HESI review Flashcards
(41 cards)
POC - incentive spirometer
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
Delegate - applying abdominal binder
This can be delegated to the UAP because it is non-invasive and non-sterile procedure
What is the case managers role when working with a client experiencing a debilitating CVA?
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
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?
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
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?
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
What are things to keep in mind in regard to kidney transplant?
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
What should the nurse do when a client refuses care, such as being weighed?
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.
What should the nurse do if a prescription has been missed
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.
Staffing criteria - what is client acuity?
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.
What should a nurse prioritize when a client is restrained?
ABC’s - the reassessing blood circulation should be a priority.
What should nurse do if a client complains of pain 1 hour after receiving a strong opioid
The nurse should reevaluate to determine if a change in plan of care is needed.
When should mandatory pre-certification be completed?
before paying for complex diagnostic procedures
What if a nurse documents someone before actual assessment or intervention has taken place?
This is considered falsification and requires disciplinary action. the nurse can be reported to the Peer Review Committee
Can a UAP obtain an indwelling catheter urine sample and fecal drainage sample?
yes - remember these are non-invasive and non-sterile procedures.
What should happen if a patient’s O2 is reading less than 90%
this indicates poor o2 saturation and they should be assessed
SBAR needs to include?
Situation
Background
Assessment (pre, intra and post op., etc.)
Recommendation
What nurse gets information on the client’s end of life choices of the client is going to palliative care?
The receiving nurse
A client has meningitis. Can a UAP care for this client? If so, how should they protect themselves?
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.
How often should UOP be measure for a client who has a nephrectomy and why?
UOP monitored hourly to assess the functioning of the remaining kidney
Describe the prescription of Isophane insuling and regular insulin 70/30
Combination of 70% intermediate-acting insulin and 30% short-acting insulin.
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
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.
What should take place if a nurse is consistently coming in late to shifts and is not providing reason to why they are late?
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.
Out of Cefltriaxone, Heparin, insulin and magnesium, what is the safest to give through an IV without a pump
Cefltriaxone - it is a cephalosporin anti-infective and is the safest option
What should the UAP keep in mind when her client has sequential compression devices on?
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
