NSG 122 Fundamental Concepts HESI Final Exam UPDATED
ACTUAL Questions and CORRECT Answers
Evidence Based Practice Evidence-based practice (EBP) in nursing is a problem-solving approach to
making clinical decisions, using the best evidence available (considered "best"
because it is collected from sources such as published research, national
standards and guidelines, and reviews of targeted literature).
Erikson's Psychosocial Theory Older Adults Integrity vs. Despair
People in late adulthood reflect on their lives and feel either a sense of
satisfaction or a sense of failure. People who feel proud of their accomplishments
feel a sense of integrity, and they can look back on their lives with few regrets.
Droplet Precautions Droplet Precautions:
Use a private room, if available. Door may remain open.
Wear PPE upon entry into the room for all interactions that may involve contact
with the patient and potentially contaminated areas in the patient's environment.
Transport patient out of room only when necessary and place a surgical mask on
the patient if possible.
Keep visitors 3 ft from the infected person.
Why are masks beneficial with droplet precautions? Masks help prevent the wearer from inhaling large-particle aerosols, which
usually travel short distances (about 3 ft), and small-particle droplet nuclei, which
can remain suspended in the air and travel longer distances. Masks also protect
the patient from the respiratory secretions of the health care worker. Masks
discourage the wearer from touching the eyes, nose, and mouth, thus limiting
contact of organisms with mucous membranes.
,Cough Etiquette Any patients, family members, and visitors with undiagnosed, transmissible
respiratory infections require education to cover their mouth and nose with a
tissue when coughing and promptly dispose of the tissue. During periods of
increased occurrence of respiratory infections, offer a surgical mask to coughing
patients and other symptomatic people upon entry to the health care facility or
office. Encourage the coughing patient to maintain more than a 3-ft separation
from other people in the health care facility or office.
Factors Affecting Risk for Infection Factors affecting the risk for infection include: integrity of mucous membranes, pH
levels of the gastrointestinal and genitourinary tracts, immune response, age, sex,
race, heredity, level of fatigue, nutritional status, stress level, use of invasive or
indwelling medical devices and immunizations (natural or acquired)
Abnormal Wound Drainage Purulent drainage is made up of white blood cells, liquefied dead tissue debris,
and both dead and live bacteria. Purulent drainage is thick, often has a musty or
foul odor, and varies in color (such as dark yellow or green), depending on the
causative organism.
Pressure Ulcer Stage 1 A stage 1 pressure injury is a defined, localized area of intact skin with
nonblanchable erythema (redness). Darkly pigmented skin may not have visible
blanching; its color may differ from the surrounding skin. The area may be painful,
firm, soft, warmer, or cooler as compared to adjacent tissue
Pressure Ulcer Stage 2 A stage 2 pressure injury involves partial-thickness loss of dermis and presents as
a shallow, open ulcer or a ruptured/intact serum-filled blister
Pressure Ulcer Stage 3 A stage 3 pressure injury presents with full-thickness tissue loss. Subcutaneous fat
may be visible and epibole (rolled wound edges) may occur, but bone, tendon, or
muscle is not exposed. Slough and/or eschar that may be present do not obscure
the depth of tissue loss. Ulcers
Pressure Ulcer Stage 4 Stage 4 injuries involve full-thickness tissue loss with exposed or palpable bone,
cartilage, ligament, tendon, fascia, or muscle. Slough or eschar may be present on
some part of the wound bed; epibole, undermining, and/or tunneling often occur
Wound Infection Symptoms of infection include purulent drainage; increased drainage, pain,
redness, and swelling in and around the wound; increased body temperature; and
increased white blood cell count. Additional signs and symptoms include delayed
healing and discoloration of granulation tissue in the wound
Braden Scale Braden Scale: mental status, continence, mobility, activity, and nutrition
Using the Braden scale (VHMMN)
Lower to 9 Very high risk-V
10 to 12 High risk-H
13 to 14 Moderate risk-M
15 to 18 Mild risk-M
19 to 23 indicate No risk-N
, Heat Application The application of heat accelerates the inflammatory response to promote
healing.
