently obtained a suprapubic cath?

Answer 31

Since this is a surgically inserted cath, the initial cath care involves removing the dressing and inspecting the surgical site (should be done by NURSE)

Question 32

What should the nurse do is the rights of medication adm. have been violated and the client receives the wrong dose, medication, route, time, etc?

Answer 32

the nurse would assess the client for adverse fx

Question 33

Living will-no heroic measures:

Answer 33

The client’s definition of “heroic measures” must be clarified first. You need to know what the client describes as “heroic” to help determine the appropriate interventions needed to meet the client’s wishes

Question 34

UAP: teaching

Answer 34

The UAP can only reinforce teaching first provided by the nurse that is related to basic procedures such as use of call light

Question 35

Hepatitis A-unit staff:

Answer 35

The nurse-manager should refer the nurse to employee health for serological testing, which will provide diagnostic evidence of the presence of hepatitis A virus. Nonspecific complaints such as fatigue, anorexia, nausea, and joint pain occur in the pre-icteric phase and usually subside with the onset of jaundice

Question 36

RN - discharge teaching

Answer 36

it is important for the nurse to assess and evaluate a client and families knowledge and needs before being discharged home. The RN will need to be assigned to the patient who needs discharge teaching, sterile procedure, and increasing the risk of infection.

(The other staff members should respond to code blue)

Question 37

What can happen if a peice of equipment can be used by more than 1 department?

Answer 37

it can be expensed to interdepartmental cost sharing, thereby sharing not only the cost, but also the benefit of the equipment

Question 38

What if someone asks if an MI is contagious to the UAP because they want to visit their loved one?

Answer 38

The MI is not contagious and the visitor does not pose a threat to the patient’s health by laying on the bed. The best answer is to explain to the UAP that the client may have a visitor lie in their bed to support their emotional needs

Question 39

What is priority assessment for a client who has pneumocytosis jirovecii pneumonia (PCP)

Answer 39

Can result in life threatening septic shock, the nurse should monitor for signs of shock

Question 40

Lewin’s unfreezing stage of change:

Answer 40

during which the change agent needs to make others aware of the need for change. During this phase, one of the nurses on the committee should always be available during scheduled shifts so that they can discuss changes of the new plan with the nurses

Question 41

Verbal prescriptions must be…

Answer 41

must be taken by a licensed nurse. The RN should stay with the unstable patient and instruct the clerk to tell the HCP that the nurse will return to the phone call ass soon as they can