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Milestone 1 - Exam Study Guide - Hesi
1. Eye drop admin: -Administer medication safely and appropriately,
-Avoid cornea, -Never touch eye or eye lid with administration device, -Pressure to lacrimal duct after giving medications, -Inner to outer canthus
2. Enema Patient Preparation: -Explain the purpose
-A reclining position for enema administration -Specifically left side-lying with the upper thigh pulled toward the abdomen if possi- ble, or the knee-chest position -If the patient has a respiratory disorder or is having difficulty breathing, elevate the head of the bed slightly. -Avoid Fowler's position because the solution will remain in the rectum and expulsion will occur rapidly, resulting in minimal cleansing. -Some patients think the solution should be expelled as soon as possible. Reinforce the need to retain the solution to achieve the desired results.
3. Residual Urine: urine that remains in the bladder after voiding
4. Ambulation Tolerance: The ability to the act, action, or an instance of moving about or walking
5. Wheelchair Transfer CVA: Bedside to Wheelchair
1) Support pt.'s weakest side
2) Turn pt. to a decubitus position
3) Place one arm under neck & other over the legs
4) "Swoop" pt. into sitting position
5) Straddle pt.'s legs
6) Put hands on pt.'s hips
7) Lift & pivot into the wheelchair
6. Wheelchair Safety: -Check wheel locks;
-Check for flat or loose tires; Check wheel spokes; -Be sure casters point forward for balance and stability;
- Be sure person's feet are on footplates before pushing or repositioning (feet cannot touch or drag on floor); -Push chair forward when transporting person, going backward ONLY through a doorway; -Lock both wheels before you transfer person to or from the wheelchair;
- Follow care plan for keeping wheels locked when not mving wheelchair (locking would keep person from moving or getting out of chair is so desired);
-RN is to protect and promote the patient's rights while in them -Need MD order and frequent monitoring by RN -Every 15 minutes (q15m) for the first hour, then every 30 minutes (q30m) to ensure proper circulation. -Removed every 2 hours (q2h) for range of motion, toileting, and offer of fluids. -Written order by provider based on exam before applied, no PRN orders, minimum q4 hour assessment for adults, MD assessment face-to-face q 24 hours, Reportable if death during use w/I 24 hours
10. Side Rails Restraints: -not considered a restraint if the patient requests that it be raised to be able
to get in and out of bed. -They have to be able to demonstrate that they can raise and lower the side rail by themselves -Usually in the hospital setting 4 side rails is considered a restraint -can pose serious risks for a confused or agitated patient. Entanglement or injury, asphyxiation and can be fatal.
11. Saline Flush: prefilled syringe with 10 mL 0.9% sodium chloride (NS)
12. Braden Scale: -Sensory perception, moisture, activity, mobility, nutrition, friction and shear
-The higher the number the greater the risk
13. Fats: 9 cals per gram
14. Alchohol: 7 cals per gram
15. Protein: 4 cals per gram
16. Carbs/Starch: 4 cals per gram
17. Sugars: 4 cals per gram
18. Nutrition Assessment Calorie counts: Records portion size patient consumes
- RN; Does not rely on memory
19. Nutrition Assessment 24 hr call method: structured interview where patient recalls food and
drink in last 24 hours, can be self administered
20. Nutrition Assessment Food frequency record/ questionnaire: (FFQ):: Finite list of foods and
beverages that that indicate # of foods
21. Nutrition Assessment Diet History: History of foods and information known about foods and
nutrition
22. Pressure ulcer-infection: 1. Hemostasis
2. Inflammatory Phase
3. Proliferation Phase
4. Maturation phase
23. Hemostasis: -Occurs immediately after initial injury
-Involved blood vessels constrict and blood clotting begins -Exudate is formed causing swelling and pain -Increased perfusion results in heat and redness -Platelets stimulate other cells to migrate to the injury to participate in other phases of healing
33. Kinking of the catheter: The touching of diametrically opposite sides of the plastic catheter alone
(without needle stylet) at a point of sharp curvature (caving-in of one side of the plastic catheter wall toward the other) and was observed visually.
34. Open wound: Sterile equipment and solutions are required for irrigating an
35. Wound irrigation: Flushing of an open wound using a medicated solution, water, sterile
saline, or an antimicrobial liquid preparation
36. Infection control biohazard: Waste contaminated with potentially infectious agents or other
materials that are deemed a threat to public health or the environ- ment.
