Hesi Review

Front 1

List the three levels of disaster management

Back 1

Disaster preparedness, disaster response,disaster recovery

Front 2

Define shock

Back 2

Wide spread reduction of tissue perfusion, which leads to generalized impairment of cellular function

Front 3

what causes shock?

Back 3

hypovolemia

Front 4

What interveentions is used to restore cardiac output when hypovolemic shock exists?

Back 4

Rapid infusion of volume-expanding fluids

Front 5

Cardiogenic shock

Back 5

release of endotoxins by bacteria which act on nerves i vascular spaces in the periphery,causing vascular pooling, reduced venous return,and reduced cardiac output and resulting in poor systemic perfusion

Front 6

In cardiognic shock, the administration of volume-expanding fluids, and what intervention can the nurse expect to perform in the event of such an occurence.

Back 6

Quick restoration of caria output an issue perfusion

Front 7

List five assessment finding that occur in most shock victims.

Back 7

Tachycardia; tachypnea, hypotension, cool clay skin; decrease in urinary output

Front 8

What is the normal CVP for an adult?

Back 8

4 to 10 cm of H20

Front 9

Once circulatig volume is restored, vasopressors may be prescribed to increase venous return. List the main drugs that are used.

Back 9

Epinephrine(Bronkaid), dopamine(Dopram, dobutamineDobutrex), norepinephrine(Levophed), or isoproterenol(Isuprel

Front 10

What is the established renal output per hour?

Back 10

30ml/hr

Front 11

List four measurable criteria that are the major expected outcome of a shock crisis

Back 11

BP mean of 80 to 90mmHg; PO2>50mmHg
CVP above 6cm of H2O
urine output at last 30ml/hr

Front 12

Define DIC

Back 12

A coagulation disorder in which there is paradoxical thrombsis and hemorrhage

Front 13

What is the effect of DIC on PT, PTT, platelets, FSPs(FDPs)?

Back 13

Prothrombin time,prolonged
partial thromboplastin time prolonged
platelets, decreased
fibrin split products, increased

Front 14

What drug is used to treat DIC?

Back 14

Heparin

Front 15

Name four nursing interventions to prevent injury in clients with DIC.

Back 15

Gentle provide oral care with mouth swabs. Minimaze needle sticks and use the smallest gauge possible when injections are necessary. Eliminate the number of BP measurements taken by cuff. Ur gentle suction to revent trauma to mucosa. Apply pressue to any oozing site.

Front 16

What Po2 value indicate hypoxemia?

Back 16

Below 50 mmHg

Front 17

What blood value indicates hypercapnia?

Back 17

Pco2 above 45 mmHg

Front 18

Identify the condition that exists when the Po2 is less than 50mmHg and Fi02 is greater than 60%

Back 18

Hypoxemia

Front 19

List three symtoms of respiratory failure in adults

Back 19

Dyspnea/tachypnea; intercostal and sternal retractions; cyanosis

Front 20

List four common causes of respiratory failure in children

Back 20

Congential heart disease; infection or sepsis; rspiratory distress syndrome; aspiration;fluid overload

Front 21

Type of shock. relat to external or internal blood loss or fluid loss (the most common cause of shock

Back 21

Hypovolemic

Front 22

Type of shock .
related to ischemia or impairment i tisse resulting from MI, serious arrhythmia, or heart failure.All of these cause decreased cardic output

Back 22

Cardiogenic

Front 23

Type of shock.
Related to allergens (anaphylaxis), spinal cord injury, or priphral neuropathies, all resulting in venous pooling and decreased blod return to the heart, which decreases cardiac output over time.

Back 23

Vasogenic

Front 24

Type of shock.
related to toxins released by bacteria, which cause vacular pooling,diinshed venous return, and reduced cardiac output

Back 24

Septic

Front 25

What percentage of O2 should a child receive in severe respiratory distress receive?

Back 25

100%

Front 26

Is an unexpected, castrophic pulmonary complication occuring in a person with no previous pulmonary problems?

Back 26

ARDS

Front 27

Condition--_____Lowered Po2, not very responsive to high concentrations of O2, often need intubation and mechanical ventilation with positive end-expiratory pressure(PEEP)

Back 27

ARDS

Front 28

The instillation and maintnence of small amounts of air into the alveolar sacs to prevent the from collapsing each time the client exhales. The amount can be set by the ventilator and is usually around 5 to 10 cm of water

Back 28

PEEP--positive end expiratory pressure

Front 29

What is the first priority when a client with an unwitnessed cardiac arrest is found?

Back 29

Begin CPR

Front 30

Define myocardial infarction

Back 30

Necrosis of the heart muscle due to poor perfusion of the heart

Front 31

What criteria should alert a criteria with known angina who takes nitroglycein tablets sublingually to cal the EMS

Back 31

Unrelieved chest pain after nitroglycerin

Front 32

After calling for help and asking someone to ial for emergency services, what is the next action of CPR?

Back 32

Call fr hel and begin CPR. For unresponsive ifants and children, CPR should b performed for 1 minute before placig a 911 call for help.

