Term 1 End Term Hesi 4

  1. Compare and contrast between standard precautions and transmission-based precautions. Be detailed and give examples of when you would use each kind .
    • Standard: all clients to prevent spread of microorganisms. Use with contact of body fluids, blood, execretions (except for sweat), mucous membranes and non- intact skin. Gloves and Hand Hygiene
    • Transmission: Known or suspected airborne, droplt, contact infections FULL PPE
  2. Double gloving: take off both and wash hands; use double gloves sparingly in most cases not necessary or useful.
  3. When a nurse gets a needle stick with a clean needle, not used, what should he/she do? If a client gets a needle stick with the same needle that just stuck them, what does the nurse tell them. What do you do?
    • 1. Wash need sticks and cuts with soap and water
    • 2. Flush nose, mouth and skin with clean water.
    • 3. Irrigate with clean water, saline or sterile irrigants.
    • 4. Report and fill out incident report.
    • 5. Seek medical Treatment
  4. In giving a bedbath, do you need gloves to wash the face? How do you wash the face?
  5. What is your FIRST action when you see a needle in the bed of a client?
    Don gloves and discard needle in sharps
  6. Define HIPAA
    Health insurance Portability and accountability Act
  7. What would an L VN do in this situation? Overhearing a staff nurse breaching HIPAA (2 actions in order of priority)
    Report to supervisor and fill out incident report
  8. What are the other two names of the Nurse Practice Act? What IS the NPA?
    • Legal Practice acts for professional nursing practice.
    • Regulates the practice of nursing in the US and Canada.
    • NAMES: Title 22 and Scope of Practice
    • COMMON PURPOSE: to protect the public.
  9. What is the number one fear from nurses receiving medication orders via telephone?
    Authenticity of Caller
  10. What would you say if another nurse drew up medications and asked you to give them for her?
    I cannot administer medications that were not drawn up by myself.
  11. What is normal range of intake and output for an adult?
    Intake: 2,500 mL Output: 1,400 to 1,500mL
  12. What is the best way to force fluids?
    Offer what they like every hour
  13. When a patient is complaining of numbness and tingling in the arms and legs, what should the nurse assess in the labs?
    Check for electrolytes (Especially K+)
  14. If a client has a catheter in place (indwelling) and c/o pain, what is the nurses FIRST action?
    Check for kinks in tubing
  15. If you are catheterizing a client for a C&S, what do you do once you see urine start to flow? FIRST?
    Insert 1 inch further
  16. What is the normal size gauge and balloon for an adult client?
    • 14-16 Fr. – Women 30ml Balloon for urine drainage.
    • 18Fr. – Men 5mL balloon or greater for hemostasis
    • 5-10mL for balloon
  17. What is the nurses first action for a client with a post-operative fever?
    • - TCDB : turn, cough and deep breath - to prevent pneumonia and to get rid of the gunk accumulated during surgery
    • - assess lungs
  18. If neither arm is available for BP reading, what is the next site and how do you apply it to that site (artery)?
    - Thigh, palpate the popliteal artery
  19. What is the best measurement of a patients pain?
    Facial expression, pain scale 0-10
  20. When someone complains of pain, what is the nurse's FIRST response?
    • Assess pain using PQRST
    • Provocative- What causes it? What makes it better? What makes it worse?
    • Quality- How does it feel, look, or sound, and how much of it is there?
    • Region- Where is it? Does it spread?
    • Severity scale- Does it interfere with activities? How does it rate on a scale of 0-10?
    • Timing- When did it begin? How often does it occur? Is it sudden or gradual ?
  21. What are the five stages of grief and what might a client say in each stage?
    Denial, Bargaining, Anger, Depression, Acceptance
  22. Oxygen saturation-
  23. Blood glucose (fasting) -
    normal: 60-99mg/dL diabetic: 70-110
  24. Potassium (K) -
    3.5-5 mEq/L
  25. Chloride (CL)-
  26. Sodium (Na)-
    134-142 mEq/L
  27. Magnesium (Mg)-
    1.3-2.1mEq/L / 1.5-2.4 / 1.6-2.6
  28. Hemoglobin (Hgb) -
    14-18g/dL (men) ; 12-16g/dL (women)
  29. White blood cells (WBC)-
    5,000 - 10,000/mm3
  30. pH of blood-
  31. pH of urine-
Card Set
Term 1 End Term Hesi 4
Term 1 End Term Hesi 4