37. NG suction: nasogastric suction. A tube that suctions fluid from the stomach
38. NG assessment: 1.Don clean gloves
2.Turn on suction unit and adjust to appropriate pressure (no more than 150 mmHg for adults)
3.Open sterile suction package with aseptic technique
4.Hyper-oxygenate the patient
5.Remove and dispose of gloves, performs hand hygiene
6.Dons PPE and sterile gloves without contamination
7.Prep for suction:
With your dominant sterile hand, pick up the sterile suction catheter With your non-dominant hand, pick up the suction tubing and connect to suction Lubricate the catheter tip by dipping into saline and checking suction
8.Perform the suctioning:
Remove oxygen delivery device with non-dominant hand Gently advance the catheter through the naris toward the trachea to reach the pharynx. DO NOT apply suction with insertion Apply suction and slowly withdraw the catheter, gently rotating as you withdraw. DO NOT apply suction for more than 10-15 seconds at a time Reapply the oxygen with non-dominant hand Allow 1-minute rest before next suction pass
9.Flush the catheter with saline and repeat suctioning process again. Alternate nostrils if not
contraindicated. DO NOT suction more than 3 times in one episode 10.Discard soiled supplies and perform hand hygiene. Keep PPE on as you will need it for tracheostomy suctioning
39. Smoking: Patients who stop often have more daytime sleepiness and report
significantly more restlessness at night.
40. True: Total withdrawal from smoking may be associated with temporary sleep disturbances.
41. Nicotine: has a stimulating effect; smokers usually have a more difficult time falling asleep.
42. False, Eliminating: Increasing cigarette smoking after the evening meal ap- pears to improve
the smoker's ability to fall asleep
43. Purulent drainage: is made up of white blood cells, liquefied dead tissue debris, and both dead and
live bacteria. Is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.
44. Serosanguineous drainage: is a mixture of serum and red blood cells. It is light pink to blood-
P = Pressure (HTN) B = BMI (>35) A = Age (>50yo) N = Neck circumf (>40cm) G = Male gender
52. Placebo Administration: It is considered unethical and deceitful to administer them. If a placebo is
ordered you must question the order.
53. Power of Attorney (POA): legal document in which one person appoints anoth- er person to act as
an agent on his or her behalf
54. Patient Outcomes: is an expected conclusion to a patient health problem, or in the event of a
wellness diagnosis, an expected conclusion to a patient's health expectation.
55. Nursing Process: 1.Assessment
2.Diagnosis
3.Planning
4.Implementation
5.Evaluation
56. benzodiazepines pregnancy: # mainly pregnancy category D. #contraindicated except for
rare exceptions when their benefits outweigh fetal & neonatal risks. #May ‘ed risk of oral cleft, preterm labor, & fetal growth restriction. "Floppy baby syndrome" (lack of tone,
sluggishness, & difficulty w/ the sucking reflex) immediately after birth & newborn withdrawal up to three months are concerns as well. #Long-term effects of exposure on child & adult development are unknown & should be avoided.
57. Grief: is an internal emotional reaction to loss caused by separation as well as loss caused by
death.
58. Engel's six stages of grief: 1.shock and disbelief,
2. developing awareness,
3. restitution,
4. resolving the loss,
5. idealization
6. outcome.
59. Kübler-Ross: 1.denial,
2.anger,
3.bargaining,
4.depression,
5.acceptance
60. palliative care: Care designed not to treat an illness but to provide physical and emotional comfort
to the patient and support and guidance to his or her family.
resonance toward cardiac dullness in the 3rd, 4th, and 5th, and perhaps 6th interspaces, from the left axillary to the right axillary lines.
73. A dull sound indicates: the presence of a solid mass under the surface
74. resonant: sound indicates hollow, air-containing structures.
75. Abdominal palpation: one finger, light, deep, masses, rebound with quick release, CVA
tenderness
76. Abdominal inspection: - skin
- contour
- muscle tone & symmetry
- umbilicus
- visible peristalsis
- pulsations
- signs of pain
77. Reasons palpate arms and legs.: To identify tenderness, warmth, erythema
78. Reasons to inspect arms and legs: To identify symmetry, range of motion, color, hair, nails
79. Menorrhagia: excessive menstrual bleeding
80. Health history Menopause: 12 consecutive months without menses. As estro- gen levels decrease,
the uterus becomes smaller, the ovaries shrink, the normal vaginal rugae flatten, and the epithelium atrophies. These normal changes may lead to difficulties such as vaginal infections, urinary tract infections (UTIs), dys- pareunia, and diminished libido. Older women are at increased risk for endometrial, vaginal, and vulvar cancers. They need education regarding unexpected signs and symptoms. The older woman also may benefit from counseling and education about intimacy difficulties and physiological changes.
81. Allergic reaction: Document throat swelling and difficulty breathing as an
82. Allergies Assessment: essential to note the type of response, such as rash, throat swelling,
difficulty breathing, or anaphylactic shock
83. Muscle atrophy: lack of muscle activity; reduces muscle size, tone, and power
84. Perianal assessment: - inspect and palpate rectal area
- note lesions, inflammation, pilonidal cyst, hemorrhoids, fissures, or nodules
85. carotid artery: Palpate the medial to the sternomastoid muscle in the neck
between the jaw and the clavicle
86. Carotid Artery: Palpate each medial to the sternomastoid muscle in the neck
one at a time, avoiding the carotid sinus.
87. Bronchial breath sounds: are loud, high-pitched, and found over the trachea and larynx.
Duration during inspiration. Quality is coarse or tubular.
88. Pedal pulse: The pulse rate obtained on the top of the foot
the patient to stick out the tongue and observe for symmetry. Ask the patient to say, "light, tight, dynamite" and note that the letters l, t, d, and n are clear and distinct.
