Hesi Flashcards
(100 cards)
1
Q
What is the purpose of the Braden Scale?
A
To assess a patient’s risk for developing pressure ulcers
Developed by Barbara Braden and Nancy Bergstrom in 1987
2
Q
What are the six categories of the Braden Scale?
A
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
3
Q
How is the Braden score interpreted?
A
The lower the score, the higher the risk of pressure ulcers.
Scores typically range from 6 to 23, with 18 or less indicating risk.
4
Q
What is a very high risk score on the Braden Scale?
A
≤ 9
5
Q
What is the purpose of IM injections?
A
To deliver medication deep into the muscle tissue for quick absorption
6
Q
Where is the deltoid muscle located for IM injections?
A
Upper arm, below the acromion process
7
Q
What are the limitations of using the deltoid muscle for IM injections?
A
- Not ideal for large volumes
- Higher risk of nerve or blood vessel injury
8
Q
What is the advantage of using the vastus lateralis muscle for IM injections?
A
Good for self-administration and well-developed in most individuals
9
Q
What is the safest site for IM injections?
A
Ventrogluteal muscle
10
Q
What should be avoided when injecting into the dorsogluteal muscle?
A
The area close to the sciatic nerve
11
Q
What does NGT residual refer to?
A
The amount of fluid remaining in the stomach after a feeding via a nasogastric tube
12
Q
What is considered a high residual volume for NGT?
A
500 ml or more
13
Q
What is the purpose of using a humidifier with a nasal cannula?
A
To moisturize nasal membranes
14
Q
What is reactive hyperemia?
A
Temporary increase in blood flow to a tissue after a period of reduced blood supply
15
Q
What are the signs of impending death in hospice patients?
A
- Decreased appetite
- Increased sleep
- Changes in breathing patterns
16
Q
What does the acronym TEDs stand for?
A
ThromboEmbolic Deterrent Stockings
17
Q
What is the first step in managing cyanotic lips?
A
Ascertain cause of cyanosis
18
Q
What is polypharmacy?
A
The use of multiple medications, often leading to increased risks of adverse reactions
19
Q
What is the role of a social worker in hospice care?
A
To provide support and resources for patients and families
20
Q
What should you do if you cannot hear the patient’s blood pressure?
A
Try palpating the blood pressure
21
Q
Fill in the blank: The Braden Scale scores are added together to determine the overall _______.
A
Braden score
22
Q
What is the correct position for using a spirometer?
A
Sit upright
23
Q
What factors can lead to compartment syndrome?
A
- Increased pressure from swelling
- Direct tissue damage
- Circumferential burns
24
Q
What is the first step when weighing a patient?
A
Weigh the patient before breakfast
25
What is the significance of measuring vital signs?
To assess the patient's health status
26
What is the technique for applying a figure 8 bandage?
Wrap in a crisscross pattern resembling the number '8'
27
What should be done when cleaning someone incontinent of feces?
Maintain hygiene measures
28
What is the primary goal of hospice planning?
To provide comfort and support for terminally ill patients
29
What are common signs of impending death in hospice patients?
* Decreased appetite and thirst
* Increased sleepiness
* Shallow and irregular breathing
* Reduction in physical activity
* Coolness in extremities
* Skin mottling
* Changes in consciousness
30
What nursing intervention is recommended for decreased appetite and thirst?
Oral care 2x, ice chips, wet washcloth to the lips, Vaseline to the lips
31
What does increased sleepiness in dying patients indicate?
Individuals may spend more time sleeping and be less responsive
32
What is Cheyne-Stokes respiration?
A breathing pattern that becomes shallow, irregular, or includes long pauses
33
What is anticipatory grief?
The experience of grief before an impending loss, particularly the death of a loved one due to illness
34
What are advanced directives?
Legal documents that allow individuals to express their wishes regarding their medical care if they are unable to communicate
35
What are the two most common types of advanced directives?
