HESI RN MED SURG
(Thoracentesis) What Position you going to place them in? - ANS Upright leaning over table to
increase lung expansion
Metabolic Acidosis Respirations - - ANS Kussmaul respirations
Wheezing - ANS are short high pitched sounds made on expiratory
Abnormal Breathe sounds - - ANS used to describe bronchial or bronchovesicular sounds
heard in the peripheral lung fields.
Adventitous sounds - - ANS are extra breath sounds that are abnormal
The presence of bronchovesicular breath sounds in the peripheral lung fields is described as? -
- ANS abnormal lung sounds
To prepare the patient for a thoracentesis, the nurse positions the patient - - ANS sitting
upright with the elbows on an over-the-bed table.
Bronchoscopy - ANS After procedure keep the patient NPO until gag reflux returns.
Hypoxemia - - ANS PaO2 is at 55% and SpO2 is 88
What test do you use to verify pulmonary embolus? - - ANS CT scan
A patient with an SaO2 of 85% has a PaO2 of 50mm Hg. This indicates? - - ANS shift to the
left in the oxygen-hemoglobin dissociation curve that could be caused by hypothermia.
Normal Arterial Blood Gases - - ANS pH 7.35-7.45, PaO2 80-100mm Hg, SaO2 >95%,
PaCO2 32-48 mm Hg, HCO3- 22-26 mEq/L
To determine when the patient with a tracheostomy tube can be effectively swallow, the nurse
deflates the cuff and? - - ANS has the patient drink a small amount of blue-colored water,
observing for coughing and colored secretions.
When obtaining a health history from a patient with possible cancer of the mouth, the nurse
would expect the patient to report? - - ANS Heavy tobacco and alcohol use.
The most normal functioning method of speech restoration in the patient with a total
larynectomy is - - ANS a voice presthesis
A patients tracheostomy tube becomes dislodged with vigorous coughing. The first action by the
nurse is to? - - ANS attempt to replace the tube
What will the nurse teach a patient with pneumonia? - - ANS Deep breathing and coughing
Fine Crackles - - ANS short-duration, discontinuous, high pitched sounds heard just before the
end of inspiration. In pneumonia or heart failure.
Coarse Crackles - - ANS long duration, discontinuous, low pitched sounds caused by air
passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of
mucosa; evident with inspiration. COPD, heart failure, and pneumonia.
Absent breath sounds - - ANS no sound evident over entire lung or area of lung. Pleural
effusion or lobectomy
Peritonsillar abscess - - ANS is a complication of acute pharyngitis or acute tonsillitis when
bacterial infection invades one or both tonsils. The tonsil may enlarge sufficiently to threaten
airway patency. Also known as the hot potato voice. The patient experience a high fever,
leukocytosis, and chills.
Sputum Test for TB - - ANS 3 seperate sputum test over 3 days. Airborne precautions until 3
negative sputum samples. HEPA mask required.
INH - - ANS latent TB and treat 6 to 9 months.
,Rifampin side effects and considerations - - ANS Hepatitis, thrombocytopenia, orange
discoloration of bodily fluids (Sputum, urine, sweat, tears).
BCG or Bacille Calmette-Guerin - ANS Immigrants have been vaccinate in parts of the world
with high TB. Do not give TB test only chest x-ray.
A patient with pneumonia has a nursing diagnosis pf ineffective airway clearance related to pain,
fatigue, and thick secretions. An appropriate nursing intervention for the patient is to - - ANS
Encourage fluid intake of 3L/day
Diagnose Pulmonary Emboli - ANS with at CAT scan or MRI
Hypothermia - - ANS SPO2 96%. What is the nurse going to do? Turn oxygen up.
Symptom of primary pulmonary hypertension - - ANS dyspnea with exertion
Sepsis - - ANS 2 blood draws from 2 different sites before start ABT
Pseudomonis - - ANS thick green mucous
Proventil side effects - - ANS tachycardia, BP changes, nervousness, palpitations, muscle
tremors, nausea, vomiting, vertigo, insomnia, dry mouth, headache, hypokalemia.
On examining a patient 8 hours after formation of a colostomy, the nurse would expect to find - -
ANS a brick-red, puffy stoma that oozes blood.
A patient is admitted to the emergency department with acute abdominal pain. The nursing
intervention that should be implemented first is - - ANS measurement of vital signs
The nurse identifies a need for additional teaching when a patient with acute infectious diarrhea
states, - - ANS "I may use over-the-counter lopermide (Immodium) or Parepectolin as need to
control the diarrhea."
