1.4 HESI MID TERM 1 REVIEW
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What is a priority action if a restraint is too tight?
Remove or loosen the restraint and exercise the limb. (137)
How do you know if a restraint is too tight?
Cyanosis or pallor, coldness of the skin, patient's complaint of tingling sensation, pain, or numbness. (137)
What are bed alarms?
Devices that trigger an alarm when the patient attempts to get out of bed unassisted.
What is a priority action when a bed alarm goes off?
Reorientate the patient and return patient to the bed and reattach alarm device to sensor. Document patient getting out of bed unassisted. (129)
What do you do if the radial pulse is irregular?
Take the pulse for 1 full minute and then take an apical pulse for 1 minute. (396)
When a stool specimen is ordered what are they testing for?
Occult blood (hidden blood) and other microorganisms. (607)
How do you transport specimens?
In a labeled specimen jar with the laboratory requisition.
How do you store stool specimens?
In some instances, refrigeration is indicated because bacteriologic changes take place if left at room temperature. (607)
What happens if urine is mixed with stool in the specimen?
Retake the stool specimen since urine can contaminate or alter lab results.
What other two names are there for urination?
Micturition or voiding. (568)
What is the drainage port on the Foley collection bag?
What are two main elements of wound healing?
Hemostasis (the arrest or cessation of bleeding) results from vasoconstriction, retraction of injured blood vessels, deposit of fibrin, and blood clot formation. Phagocytosis is when macrophages (certain white blood cells_ engulf microorganisms and cellular debris. (469)
What is evisceration?
The protrusion of the internal viscera through an incision. (470)
What is dehiscence?
The partial or total rupturing of a sutured wound. (470)
What do you need to do if a evisceration or dehiscence happens?
The would should be quickly supported by large sterile dressings soaked in sterile saline. Place the patient in bed with knees bent to decrease pull on the incision. The surgeon should be notified because immediate surgical repair is necessary. (470)
Define the following terms:
- - Serous: consists chiefly of serum (the clear potion of the blood) derived from blood. (470)
- - Serasanguineous: blood-tinged drainage. (470)
- - Tenacious: adhesive or sticky; viscous or glutinous.
- - Purulent: thicker than serous exudates because it contains pus. Pus consists of leukocytes, liquefied dead tissue debris, dead and living bacteria.
- - Epigastric: middle upper region of the abdomen.
- - Hypochondriac: area pertaining to under the ribs.
- - Umbilical: center region of the abdomen, navel
- - Hypogastric: region of the abdomen, below the navel.
- - Malleolus: bony sides of the ankle joints.
- - Calcaneous: the heel bone
- - Ischial tuberocity: the lowest and rearmost of the three bones that make up each half of the pelvis
- - Iliac crest: The the iliac crest is the curved ridge at the top of the pelvic bone
- - Sacrum: a triangular bone at the base of the spine that joins to a hip bone on each side and forms part of the pelvis
- - Coccyx: a small triangular bone at the base of the spinal column
What is NPO?
Nothing by mouth. (537)
What is a progressive diet?
A diet that starts off with liquid or soft foods and gradually increases to a regular diet. (537)
How do you know how to progress a client's diet after surgery?
If no nausea occurs, normal intestinal motility has returned, and if the client feels like eating, the diet may be advanced to a full liquid, light, or regular diet. (537)
How many mL is in 1 liter?
How many mL in an oz?
What methods of fluid intake are there for I/Os?
Measuring and recording all fluid taken in and excreted during the 24 hour period. (559)
What do you do if a pre-op client drinks fluid before surgery while NPO?
Postpone the surgery because patient may vomit and aspirate vomitus during surgery. (724)
What precautions do you need to use for the following? MRSA, VRE, TB, HEP B & C, C-DIFF
- -MRSA: Contact Precaution
- - VRE: Contact Precaution
- - TB: Airborne Precaution
- - Hepatitis B and C : Universal
- - Clostridium Difficile: Contact
What is the number one way to prevent infection?
Washing your hands. (164)
What are standard precautions?
Precautions used with all clients to prevent spread of microorganisms; applied to all body systems. (157)
What are transmission based precautions?
Guidelines used in addition to Standard Precautions for any client with known or suspected infections that are spread by airborne or droplet transmission, or by physical contact. (157)
When do you use standard precautions and transmission based precautions?
Standard precautions are used in the care for all patients. Transmission-based precautions are used in addition to standard precautions for any patient with known or suspected infections that are spread by airborne or droplet transmission or by physical contact. (157)
How do you put on and off PPE correctly?
Define the following:
- - CVA: cerebral vascular accident (a stroke)
- - Lumbar: relating to or situated in the loins or the small of the back
- - Sacral: relating to or near the sacrum at the base of the spine
- - Dorsal: toward the back of, opposite of ventral
- - Ventral: toward the front of the body or the belly
- - Superior: above or in a higher position
- - Inferior: a point lower than or below a reference point
- - Anterior: toward the front of the body or the belly
- - Posterior: toward the back of, opposite of ventral
- - Proximal: a point nearer the origin of a structure
- - Distal: farther away from the origin of a structure
- - Laminectomy: spine operation to remove the portion of the vertebral bone called the lamina
- - Adjuvant: agents that modify the effect of other drugs while having few if any direct effects when given by themselves
- - Modality: a condition that modifies drug action; a condition under which symptoms develop, becoming better or worse.
- - Speculum: a medical instrument used to hold open a body passage such as the anus or vagina so that it can be examined
- - Dysphagia: difficulty in swallowing
How do you do CPR in order?
See page 817 Ramont.
How do you perform unconscious mouth care on a resident?
Prepare the patient lying in a side-lying position with head of the bed lowered. Place the towel under the clients chin. Place the curved basin against the client's lower chin. Don gloves and clean the teeth. Allow saliva to drain into basin. (458)
What points does the nurse need to keep in mind with a comatose or unconscious patient?
The nurse must remember to change the patients positions q2h in order to avoid pressure ulcers
Standard Precautions apply to..
- apply to:
- 1. blood
- 2. all bodily fluids, secretions, excretions (expect sweat)
- 3. non-intact skin
- 4. mucous membranes
Standard Precautions reduce..
transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.
Standard precautions includes the use of:
hand washing and PPE when touching patients bodily fluids
Transmission-Based Precautions is defined by
used alongside standard precautions for patients with known or suspected infectious diseases
Types of Transmission Based Precautions
- Airborne Precautions
- Droplet Precautions
- Contact Precautions
Define Airborne Precautions
- used for infections
- spread in small particles in the air such as chicken pox.
- used for infections
- spread in large droplets by coughing, talking, or sneezing such as
- used for infections
- spread by skin to skin contact or contact with other surfaces such
- herpes simplex virus.
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