* Living Will
* Durable Power of Attorney for Healthcare (Health Care Proxy)
36
What is a tort?
A wrongful act or infringement of a right leading to civil legal liability
37
What are the stages of pressure ulcers?
* Stage 1: Intact skin with non-blanchable redness
* Stage 2: Partial-thickness skin loss
* Stage 3: Full-thickness skin loss without exposed bone, tendon, or muscle
* Stage 4: Full-thickness skin loss with exposed bone, tendon, or muscle
* Unstageable: Full-thickness skin loss with slough or eschar
* Deep Tissue Injury: Purple or maroon localized area due to damage to underlying soft tissue
38
What is stress incontinence?
Involuntary loss of a small amount of urine with increased abdominal pressure
39
What is urge incontinence?
Involuntary urine loss after a sudden urge to void, often associated with bladder inflammation or CNS disorders
40
What is the recommended amount of physical activity for adults?
At least 150 minutes of moderate-intensity aerobic activity per week or 75 minutes of vigorous-intensity aerobic activity
41
What is a prebiotic-rich diet?
A diet that supports gut health by nourishing beneficial bacteria and promoting regular bowel movements
42
What are the four main types of nutrients mentioned?
* CHON (4 cal/g)
* CHO (4 cal/g)
* Fats (9 cal/g)
* Vitamins
43
What dietary considerations should be made for patients with COPD?
Avoid foods high in carbohydrates and increase fats as a source of energy
44
What is foot drop?
The inability to lift the front part of the foot, causing the toes to drag when walking
45
What are common causes of foot drop?
* Nerve damage
* Muscle weakness
* Other medical conditions (e.g., stroke, MS)
* Spinal conditions
* Diabetes
* Trauma
46
What are some treatments for foot drop?
* Braces or splints
* Physical therapy
* Nerve stimulation
* Surgery
* Assistive devices
47
What are complications of prolonged immobility?
* Muscle loss
* Bone weakening
* Skin breakdown
* Increased risk of infections
* Blood clots
* Cognitive decline
48
What actions should be taken when a patient is in restraints?
* Frequent assessments
* Remove and reapply restraints every two hours
* Ensure basic needs are met
49
What is a biohazard container?
A specialized container for the safe storage and disposal of biohazardous waste
50
What items should be placed in a biohazard container?
* Contaminated blood
* Bodily fluids
* Swabs
* Microbiology cultures
* Items heavily contaminated with blood
51
What items should be placed in a biohazard container?
Contaminated blood, bodily fluids, swabs, microbiology cultures, tubes, gauze pads, bandages, absorbent materials.
## Footnote
Items heavily contaminated with blood or bodily fluids should also be included in the biohazard container.
52
What is a sharps container used for?
Disposing of sharp objects like needles, blades, and broken glass.
## Footnote
A sharps container should be closed when it's about 3/4 full or when it reaches the clearly marked fill line.
53
What are red bags or containers used for?
Disposing of contaminated materials like tissues, fluids, and other solid waste.
54
What is dependent edema?
Swelling that occurs in the lower body due to gravity.
55
What is pitting edema?
A symptom of edema where pressing on the area creates a temporary indentation or pit.
56
What does the 1+ pitting edema scale represent?
A slight indentation (2mm) that disappears immediately or within a few seconds.
57
What does the 4+ pitting edema scale represent?
A very deep indentation (8mm or more) that takes more than 60 seconds to disappear.
58
What does SBAR stand for?
Situation, Background, Assessment, Recommendation.
59
What is the primary action of digoxin?
Increases the force of contraction but decreases heart rate.
60
What are the nursing goals of early ambulation?
Reduced risk of complications, faster recovery, shorter hospital stays, improved muscle strength and circulation, improved mental and physical well-being.
61
What is the normal potassium (K) value?
3.5 to 5 mEq/L.
62
What are the symptoms of hypokalemia?