Following a Billroth II procedure, a patient develops dumping syndrome. The nurse explains that
the symptoms associated with this problem are caused by - - ANS movement of fluid into the
small bowel because concentrated food and fluids move rapidly into the intestine
Nursing management of the patient with chronic gastritis includes teaching the patient to - -
ANS Maintain a non irritating diet with six small meals a day
Following a patient's esophagogastrostomy for cancer of the esophagus, it is important for the
nurse to - - ANS maintain the patient in sem-fowler's or fowler's position
The nurse teaches the patient with a hiatal hernia or GERD to control symptoms by - - ANS
Sleeping with the head of the bed elevated on 4 to 6 inch blocks
A patient treated for vomiting for several days from an unknown cause is admitted to the
hospital. The nurse anticipates collaborative care to include - - ANS IV replacement of fluid
and electrolytes.
The nurse is caring for a patient receiving 1000mL of PN solution over 24 hours. When it is time
to change the solution, 150mL remain in the bottle. The most appropriate action by the nurse is
to - - ANS Hang a new solution and discard the unused solution.
Before administering a bolus of intermittent tube feeding to a patient with percutaneous
endoscopic gastrostomy (PEG), the nurse aspirates 220mL of gastric contents. The nurse
should - - ANS return the aspirate to the stomach and continue with the tube feeding as
planned.
The nurse evaluates that patient teaching about a high-calorie, high protein diet has been
effective when the patient selects for breakfast from the hospital menu - - ANS two poached
eggs, hash brown potatoes, and whole milk
, While receiving a unit of packed RBCs, the patient develops chills and a temperature of 102.2 F.
The priority action for the nurse to take is - - ANS Stop the transfusion and removes the IV
catheter
A patient is admitted to the hospital for evaluation and treatment of thrombocytopenia. Which of
the following actions is most important for the nurse to implement? - - ANS Monitoring the
patient for headaches, vertigo, or confusion
A patient has a platelet count of 50,000/uL and is diagnosed with immune thrombocytopenia
purpura. The nurse anticipates that initial treatment will include - - ANS corticosteroids
During the assessment of a patient with cobalamin deficiency, the nurse would expect to find
that the patient has? - - ANS Paresthesia of the hands and feet
The strict vegetarian is at highest risk for the development of ? - cobalamin deficiency anemia -
ANS cobalamin deficiency anemia
Endoscopic retrograde cholangiopanceatography (ERCP) - - ANS Nursing responsibility is to
explain procedure to patient, including patients role. Keep patient NPO 8 hour before procedure.
Ensure consent is signed. Administer sedation. Administer ABT. Check VS and check for
perforation or infection. Check Gag reflex
Esophagogastroduodenoscopy (EGD). - - ANS After procedure you keep the patient NPO
until gag reflex returns. Gently tickle back of throat to determine reflex. Use warm saline gargles
for relief of throat. Check temp for 15-30min for 1-2hr.
Nursing responsibility for ultrasound - - ANS Instruct patient to be NPO 8-12 hour before
ultrasound. Air or gas can reduce quality of images. Food intake can cause gallbladder
contraction, resulting in suboptimal study
Palpate the liver - - ANS place your left hand behind the patient to support the right eleventh
and twelfth ribs. Press the left hand forward and place the right hand on patients right abdomen
later to the rectus muscle.
Abdomen auscultation need further evaluation - ANS absent
Jaundice (History) - - ANS Need for patient teaching inf they take tylenol.
After Procedure colonoscopy - - ANS Be aware patient may experience abdominal cramping.
Observe for rectal bleeding and signs of perforation (e.g., malaise, abdominal distension,
tenesmus). Check vital signs.
Before procedure colonoscopy - - ANS Bowel preparation is done. May be on clear liquid diet
for 1-2 days. Enema given the night before. 1 gallon of GoLYTELY evening before. Explain the
that the flexible scope will be inserted in side lying position. Sedation will be give
PRBCS develops chills, fever, anxiety 30 minutes after infusion started. What does the nurse
do? - ANS stop the transfusion.
Blood transfusion reactions the following steps need to be taken - - ANS 1. stop transfusion. 2.
maintain patent IV line with saline solution. 3. notify blood bank and the healthcare provider
immediately; 4. recheck identifying tags and numbers; 5. monitor VS and urine output; 6. treat
symptoms per physician order; 7. save the blood bag and tubing and send them to the blood
bank for examination; 8. complete transfusion report; 9. collect required blood and urine
specimens at intervals stipulated by hospital policy to evaluate hemolysis and 10. document on
transfusion reaction form and patient chart.
