HESI Mid Program Exam Medical-Surgical
to promote wellness, prevent illness, facilitate coping and restore health. - ANS-Four common
goals of nursing
Cultural influence
Perception that supplements are safer and healthier than conventional drugs
Sense of control over one's care
Limited access to professional care
Lack of health insurance
Convenience
Media hype and aggressive marketing
Recommendation from family and friends - ANS-Reasons why clients use herbal medications
-dehydration from excessive fluid loss in diaphoresis.
-increases metabolism and oxygen demand. - ANS-increased temperature
Altered LOC, depressed or absent gag and cough reflexes, or is susceptible to aspirating
oropharyngeal secretions; when feeding, raise the HOB and position the client on his or her
side, not on the back - ANS-High risk for pneumonia
are heard over areas of density or consolidation. Sound waves are easily transmitted over
consolidated tissue. - ANS-bronchial breath sounds
Irritability and restlessness - ANS-Early signs of cerebral hypoxia (brain is not getting enough
energy)
flu shots, pneumonia immunizations, avoiding sources of infection and indoor pollutants (dust,
smoke, and aerosols) no smoking - ANS-pneumonia preventatives
older adults
flu shots, pneumonia immunizations, infection avoidance, sensible nutrition, adequate fluid
intake, balance of rest and activity. - ANS-pneumonia preventatives
immunosuppressed and debilitated persons
Elevate HOB at least 30 degrees to feed and for 1hr after feeding, position on the side to
prevent aspiration, frequently turn patient. - ANS-pneumonia preventatives
comatose and immobile patients
elevate HOB 30-45 degrees to prevent aspiration and ventilator- associated pneumonia. -
ANS-pneumonia preventatives
ventilated clients
,happens through the lungs, most often to correct acid-base imbalances. - ANS-respiratory
compensation
can be facilitated by semi-fowler or high fowler positions, which lessen pressure on the
diaphragm from abdominal organs. - ANS-productive cough and comfort
adult 7.35-7.45
child 7.36-7.44 - ANS-ph
35-45 mm Hg - ANS-PCO2
80-100 mm Hg - ANS-PO2
22-26 mEq/L - ANS-HCO3
indicative of emphysema and is caused by using overinflated muscles to breathe, which causes
the person to work harder to breathe, but the amount of O2 taken in is inadequate to oxygenate
the tissues. - ANS-Barrel chest
occurs with chronic bronchitis and leads to generalized cyanosis and often right-sided heart
failure. The client may appear cyanotic (blue-tinged skin) - ANS-Insufficient oxygenation
manifested by cyanosis and slow capillary refill (>3 seconds) a chronic sign is clubbing of the
fingernails, and a late sign is clubbing of fingers. - ANS-Inadequate arterial oxygenation
use O2 with caution. stimulus to breathe is hypoxia, not the usual hypercapnia, the stimulus to
breathe for healthy persons. If too much oxygen is given, the client may stop breathing. -
ANS-COPD
A- airway first
B- breathing
C- circulation - ANS-When asked to prioritize nursing actions, use the ABC rule
C- circulation first
A- then airway
B- then breathing - ANS-cardiopulmonary resuscitation (CPR) circumstances, follow the CAB
guidelines.
If breath sounds are clear but the client is cyanotic and lethargic, adequate oxygenation is not
occurring. - ANS-Look and Listen!
, the key is to auscultate breath sounds as well as visualize the client. Breath sounds are better
"described" not named. ("crackles," "wheeze," high pitched whistling sound") - ANS-respiratory
status
The tongue and mouth often appear white, gray, dark brown, or black and may appear patchy. -
ANS-Cancer of the larynx
Involves cleaning the inner cannula, suctioning, and applying clean dressings. Suctioning is
preformed PRN but is not required every time tracheostomy care is provided. -
ANS-tracheostomy care
choking, they cannot cough as before because there glottis is gone. teach the "glottal stop"
technique to remove secretions. (take a deep breath, momentarily occlude the tracheostomy
tube, cough and simultaneously remove the finger from the tube.) - ANS-What is a big fear for
laryngectomy patients?
if the chest tube becomes disconnected, do not clamp! Immediately place the end of the tube in
a container of sterile saline or water until new drainage system can be connected.
If it is removed cover with dry sterile dressing.
Notify HCP immediately - ANS-Chest tubes
will occur if there is no external suction. - ANS-Fluctuations (tidaling)
inability of air sacs to fill and empty properly (emphysema, cystic fibrosis)
Obstruction of the air passages (carcinoma, asthma, chronic bronchitis)
Accumulation of fluid in the air sacs (pneumonia)
Respiratory muscle fatigue (COPD, pneumonia, degenerative diseases such as multiple
sclerosis (MS), myasthenia gravis (MG) - ANS-Ineffective breathing patterns
excrete approximately 1 mL of urine per kg of body weight per hr, which is about 1-2L/24hrs for
adults. - ANS-Normal kidneys
1L of water - ANS-1 kg of weight =
Dyspnea
tachycardia
jugular vein distention
peripheral edema
pulmonary edema
weight gain - ANS-Excess fluid symptoms
decreased urine output
reduction in body weight
decreased skin turgor
to promote wellness, prevent illness, facilitate coping and restore health. - ANS-Four common
goals of nursing
Cultural influence
Perception that supplements are safer and healthier than conventional drugs
Sense of control over one's care
Limited access to professional care
Lack of health insurance
Convenience
Media hype and aggressive marketing
Recommendation from family and friends - ANS-Reasons why clients use herbal medications
-dehydration from excessive fluid loss in diaphoresis.