The application of local heat dilates peripheral blood vessels, increases tissue
metabolism, reduces blood viscosity and increases capillary permeability, reduces
muscle tension, and helps relieve pain. Vasodilation increases local blood flow. In
turn, the supply of oxygen and nutrients to the area is increased, and venous
congestion is decreased
Careful on large parts of the body
Dysnpea Positioning High Fowler's Position because accessory muscles can easily be used to promote
respirations
Partial Rebreather Mask Low Flow 8-11L/min, set flow rate so the mask remains two thirds full during
inspiration, keep reservoir bag free of twists or kinks
Cyanosis Cyanosis (bluish discoloration) of these areas indicates decreased blood flow or
poor blood oxygenation
Fish Oil Of all the natural products, fish oil and glucosamine, chondroitin, or a combination
supplement were the products most commonly used by adults in 2012.
Beneficial to many aspects of health; from muscle activity to cell growth.
Ventrogluteal The ventrogluteal site is recommended for general IM injections in adults
Adult Ear Drop Administration up and back
Clear Liquid Diet Clear liquids are transparent and liquid at room temperature. Example: apple
juice, popsicle, coffee tea, clear broth, gelatin, clear fruit juice like apple,
cranberry, and grape.
GT Feeding Residual Check gastric residual (feeding remaining in the stomach) before each feeding or
every 4 to 6 hours during a continuous feeding (according to institution policy).
High gastric residual volumes (200 to 250 mL or greater) can be associated with
high risk for aspiration and aspiration-related pneumonia
24 Hour Urine Specimen Collection of ALL urine voided during a 24 hour period.
Initiate a collection at a specific time (which is recorded) by asking the patient to
empty the bladder. Discard this urine and then collect all urine voided for the next
24 hours. At the end of the 24 hours, ask the patient to void. Add this urine to the
previously collected urine, and then send the entire specimen to the laboratory.
Catheter Insertion Steps Female Hand Hygiene
Assist patient in to dorsal recumbent position with knees flexed
Open cath tray with sterile technique
With thumb and finger of nondominant hand, spread the labia and identify the
meatus.
Using the dominant hand, clean the labial fold from top to bottom.
With the dominant hand, hold a lubricated catheter 2 to 3 inches from the tip and
insert slowly into the urethra.
Advance the catheter another 2 to 3 inches after the initial return of urine.
Inflate catheter balloon
Secure to patient's leg
ACTUAL Questions and CORRECT Answers
Evidence Based Practice Evidence-based practice (EBP) in nursing is a problem-solving approach to
making clinical decisions, using the best evidence available (considered "best"
because it is collected from sources such as published research, national
standards and guidelines, and reviews of targeted literature).
Erikson's Psychosocial Theory Older Adults Integrity vs. Despair
People in late adulthood reflect on their lives and feel either a sense of
satisfaction or a sense of failure. People who feel proud of their accomplishments
feel a sense of integrity, and they can look back on their lives with few regrets.
Droplet Precautions Droplet Precautions:
Use a private room, if available. Door may remain open.
Wear PPE upon entry into the room for all interactions that may involve contact
with the patient and potentially contaminated areas in the patient's environment.
Transport patient out of room only when necessary and place a surgical mask on
the patient if possible.
Keep visitors 3 ft from the infected person.
Why are masks beneficial with droplet precautions? Masks help prevent the wearer from inhaling large-particle aerosols, which
usually travel short distances (about 3 ft), and small-particle droplet nuclei, which
can remain suspended in the air and travel longer distances. Masks also protect
the patient from the respiratory secretions of the health care worker. Masks
discourage the wearer from touching the eyes, nose, and mouth, thus limiting
contact of organisms with mucous membranes.
,Cough Etiquette Any patients, family members, and visitors with undiagnosed, transmissible
respiratory infections require education to cover their mouth and nose with a
tissue when coughing and promptly dispose of the tissue. During periods of
increased occurrence of respiratory infections, offer a surgical mask to coughing
patients and other symptomatic people upon entry to the health care facility or
office. Encourage the coughing patient to maintain more than a 3-ft separation
from other people in the health care facility or office.
Factors Affecting Risk for Infection Factors affecting the risk for infection include: integrity of mucous membranes, pH
levels of the gastrointestinal and genitourinary tracts, immune response, age, sex,
race, heredity, level of fatigue, nutritional status, stress level, use of invasive or
indwelling medical devices and immunizations (natural or acquired)
Abnormal Wound Drainage Purulent drainage is made up of white blood cells, liquefied dead tissue debris,
and both dead and live bacteria. Purulent drainage is thick, often has a musty or
foul odor, and varies in color (such as dark yellow or green), depending on the
causative organism.
