1.3 HESI MID TERM 1 REVIEW

Rescue the patient.

Average BP is 120/80 mg Hg. Normal range is 100-140 over 65-95. Normal BP for a teenager 110/64, 5 year old child 96/52, infant 80/40. (387)

12-20 per minute.

36 to 38 degrees Celsius (96.8 - 100.4). Average temperature is 98.6 but many factors can affect the range. (374)

From 60 to 99 mg/dL (3.9 to 5.5 mmol/L) (online)

Information obtained from what the client says. They describe the patient's perceptions and experience of the problem. When possible, the nurse quotes the client's words, otherwise they are summarized. (93)

Objective information consists of information that is measured or observed by the use of the senses (e.g. vital signs) (93)

Normal saturation levels are 95-100% (504)

A pulse oximeter is a medical device that indirectly measures the oxygen saturation of a patient's blood on the finger. It is non-invasive.

Move a client up in bed by cradling them with one arm below their knees and one arm on their back. Two nurse method has nurses interlock arms when cradling the patient. Two nurses using a turn sheet utilizes the sheet to move the patient. Log rolling turns the patient laterally while the patient stays as stiff as possible. (777)

• Stand with another nurse on the same side of the bed. Assume a broad stance with one foot forward and grasp half of the fan folded or rolled edge of the turn sheet. On a signal, pull the client toward both of you. Before turning the client, place a pillow that supports
• How would the nurse transfer a client from the bed to a wheel chair and what considerations would the nurse need to account for?
• First the nurse would move the patient to the sitting position on the edge of the bed by maneuvering the patient's legs over the bed while propping him up from the raised headrest. Support the client's shoulders and thigh while doing this. Lower the bed. Then position the wheelchair close and parallel to the bed, locks engaged. Position the patients stronger leg under the bed. Give explicit instructions to the patient about moving forward and off the bed into the wheelchair. Ask the patient to push with the back foot and rock to the forward foot. Assist the client to sit. Also it may help to assess how much the patient is able to help you during the transfer. Assess for orthostatic hypotension before transferring.(779-781)

The nurse needs to give instructions on when to move and how it will be done. The nurse will instruct the patient to help if he is able to. He is to push with the back foot and move forward on the other foot while the nurse supports him. The nurse should let the patient know that he can hug the nurse if he needs to for support. (781)

• Pluck the palmar surface below the cuff of the contaminated glove and pull off glove. Ball contaminated glove in the hand with a glove still on. Insert fingers of clean hand under the glove to remove the second contaminated glove. Pull 2nd glove inside out over the 1st glove. (167)
• 75. Describe how to get a clean catch urine specimen and the instructions to the client.
• The perineal is cleaned first. Clean-catch kit is used to catch urine midstream after the distal urethra is cleared of bacteria. Begin urin flow and stop the flow. Restart urine flow once container is in place to collect 30-60 mL of urine in the container. Cap the container tightly only touching the outside of the container. Label specimen and transport it to the laboratory. Bacterial cultures must be started immediately before any contaminating organisms can grow, multiply and produce false results. (585)

Going from one unit of measurement to another.

An incontinent patient can have maceration (softening of the tissue) due to wetness. Also, enzymes from the feces can break down the skin leading to infection or skin breakdown. Interventions are catheters that divert the urine, diapers which limit the amount of feces and urine contact. (571, 620, 483)

A patient that is not breathing would require CPR or may require intubation to keep the airway open for oxygen. (817)

A low sodium diet is a diet that includes no more than 1,500 to 2,400 mgs of sodium per day. It is recommended for patients who suffer from congestive heart failure, cirrhosis, kidney disease, hypertension and diabetes. Sea salt is a great alternative if salt is unavoidable. Drink plenty of water.

Duplicate question. See question 41.

Consent from the patient and if the patient is on any drugs in which shaving with a blade is contraindicated (i.e. anticoagulants). Ask if patient is on asperin medication, as that too can thin the blood. Check if patient is a hemopheliac. (437)

Measuring and recording all fluid taken in and excreted during the 24 hour period. (559)

The nurse should use therapeutic communication techniques and ask the patient open-ended questions that encourage the patient to verbalize and express his reasons for having anxiety. Explaining the procedures thoroughly so the patient can understand can also decrease anxiety. (230)

Contact Precautions are designed to reduce the risk of transmission of organisms and specific diseases by direct or indirect contact. Contact Precautions are to added to Standard Precautions for patients known or suspected to have organisms and/or diseases easily transmitted via direct or indirect contact.