-increases metabolism and oxygen demand. - ANS-increased temperature
Altered LOC, depressed or absent gag and cough reflexes, or is susceptible to aspirating
oropharyngeal secretions; when feeding, raise the HOB and position the client on his or her
side, not on the back - ANS-High risk for pneumonia
are heard over areas of density or consolidation. Sound waves are easily transmitted over
consolidated tissue. - ANS-bronchial breath sounds
Irritability and restlessness - ANS-Early signs of cerebral hypoxia (brain is not getting enough
energy)
flu shots, pneumonia immunizations, avoiding sources of infection and indoor pollutants (dust,
smoke, and aerosols) no smoking - ANS-pneumonia preventatives
older adults
flu shots, pneumonia immunizations, infection avoidance, sensible nutrition, adequate fluid
intake, balance of rest and activity. - ANS-pneumonia preventatives
immunosuppressed and debilitated persons
Elevate HOB at least 30 degrees to feed and for 1hr after feeding, position on the side to
prevent aspiration, frequently turn patient. - ANS-pneumonia preventatives
comatose and immobile patients
elevate HOB 30-45 degrees to prevent aspiration and ventilator- associated pneumonia. -
ANS-pneumonia preventatives
ventilated clients
,happens through the lungs, most often to correct acid-base imbalances. - ANS-respiratory
compensation
can be facilitated by semi-fowler or high fowler positions, which lessen pressure on the
diaphragm from abdominal organs. - ANS-productive cough and comfort
adult 7.35-7.45
child 7.36-7.44 - ANS-ph
35-45 mm Hg - ANS-PCO2
80-100 mm Hg - ANS-PO2
22-26 mEq/L - ANS-HCO3
indicative of emphysema and is caused by using overinflated muscles to breathe, which causes
the person to work harder to breathe, but the amount of O2 taken in is inadequate to oxygenate
the tissues. - ANS-Barrel chest
occurs with chronic bronchitis and leads to generalized cyanosis and often right-sided heart
failure. The client may appear cyanotic (blue-tinged skin) - ANS-Insufficient oxygenation
manifested by cyanosis and slow capillary refill (>3 seconds) a chronic sign is clubbing of the
fingernails, and a late sign is clubbing of fingers. - ANS-Inadequate arterial oxygenation
use O2 with caution. stimulus to breathe is hypoxia, not the usual hypercapnia, the stimulus to
breathe for healthy persons. If too much oxygen is given, the client may stop breathing. -
ANS-COPD
A- airway first
B- breathing
C- circulation - ANS-When asked to prioritize nursing actions, use the ABC rule
C- circulation first
A- then airway
B- then breathing - ANS-cardiopulmonary resuscitation (CPR) circumstances, follow the CAB
guidelines.
If breath sounds are clear but the client is cyanotic and lethargic, adequate oxygenation is not
occurring. - ANS-Look and Listen!
, the key is to auscultate breath sounds as well as visualize the client. Breath sounds are better
"described" not named. ("crackles," "wheeze," high pitched whistling sound") - ANS-respiratory
status
The tongue and mouth often appear white, gray, dark brown, or black and may appear patchy. -
ANS-Cancer of the larynx
Involves cleaning the inner cannula, suctioning, and applying clean dressings. Suctioning is
preformed PRN but is not required every time tracheostomy care is provided. -
ANS-tracheostomy care
choking, they cannot cough as before because there glottis is gone. teach the "glottal stop"
technique to remove secretions. (take a deep breath, momentarily occlude the tracheostomy
tube, cough and simultaneously remove the finger from the tube.) - ANS-What is a big fear for
laryngectomy patients?
if the chest tube becomes disconnected, do not clamp! Immediately place the end of the tube in
a container of sterile saline or water until new drainage system can be connected.
If it is removed cover with dry sterile dressing.
Notify HCP immediately - ANS-Chest tubes
will occur if there is no external suction. - ANS-Fluctuations (tidaling)
inability of air sacs to fill and empty properly (emphysema, cystic fibrosis)
Obstruction of the air passages (carcinoma, asthma, chronic bronchitis)
Accumulation of fluid in the air sacs (pneumonia)
Respiratory muscle fatigue (COPD, pneumonia, degenerative diseases such as multiple
sclerosis (MS), myasthenia gravis (MG) - ANS-Ineffective breathing patterns
excrete approximately 1 mL of urine per kg of body weight per hr, which is about 1-2L/24hrs for
adults. - ANS-Normal kidneys
1L of water - ANS-1 kg of weight =
Dyspnea
tachycardia
jugular vein distention
peripheral edema
pulmonary edema
weight gain - ANS-Excess fluid symptoms
decreased urine output
reduction in body weight
decreased skin turgor