Front 33

True or false? In feeling for the presence of a carotid pulse, no more than 5 seconds should be used

Back 33

False. Palpate for no more than 10 seconds, recognize that arrhythmias or bradycardia could be occuring

Front 34

During one rescures CPR, what is the ratio of compression to ventialtions for an adult and child.

Back 34

Adult: 30:2 x 5 cycles
Child 15:2 for a child or neonate with two rescuers

Front 35

What is the first drug most likely usied for an hospital cardiac arrest?

Back 35

Epinephrine

Front 36

A client in cardiac arrest is noted on the bedside monitor to be in pulseless ventricular tachycardia. What is the first action that should be taken?

Back 36

Defibrillation

Front 37

True or False:
A precordial thump is a routine activity for an in-hospital cardiac arrest.

Back 37

false. A thump is indicated only in pulseless VT or VF or when ventricular asystole on monitor responds to a thump with a QRS cmplex

Front 38

How would a nurse assess theadeqaucy of compressions during CPR?. How would the nurse assess the adequacy of ventilation during CPR?

Back 38

Check for a pulse, watch or chest excursions and ascultate bilaterally for breath sounds

Front 39

If a person is choking, when should the rescurer intervene?

Back 39

When the person points to his or her throat and can no longer cough, talk, or make sounds.

Front 40

One should never make a blank sweep into the mouth of a choking child or infant.Why?

Back 40

Because acidosis should b relieved with improved ventlation; bicarbonate can actually contribute to increased CO2.

Front 41

Regulate calcium and phosphorus balance

Back 41

Parathyroid

Front 42

Secrete aldosterone which causes sodium retention ( which causes water retention) and potassium excretion

Back 42

Adrenal glands

Front 43

Secretes antiduretic hormone (ADH), which causes the body to retain water

Back 43

Pituitary

Front 44

Composition of ECG:
Represents depolarization of the atrial muscle. Should be rounded and without peaking or notching

Back 44

P wave: atrial systole

Front 45

Composition of ECG:
Prepresents depolarization of the ventricular muscle. Normally follows P wave

Back 45

QRS complex: ventricular systole
measured from the beginning of the QRS to the end of the QRS (normal <0.11 sec.)

Front 46

Composition of ECG:
Represents repolrization of the ventricular muscle. Follows QRS complx Usually is slightly rounded, without peaking or nothching

Back 46

T wave: ventricular diastole

Front 47

Composition of ECG:
Represents early ventricular repolarization. Is measured from th end of the S wave to the beginning of the T wave.

Back 47

ST segment

Front 48

Composition of the ECG:
Represebts the time required for the impukse to travel from the atria (SA node), through the A-V node, to the Purkinje in the ventricles. s measured from the P wave to the beginning of the QRS complex A-V ndal function 0.12-0.20

Back 48

PR interval

Front 49

Composition of ECG:
Is not always present
Is most prominent in the presence of hypokalemia

Back 49

U wave

Front 50

Composition of ECG:
Represnts the time required to completly depolarize and repolarize the ventricles. Is measured from the begining of the QRS complex to the end of tht T wave

Back 50

QT interval

Front 51

What modalities are associated with gate control pain theory?

Back 51

Massage, heat and cold, acupuncture, TENS

Front 52

How does past experience with pain ifluence current pain experience?

Back 52

The more pain experienced in childhood, the greater the preception of pain in adulthood or current pain experience.

Front 53

What modalities are thought to increase theproduction of endogenous opiates?

Back 53

Acupunture, administration of placebos, TENS

Front 54

What six factors should the nurse iclud in assessing pain?

Back 54

Location, intensity, comfort measures, quality, chronology, and subjective view of pain

Front 55

What mechanisms is involved in the reduction of pain through the administratio of nonsteriodal antiinflammatory medication?

Back 55

NSAIDa act by a peripheral mechanism at the level of damaged tissue by inhiitig prostaglandin synthesis and othe chemical mediators involved in pain transmission

Front 56

If narcotic agonist/antagonist drus are administered to a client already taking narcotic drugs, what may be the result?

Back 56

Intiation of withdrawal symptoms

Front 57

List four side effects of narcotics medications,

Back 57

Nausea, vomiting; constipatio, CHN depression; respiratory depression

Front 58

What is the antidote for narcotic-induced respiratory depression?

Back 58

Narcan ( Naloxone)

Front 59

What is the first sign of tolerance to pain analgesics?

Back 59

decreased duration of drug effectiveness

Front 60

Which route of administration for pain meications has the quickest onset and shortest duration?

Back 60

Intravenous push, or bolus

Front 61

List six modalities that are considered noninvasive, nonphamacologic pain relief measures.

Back 61

Heat and cold application; TENS; assage; distraction; relaxation techniqus' biofeedback techniques.

Front 62

List four common symptoms of pneumonia that the nurse might note on a physical exam.