The time of the walk, the distance walked or time taken, and all nursing assessments. (787)

The nurse should educate the client/family that it is contagious. If the client has head lice, their hair is washed with lice killing shampoo (pyrethrin shampoo). Bed linens are changed and the treatment is repeated 12-24 hours later if needed. If the patient has pubic or body lice, the patient takes a bath or shower, dries and applies the lotion or cream to the entire body or the pubic area. After 12 to 24 hours, the lotion is washed off and clean clothing and linens are supplied. Scabies is a contagious skin infection by the itch mite. Itching is more pronounced at night because the increased warmth of the skin stimulates the parasites. Treatment involves thorough cleansing of the body with soap and water to remove scales and debris from crusts, then applying scabicide lotion. (435)

The nurse needs to assess the patient's ability to help in maintaining hygiene and also factors that may influence hygienic practices such as culture, religion, environment, developmental area, health and energy and personal preference. Provide the patient with privacy. Nurse must also consider the embarrassment the patient may feel from not being able to care for his own personal hygiene. (428)

• - Ankylosed: Permanent immobility of a joint.
• - Atrophy: unused muscles atrophy (decrease in size) losing most of their normal strength and function.
• - Osteoporosis: without the stress of weight-bearing activity, bones demineralize. Calcium becomes depleted. (753)
• - Vertigo: a strong sensation of spinning around in space, which impairs balance (752)
• - Contractures: when muscle fibers are not able to shorten and lengthen for a prolonged time, permanent shortening of the muscle.

Runs from one side of the body to the other, separating the body into front and back portions (343)

Runs from from to back, separating the body into left and right portions. If the portions are equal, it's called midsagittal.(343)

Cuts the body horizontally, creating a superior and inferior portion. (343)

Right/Left hypochondriac, right/left lumbar, right/left iliac, epigastric, umbilical, hypogastric.(343)

Left upper quadrant (LUQ): pancreas, stomach, spleen, transverse and descending colon. Right upper quadrant (RUQ): liver, galbladdar, vile duct, transverse and ascending colons. Left lower quadrant (LLQ): Descending and sigmoid colon., Right lower quadrant (RLQ): appendex, cecum, ileoceca bowel.. (344)

Can be divided into cranial and spinal cavities. (343)

Space inside the skull and is where the brain is located. (343)

The ventral cavity can be divided into the thoracic and abdominopelvic cavities. (343)

The spinal cavity is where the spinal cord is housed. (343)

The thoracic cavity is above the diaphragm and contains the heart, lungs, and major blood vessels that are attached to the heart. These organs are protected by the ribcage. (343)

It is located below the diaphragm and extends to the top of the hipbones. The stomach, kidneys, liver, spleen, gallbladder, and most of the intestines are contained in it. (343)

The pelvic cavity is below the abdominal cavity and contains the urinary bladder, rectum, and internal parts of both male and female reproductive systems. (343)

The Health Insurance Portability and Accountability Act of 1996 mandated regulations that govern privacy standards for healthcare information. HIPAA regulations specify the purpose for which information may and may not be released without authorization from the client. These limit information such as condition and location of patient, death of a patient, if patient was treated and released, etc. (181-182)

Heat causes vasodilation and increases blood flow to the affected area, bringing oxygen, nutrients, antibodies, and leukocytes. Heat also increases capillary permeability, increases cellular metabolism, relaxes muscles, and reduces joint stiffness by decreasing viscosity of synovial fluids. (475)

Based on the patients thermal tolerance or orders. (475)

Cold causes vasoconstriction and limits swelling and bleeding. It also has a local anesthetic effect.

Applying cold to an injury causes vasoconstriction and has a local anesthetic effect. It decreases bleeding and limits swelling. (475)

Heat is used for clients with musculoskeletal problems such as joint stiffness from arthritis, contractures, and low back pain. Heat also improves healing. Ice is used for sports injuries to limit swelling and bleeding and dull the pain. (475)

No, doing so could cause burns or damage the skin of the patient.

To relieve muscle tension, promote physical and mental relaxation, and to relieve insomnia. Back rubs also increase circulation. (787)

Skin lesions, pressure ulcers, rashes, and other skin problems.

No.

It allows patients to self-administer medication to lessen breakthrough pain. (415)

Repeat each movement three times to allow muscles to stretch and warm. (772)

Any part of the body that can flex and extend such as the arm, legs, wrists, head, and fingers. (774)

• - Flexion: decreasing the angle of the joint (bending)
• - Extension: (Inversion) Increasing the angle of the joint
• - Abduction: Movement of the bone away from the midline of the body
• - Adduction: Movement of the bone towards the midline of the body
• - Rotation: Movement of the bone around its central axis
• - Supination: Moving the bones of the forearm so that the palm of the hand faces downward when held in front of the body
• - Pronation: Moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body (752)

• Joint pain and stiffness: Range of motion exercises, heat to decrease joint pain
• Increased use of the Valsalva Maneuver: Exhale through the mouth when straining.
• Disuse atrophy: Practice range of motion and resistance exercises.
• Renal calculi: use of catheters would prevent precipitate from forming.
• Urinary retention: bed pans and bed side commodes for easy elimination. (753)

Pressure ulcers are caused by pressure on the skin resulting in a deficiency of blood supply to the tissue. Friction ulcers are caused by sheets rubbing against the skin and removing superficial layers of the skin, making it more prone to breakdown. (482)

Heels, sacrum, elbows, scapulae, back of head. (486)

Malleolus (ankles), knee, greater trochanter, ilium, shoulder, ear, side of head.