Pressure Ulcer Stage 1 A stage 1 pressure injury is a defined, localized area of intact skin with
nonblanchable erythema (redness). Darkly pigmented skin may not have visible
blanching; its color may differ from the surrounding skin. The area may be painful,
firm, soft, warmer, or cooler as compared to adjacent tissue
Pressure Ulcer Stage 2 A stage 2 pressure injury involves partial-thickness loss of dermis and presents as
a shallow, open ulcer or a ruptured/intact serum-filled blister
Pressure Ulcer Stage 3 A stage 3 pressure injury presents with full-thickness tissue loss. Subcutaneous fat
may be visible and epibole (rolled wound edges) may occur, but bone, tendon, or
muscle is not exposed. Slough and/or eschar that may be present do not obscure
the depth of tissue loss. Ulcers
Pressure Ulcer Stage 4 Stage 4 injuries involve full-thickness tissue loss with exposed or palpable bone,
cartilage, ligament, tendon, fascia, or muscle. Slough or eschar may be present on
some part of the wound bed; epibole, undermining, and/or tunneling often occur
Wound Infection Symptoms of infection include purulent drainage; increased drainage, pain,
redness, and swelling in and around the wound; increased body temperature; and
increased white blood cell count. Additional signs and symptoms include delayed
healing and discoloration of granulation tissue in the wound
Braden Scale Braden Scale: mental status, continence, mobility, activity, and nutrition
Using the Braden scale (VHMMN)
Lower to 9 Very high risk-V
10 to 12 High risk-H
13 to 14 Moderate risk-M
15 to 18 Mild risk-M
19 to 23 indicate No risk-N
, Heat Application The application of heat accelerates the inflammatory response to promote
healing.
The application of local heat dilates peripheral blood vessels, increases tissue
metabolism, reduces blood viscosity and increases capillary permeability, reduces
muscle tension, and helps relieve pain. Vasodilation increases local blood flow. In
turn, the supply of oxygen and nutrients to the area is increased, and venous
congestion is decreased
Careful on large parts of the body
Dysnpea Positioning High Fowler's Position because accessory muscles can easily be used to promote
respirations
Partial Rebreather Mask Low Flow 8-11L/min, set flow rate so the mask remains two thirds full during
inspiration, keep reservoir bag free of twists or kinks
Cyanosis Cyanosis (bluish discoloration) of these areas indicates decreased blood flow or
poor blood oxygenation
Fish Oil Of all the natural products, fish oil and glucosamine, chondroitin, or a combination
supplement were the products most commonly used by adults in 2012.
Beneficial to many aspects of health; from muscle activity to cell growth.
Ventrogluteal The ventrogluteal site is recommended for general IM injections in adults
Adult Ear Drop Administration up and back
Clear Liquid Diet Clear liquids are transparent and liquid at room temperature. Example: apple
juice, popsicle, coffee tea, clear broth, gelatin, clear fruit juice like apple,
cranberry, and grape.
GT Feeding Residual Check gastric residual (feeding remaining in the stomach) before each feeding or
every 4 to 6 hours during a continuous feeding (according to institution policy).
High gastric residual volumes (200 to 250 mL or greater) can be associated with
high risk for aspiration and aspiration-related pneumonia
24 Hour Urine Specimen Collection of ALL urine voided during a 24 hour period.
Initiate a collection at a specific time (which is recorded) by asking the patient to
empty the bladder. Discard this urine and then collect all urine voided for the next
24 hours. At the end of the 24 hours, ask the patient to void. Add this urine to the
previously collected urine, and then send the entire specimen to the laboratory.
Catheter Insertion Steps Female Hand Hygiene
Assist patient in to dorsal recumbent position with knees flexed
Open cath tray with sterile technique
With thumb and finger of nondominant hand, spread the labia and identify the
meatus.
Using the dominant hand, clean the labial fold from top to bottom.
With the dominant hand, hold a lubricated catheter 2 to 3 inches from the tip and
insert slowly into the urethra.
Advance the catheter another 2 to 3 inches after the initial return of urine.
Inflate catheter balloon
Secure to patient's leg