Back 62

Tachypnea, fever with chills, productive cough, bronchial breath sounds

Front 63

State four nursing interventions for assisting the client to cough productively

Back 63

Encourage deep breathing; increase fluid intake to 3 1/day;use humidity to loosen secretions; suction airway to stimulate coughing

Front 64

What symptoms of pneumonia might the nurse expect in an older adult?

Back 64

Confusion, lethargy, anorexia, rapid respirator rate

Front 65

What should the O2 flow rate be for the clent with COPD?

Back 65

Between 1 to 2 liters per nasal cannula; too much O2 may eliminate the COPD client's stimulus to breathe. A COPD client has a hypoxic drive to breathe.

Front 66

How does the nurs prevent hypoxia during suctioning?

Back 66

Deliver 100% oxygen (hyperinflating) before and each endotacheal suctioning

Front 67

During mechanical ventilation, what are three major nursing interventions?

Back 67

Monitor client's respiratory status and secure connections;establish a communication mechanism with the client; keep airway clear by coughing and suctioning

Front 68

When examining a client with emphysema, what physical findings is the nurse likely to see?

Back 68

Barrel chest, dry or productive cough, decreased breath sounds, dyspnea, crackles in lungs fields.

Front 69

What is the most common risk factor associated with lung cancer?

Back 69

Smoking

Front 70

Describe the properative nursing care for a client undergoing a laryngectomy.

Back 70

Involve family and client in anipulation of tracheostomy equpiment before surgery; plan acceptable communications methods; refer to speech pathologist; discuss rehabilitation program

Front 71

List five nursing interventions after chest tube insertion

Back 71

Maintin a dry occulsive dressing on chest tube. Keep all tubing connections tight and taped.Monitor client's clinical ststus. Encourage the client to breath deeoply periodically. Monitir the fluif drainage an mark the time of measurement and fluid level.

Front 72

What immediate action should the nurse take when a chest tube becomes disconnected from a bottle or suction apparatus? What should the nurse do if the chest tube accidently removed from the client?

Back 72

Place the end of the tube in asterile water container at a 2 cm level. Apply an occlusive dressig and notify health care provider.

Front 73

What instruction should be given to a client following radiation therapy?

Back 73

Do not wash off lines; wear soft cotton garments; avoid use of powders and creama on radiation site.

Front 74

What precautions are required for clients with TB when placed on respiratory isolation?

Back 74

A mask for anyone entering the room;private room; client must wear msk leaving room

Front 75

Lit four components of teaching for the client with tuberculosis

Back 75

Cugh into tissues and dispose immediately into special bags. Long-term need for daily medication.Good handwashing technique. Report symptoms of deterioration.i.e.,blood in scretions.

Front 76

Accumulation of waste products from protein metabolism is the primary cause of what?

Back 76

Uremia

Front 77

Protein must be resticted under what condtion?

Back 77

Chronic renal failure CRF

Front 78

What is most often used as an indicator of the lvel of protein consumption?

Back 78

GFR glomerular filtration rate

Front 79

Differeniate between acute renal failure and chronic renal failure.

Back 79

Acute renal failure ofn reversible, abrupt deterioration of kdney fuctin. Chronic real failure: irreversile, slow deterioration of kidney fnton characteized by increasig BUN and creatnine. Eventually dialysis is required.

Front 80

During the oliguic phase of renal failure , protein should be severely restricted. What is the rationale for this restriction?

Back 80

Toxic metabolites that accumulate in the blood (urea,creatinine) are derived mainly from protein catabolism.

Front 81

Identify two nursing interventions for the client on hemodialysis.

Back 81

Do not take BP or perform venipunctures on the arm with the AV sunt, fistula, or graft. Assess access site for thrill nd bruit.

Front 82

What is the highest priority nrig diagnosis for the clients in any type of renal failure?

Back 82

Risk for imbalanced fluid volume

Front 83

A client in renal failure asks why he is being give antacids. How should the nurse reply.

Back 83

Calcium and aluminm antacids bind phosphates nd help to keep phosphates for being absorbed into blood stream,therby peventing rising phosphate levels; must be taken with food

Front 84

List four essential elements of a teaching plan for clients with frequent urinary tract infections.

Back 84

Fluid itake 3 l/day, good handwashing; void every 2 to 3 hours during waing hours; take all prescribed medications ;wear cotton undergarments

Front 85

What are the most important nursing interventions for clients with possible renal calculi?

Back 85

Straining allurine is the most important. Other interventions include accurate intake and output documentation and administering analgesics a needed

Front 86

What discharge instructions should be given to a client who has had urinary calculi?

Back 86

Maintin high fluid intake of 3 o 4 l/day. Pursue follow-up care (stones tend to reoccur). Follow prescribed diet based on calculi content. Avoid supine position.

Front 87

Following transurethral resection of the prostate gland (TURP), hematuria should subsie by what post-operative day?

Back 87

The fourh day

Front 88

After the urinary catheter is removed inthe TURP client, what are three priority nursig actions?

Back 88

Cotinued strict I&O. Cotinued observations for hematuria. Infom clint burning and frequency may last for a week