Decreased GI function, muscle weakness, cardiac dysrhythmias, decreased reflexes, oliguria.
63
What are the symptoms of hyperkalemia?
Muscle weakness, nausea, diarrhea, oliguria.
64
What are standard precautions?
Infection control practices to prevent the transmission of microorganisms between patients, healthcare workers, and the environment.
65
What is the key difference between Universal Precautions and Standard Precautions?
Universal Precautions focused on blood and certain body fluids, while Standard Precautions expanded to include all body fluids, except sweat.
66
What can you delegate to a UAP regarding immobile patients?
Bathing, toileting, dressing, ambulating, positioning, vital signs, bed making, specimen collection, feeding patients without swallowing precautions.
67
What is the purpose of a focused assessment?
To concentrate on specific body systems related to a patient's current problem or concern.
68
What are environmental modifications for fall prevention?
Keep pathways clear, ensure adequate lighting, maintain non-slip flooring, remove clutter.
69
What should be included in documentation of a patient's treatment refusal?
Specific details about the treatment offered, patient's reasons for refusal, education or discussions that took place, patient's competence, nature of refusal, alternative options discussed.
70
What is intertrigo?
A rash in skin folds due to friction and moisture.
71
What is the effect of a back rub according to the gate control theory?
It can help reduce pain perception by stimulating non-painful input.
72
What type of razor should be used for patients on anticoagulants?
Electric razor.
73
What should a doctor's order contain?
Patient's name, date of order, specific test or service requested, clinical indication, ordering provider's name, authentication, and medication details if applicable.
74
What is dyspnea?
Difficulty in breathing.
75
What is orthopnea?
Difficulty in breathing when lying flat, relieved by a change in position.
76
What are nutrient-rich food sources for increased energy?
Carbohydrates, proteins, fats.
77
What is dyspnea?
General term for difficulty breathing
78
What is orthopnea?
Feeling of breathlessness that worsens or only occurs when lying flat
79
What are nutrient-rich food sources for increased energy?
Consider carbohydrates (CHO), proteins (CHON), and fats
80
What is hyponatremia?
Condition characterized by low sodium levels in the blood
81
What is urinary retention?
Inability to completely empty the bladder
82
What are the two types of urinary retention?
* Acute (sudden onset) * Chronic (gradual onset)
83
What can cause urinary retention?
* Obstructive factors * Infectious factors * Neurological issues * Medication-related factors
84
What is the purpose of a medication scan?
To verify patient's identity using a barcode reader
85
What are preventative measures for men in health screenings?
* Testicular Self-Examination (TSE) * Prostate-Specific Antigen (PSA) testing
86
What are preventative measures for women in health screenings?
* Mammogram * Pap smear * Self-Breast Examination (SBE)
87
What is the relationship between fatigue and anemia?
Decreased oxygen carrying capacity leads to easy fatigability
88
What are normal pulse oximeter values for healthy adults?
95-100%
89
What does SpO2 levels below 90% indicate?
Hypoxemia (low oxygen levels)
90
What is shivering fever?
Body's natural response to raise temperature to fight off infection
91
What is C. difficile (C-diff)?
Caused by overuse of strong antibiotics leading to diarrhea
92
What is the role of suppositories in prostatectomy?
Used to manage bowel function and prevent complications
93
What happens to blood pressure in acute kidney insufficiency?
Blood pressure goes up
94
What electrolytes are affected by kidney problems?
* Potassium * Calcium * Magnesium
95
What is the definition of pulse deficit?
Apical pulse minus radial pulse
96
What is pulse pressure?
Systolic Blood Pressure (SBP) minus Diastolic Blood Pressure (DBP)
97
What are actions to take for hyponatremia?
98
What is the impact of insomnia related to medication reaction?
May lead to sundowning
99
What is the difference between narcotic and non-narcotic analgesics?
100
What should be assessed in food borne diarrhea (FBD)?
Incontinence
