HESI Fundamentals Exam Practice
Questions
False-low readings on BP cuff factors: - ✔✔- Cuff too wide
- Above heart level
- Stethoscope applied too firmly against AC fossa
- Inadequate inflation level
False-high readings on BP cuff factors: - ✔✔- Cuff too narrow or too short
- Cuff wrapped too loosely or unevenly
- Arm below heart level
- Arm not supported
- Inflating too slowly
- Repeating assessments too quickly
Technique for taking BP in the leg; popliteal artery. - ✔✔Lower extremity BP cuff positioned
above popliteal artery at mid-thigh with knee flexed.
Popliteal BP - ✔✔Systolic BP: 10-40 mmHg higher than brachial.
Diastolic BP: remain the same.
Orthostatic BP readings: - ✔✔(Postural Hypotension)
- Obtain supine, sitting, and standing (1-3 mins between each).
- Observe pt. for dizziness, fainting, lightheadedness.
- Record pts. position with each reading (remember safety!)
- Don't delegate this!
,NORMAL VITA SIGNS - ✔✔Blood pressure: 120/80
Temperature:
RR:
HR:
O2: 95-100%
Pulse Deficit - ✔✔The difference between the rate of an apical pulse and the rate of a radial
pulse.
- Count apical pulse while a colleague counts radial pulse. Count out loud to simultaneously
assess pulses. If pulse count differs by more than 2, a pulse deficit exists, which sometimes
indicates alterations in cardiac output.
Pulse deficit in lower extremities - ✔✔- If pedal pulse is weak on one side, assess next pulse up
(posterior tibial).
- If that pulse is weak, move up to popliteal.
- Compare one extremity to another.
Apical pulse - ✔✔Taken for 1 full minute; PMI (point of maximal impulse) located at 4th or 5th
intercostal space (ICS), medial/left mid-clavicular line (MCL).
Pt. with elevated BP, c/o headache, and what might that indicate? what do you do next? -
✔✔Reassess using other arm. Do not keep taking BP on same extremity.
Normal heart sounds - ✔✔S1 and S2 (lub dub)
If there's a fever? - ✔✔Assess for more data needed!
, Exercise and sleep - ✔✔Exercise 2hrs before bedtime; allows cool down period and fatigue that
promotes relaxation.
- Should not exercise closer to bedtime.
Factors affecting sleep - ✔✔- drugs and substances
- lifestyle
- usual sleep patterns
- emotional stress
- environment
- exercise and fatigue
- food and caloric intake
Sleep is subjective - ✔✔Take what the patient says.
Sleep problems - ✔✔Altered sleep and pain; treat pain first.
Benzodiazepines (lam, pam) and barbiturates (barbital) - ✔✔Be aware of CNS depression;
If taking a benzo for sleep, nurse needs to provide continued assessment for respiratory
depression.
ANTIDOTE: Flumazenil (Romazicon).
Prioritize assessment in a variety of patients: - ✔✔Think ABC's, acute/chronic pain, and
unstable/stable.
Normal sleep patterns and interventions to help pt. return to normal sleep patterns; - ✔✔types
of non-pharmacologic interventions (before giving meds).
- Environmental control
Questions
False-low readings on BP cuff factors: - ✔✔- Cuff too wide
- Above heart level
- Stethoscope applied too firmly against AC fossa
- Inadequate inflation level
False-high readings on BP cuff factors: - ✔✔- Cuff too narrow or too short
- Cuff wrapped too loosely or unevenly
- Arm below heart level
- Arm not supported
- Inflating too slowly
- Repeating assessments too quickly
Technique for taking BP in the leg; popliteal artery. - ✔✔Lower extremity BP cuff positioned
above popliteal artery at mid-thigh with knee flexed.
Popliteal BP - ✔✔Systolic BP: 10-40 mmHg higher than brachial.
Diastolic BP: remain the same.
Orthostatic BP readings: - ✔✔(Postural Hypotension)
- Obtain supine, sitting, and standing (1-3 mins between each).
- Observe pt. for dizziness, fainting, lightheadedness.
- Record pts. position with each reading (remember safety!)
- Don't delegate this!
,NORMAL VITA SIGNS - ✔✔Blood pressure: 120/80
Temperature:
RR:
HR:
O2: 95-100%
Pulse Deficit - ✔✔The difference between the rate of an apical pulse and the rate of a radial
pulse.
- Count apical pulse while a colleague counts radial pulse. Count out loud to simultaneously
assess pulses. If pulse count differs by more than 2, a pulse deficit exists, which sometimes
indicates alterations in cardiac output.
Pulse deficit in lower extremities - ✔✔- If pedal pulse is weak on one side, assess next pulse up
(posterior tibial).
- If that pulse is weak, move up to popliteal.
- Compare one extremity to another.
Apical pulse - ✔✔Taken for 1 full minute; PMI (point of maximal impulse) located at 4th or 5th
intercostal space (ICS), medial/left mid-clavicular line (MCL).
Pt. with elevated BP, c/o headache, and what might that indicate? what do you do next? -
✔✔Reassess using other arm. Do not keep taking BP on same extremity.
Normal heart sounds - ✔✔S1 and S2 (lub dub)
If there's a fever? - ✔✔Assess for more data needed!
, Exercise and sleep - ✔✔Exercise 2hrs before bedtime; allows cool down period and fatigue that
promotes relaxation.
- Should not exercise closer to bedtime.
Factors affecting sleep - ✔✔- drugs and substances
- lifestyle
- usual sleep patterns
- emotional stress
- environment
- exercise and fatigue
- food and caloric intake
Sleep is subjective - ✔✔Take what the patient says.
Sleep problems - ✔✔Altered sleep and pain; treat pain first.
Benzodiazepines (lam, pam) and barbiturates (barbital) - ✔✔Be aware of CNS depression;
If taking a benzo for sleep, nurse needs to provide continued assessment for respiratory
depression.
ANTIDOTE: Flumazenil (Romazicon).
Prioritize assessment in a variety of patients: - ✔✔Think ABC's, acute/chronic pain, and
unstable/stable.
Normal sleep patterns and interventions to help pt. return to normal sleep patterns; - ✔✔types
of non-pharmacologic interventions (before giving meds).
- Environmental control
