HESI Foundations Exam Complete Verified Solution 2023

HESI Foundations Exam Complete Verified Solution 2023 Rectal Temp Insert lubricated thermometer probe(w/cover) into rectum 1-1.5in toward umbilicus; reading is usually 0.9F greater than oral temp Axillary Temp Place thermometer probe in center of axilla; have pt place arm across chest; reading is usually 0.9F lower than oral temp Orthostatic BP readings Orthostatic hypotension aka postural hypotension; obtain supine, sitting, & standing(1-3 min between each); observe pt for dizziness, fainting, lightheadedness; record pts position with each reading; DO NOT DELEGATE Exercise & Sleep Exercise 2hrs before bedtime; allows cool down period and fatigue that promotes relaxation Soaking Feet Part of routine pt hygiene; DO NOT soak feet of pts with diabetes or other peripheral vascular disorders. Can delegate to NAP, but NAP CANNOT trim nails; Soak feet for 10-20 min in warm water, rewarm water after 10min; Nurse can trim nails using clippers, straight across and even with fingertips; DO NOT trim in pts with circulatory problems; Dry thoroughly, apply lotion. Indwelling Catheter Ambulation; never raise drainage bag above level of bladder; prior to ambulation, drain all urine from tubing into drainage bag False-low readings on BP cuff cuff to wide, arm above heart level False-high readings on BP cuff cuff to narrow/short, cuff to loose or uneven, arm not supported False-high diastolic readings on BP cuff deflating cuff to slowly, inflating to slowly Normal vitals