101. It will read inaccurately: Do not use an extremity with a shunt, on the same side as a
mastectomy, or with an intravenous (IV) infusion. Why?
102. Cranial Nerve XII abnormalities: Fasciculations, asymmetry, atrophy, or de- viation from midline
may occur with general neuromuscular conditions or lesions of the hypoglossal nerve.
103. Cranial Nerve XI: Spinal accessory
104. Cranial Nerve XI controls: - (motor)
-trapezius and sternomastiod muscles
105. Cranial Nerve XI technique: Evaluate the sternomastoid and trapezius mus- cles for bulk, tone,
strength, and symmetry. Ask the patient to press against resis- tance on the opposite side of the chin. Also ask the patient to shrug the shoulders against resistance. The movements should be strong and symmetrical.
106. Cranial Nerve XI abnormalities: Weakness or asymmetry in movement ac- companies
neurological and musculoskeletal problems.
107. Cranial Nerve X controls: -sensory and motor
-includes gag reflex
108. Cranial Nerve X: Vagus
109. Cranial Nerve X Techniques: Evaluate the motor component by asking the patient to open the
mouth and stick out the tongue, which should be symmetrical. Place a tongue blade on the middle of the tongue and have the patient say "ah"; observe the uvula and soft palate for symmetry. Evaluate the sensory component by stimulating the gag reflex, which is tested only when a problem is suspected. Inform the patient that you will be touching the posterior pharyngeal wall and it may cause gagging. Observe for upward movement of the palate and contraction of the pharyngeal muscles with the gag reflex.
110. Cranial Nerve X Abnormalities: Injury to the vagus or glossopharyngeal nerve causes the
uvula to deviate from midline. Asymmetry of the soft palate or tonsillar pillars is also abnormal. An impaired gag reflex, coughing during oral feeding, and changes in voice after swallowing are all associated with aspiration. Closely evaluate patients with any of these symptoms.
111. Cranial Nerve IX Abnormalities: Impaired taste or swallowing is common following a stroke.
112. Cranial Nerve IX Techniques: Evaluate sensory function with CN VII. Evaluate motor function with
CN X upon swallowing.
113. Cranial Nerve IX: -sensory and motor
114. Cranial Nerve VIII Techniques: Evaluate hearing during normal conversation using a simple
whisper test or with an audiometer.
115. Cranial Nerve VIII abnormalities: Inability to hear conversation is abnormal; note the presence
of a hearing aid.
feels them. Be sure to evaluate all three divisions of the nerve at the scalp (ophthalmic), cheek (maxillary), and chin (mandibular) areas on each side. Evaluate motor function by observing the face for atrophy, deviation, and fasciculations. Ask the patient to tightly clench the teeth; palpate over the jaw for masseter muscle symmetry. Ask the patient to open the jaw against resistance; normal movement is symmetrical. The corneal reflex is not normally tested unless motor or sensory abnormalities are noted. Have the patient remove any contact lenses. Instruct him or her to look up. Inform the patient that you will touch the eye with a cotton swab wisp. Bring the swab in from the side and lightly touch the cornea, not the conjunctiva. Normally the patient blinks bilaterally as stimulation is applied. Decreased or dulled sensation, weakness, or asymmetrical movements are un- expected findings associated with CN V. A weak blink from facial weakness may result from paralysis of CN V or CN VII. A depressed or absent corneal response is common in contact
122. Cranial Nerve V Abnormalities: Decreased or dulled sensation, weakness, or asymmetrical
movements are unexpected findings associated with CN V. A weak blink from facial weakness may result from paralysis of CN V or CN VII. A depressed or absent corneal response is common in contact lens wearers.
123. Cranial Nerve III: Oculomotor
124. Cranial Nerve IV: - Trochlear
125. Cranial Nerve VI: - abducens
126. Cranial Nerve III, VI, AND VI: Assess pupils for size, shape, and equality. Assess the six
cardinal positions of gaze. Observe for nystagmus in one or both eyes
127. Cranial Nerve II: - sensory
128. Cranial Nerve I Technique: is tested when symptoms involve smell or ab- normal findings
warrant evaluation. First assess patency by closing off one nostril and asking the patient to inhale; perform the same technique on the opposite side. Occlude one nostril. Tell the patient to close the eyes, place a familiar scent near the open nostril, and ask the patient to inhale and identify the scent. Repeat on the opposite side. Commonly used fragrances include orange, peppermint, cinnamon, and coffee
129. Cranial Nerve I: - Olfactory
130. Cranial Nerve I Abnormalities: Only a few neurological conditions are linked with olfactory
deficits. It is important to test for patency of the nares, which can influence the ability to smell. Other influences include allergies, mucosal inflamma- tion, increased age, and excessive tobacco smoking. An olfactory tract lesion may compromise the ability to discriminate odors (anosmia).
131. Facial weakness: by a lesion in the right frontal motor control center occurs on the left side of
the face
132. Lesion: A affecting the right facial nerve itself produces weakness on the entire right
