Exit HESI (Testing, Leadership, Advanced Clinical Concepts, and Medical-Surgical) Study Guide 2024

Examples of negative style questions - "Which response should the nurse question?" "Which response indicates the nurse needs to reteach the patient?" Note: most questions on the HESI are written in positive style, not negative How to determine priority for answers - In addition to ADPIE, ABC, and picking the least invasive intervention first, you can use Maslow's hierarchy of needs to set priorities for what should be done first 1. Physiological: food, water, warmth, rest 2. Safety: safety and security 3. Belonging and love: intimate relationships and friends 4. Esteem: prestige, feelings of accomplishment, and self-image 5. Self-actualization: utilizing one's full potential, morality, spontaneity, creativity, etc. Explaining procedures to clients - Remember, the nurse cannot explain it first... It needs to be the healthcare provider. The RN's responsibility is that the informed consent form is signed, but not to ensure the patient understands. If the patient has questions about a procedure before signing, the HCP needs to come back to further explain Good Samaritan Act - This protects health practitioners against malpractice claims for care provided in emergency situations (i.e. a nurse giving CPR at the site of a car accident) Use of restraints - Restraints of any kind may constitute false imprisonment if used incorrectly. Clients may only be restrained in an emergency, for a limited time, or for the purpose of protecting the client from injury or harm What types of procedures should be assigned to a professional nurse? - Sterile or invasive procedures Note: the test uses the acronym UAP, meaning unlicensed assistive personnel. These would be examples of people who are not professional nurses and could not carry out such procedures What actions should a nurse take if he or she questions a health care provider's prescription and believes it to be wrong? - Inform the HCP; record that the HCP was informed and what his or her response was to that information; inform nursing supervisor; refuse to carry out prescription UAPs - Unlicensed assistive personnel cannot be given tasks that require the use of these parts of the nursing process: assessments (like actual assessing the patient, not vital signs), analysis, diagnosis, planning, and evaluation. Delegated activities would fall within the "implementation" phase More on prioritization - Which client is the most critically ill? Which client is most likely to experience a significant change in condition? Which client requires an assessment by an RN? What is ARDS? - An unexpected, catastrophic pulmonary complication occurring in a person with no previous pulmonary problems. Client are critically ill and managed in intensive care setting. Mortality rate is 50% Prevent complications of clients on mechanical ventilation with ARDS - -Elevate HOB ≥ 30º -Assist with sedation vacations -Implement comprehensive oral hygiene -Implement comprehensive mobilization program Frequency of suctioning - Suction only when secretions are present (but assess need for suctioning q2h) What test is done before drawing ABGs? - Allen's test for collateral circulation and arterial patency Signs of acute respiratory failure in children - Restlessness, tachypnea, tachycardia, and diaphoresis -A child in severe distress should be on 100% O2 Respiratory failure lab values - PCO2>45 or PO2<60 on 50% O2 signifies respiratory failure Four common causes of respiratory failure in children - Congenital heart disease, infection or sepsis, respiratory distress syndrome, aspiration, fluid overload, or dehydration Early signs of shock - Agitation and restlessness (resulting from cerebral hypoxia) Pathophysiology of shock - Leads to widespread cellular injury and impairs the integrity of the capillary membranes. Fluid and osmotic proteins seep into the extravascular spaces, further reducing cardiac output. If all organs are damaged from decreased perfusion, the damage could be permanent.