Delegation of Blood transfusions - - ANS NAP can obtain blood products from the blood bank
as directed by RN. Take VS before the transfusion and after the first 15 minutes.
(Thoracentesis) What Position you going to place them in? - ANS Upright leaning over table to
increase lung expansion
Metabolic Acidosis Respirations - - ANS Kussmaul respirations
Wheezing - ANS are short high pitched sounds made on expiratory
Abnormal Breathe sounds - - ANS used to describe bronchial or bronchovesicular sounds
heard in the peripheral lung fields.
Adventitous sounds - - ANS are extra breath sounds that are abnormal
The presence of bronchovesicular breath sounds in the peripheral lung fields is described as? -
- ANS abnormal lung sounds
To prepare the patient for a thoracentesis, the nurse positions the patient - - ANS sitting
upright with the elbows on an over-the-bed table.
Bronchoscopy - ANS After procedure keep the patient NPO until gag reflux returns.
Hypoxemia - - ANS PaO2 is at 55% and SpO2 is 88
What test do you use to verify pulmonary embolus? - - ANS CT scan
A patient with an SaO2 of 85% has a PaO2 of 50mm Hg. This indicates? - - ANS shift to the
left in the oxygen-hemoglobin dissociation curve that could be caused by hypothermia.
Normal Arterial Blood Gases - - ANS pH 7.35-7.45, PaO2 80-100mm Hg, SaO2 >95%,
PaCO2 32-48 mm Hg, HCO3- 22-26 mEq/L
To determine when the patient with a tracheostomy tube can be effectively swallow, the nurse
deflates the cuff and? - - ANS has the patient drink a small amount of blue-colored water,
observing for coughing and colored secretions.
When obtaining a health history from a patient with possible cancer of the mouth, the nurse
would expect the patient to report? - - ANS Heavy tobacco and alcohol use.
The most normal functioning method of speech restoration in the patient with a total
larynectomy is - - ANS a voice presthesis
A patients tracheostomy tube becomes dislodged with vigorous coughing. The first action by the
nurse is to? - - ANS attempt to replace the tube
What will the nurse teach a patient with pneumonia? - - ANS Deep breathing and coughing
Fine Crackles - - ANS short-duration, discontinuous, high pitched sounds heard just before the
end of inspiration. In pneumonia or heart failure.
Coarse Crackles - - ANS long duration, discontinuous, low pitched sounds caused by air
passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of
mucosa; evident with inspiration. COPD, heart failure, and pneumonia.
Absent breath sounds - - ANS no sound evident over entire lung or area of lung. Pleural
effusion or lobectomy
Peritonsillar abscess - - ANS is a complication of acute pharyngitis or acute tonsillitis when
bacterial infection invades one or both tonsils. The tonsil may enlarge sufficiently to threaten
airway patency. Also known as the hot potato voice. The patient experience a high fever,
leukocytosis, and chills.
Sputum Test for TB - - ANS 3 seperate sputum test over 3 days. Airborne precautions until 3
negative sputum samples. HEPA mask required.
INH - - ANS latent TB and treat 6 to 9 months.
,Rifampin side effects and considerations - - ANS Hepatitis, thrombocytopenia, orange
discoloration of bodily fluids (Sputum, urine, sweat, tears).
BCG or Bacille Calmette-Guerin - ANS Immigrants have been vaccinate in parts of the world
with high TB. Do not give TB test only chest x-ray.
A patient with pneumonia has a nursing diagnosis pf ineffective airway clearance related to pain,
fatigue, and thick secretions. An appropriate nursing intervention for the patient is to - - ANS
Encourage fluid intake of 3L/day
Diagnose Pulmonary Emboli - ANS with at CAT scan or MRI
Hypothermia - - ANS SPO2 96%. What is the nurse going to do? Turn oxygen up.
Symptom of primary pulmonary hypertension - - ANS dyspnea with exertion
Sepsis - - ANS 2 blood draws from 2 different sites before start ABT
Pseudomonis - - ANS thick green mucous
Proventil side effects - - ANS tachycardia, BP changes, nervousness, palpitations, muscle
tremors, nausea, vomiting, vertigo, insomnia, dry mouth, headache, hypokalemia.
On examining a patient 8 hours after formation of a colostomy, the nurse would expect to find - -
ANS a brick-red, puffy stoma that oozes blood.
A patient is admitted to the emergency department with acute abdominal pain. The nursing
intervention that should be implemented first is - - ANS measurement of vital signs
The nurse identifies a need for additional teaching when a patient with acute infectious diarrhea
states, - - ANS "I may use over-the-counter lopermide (Immodium) or Parepectolin as need to
control the diarrhea."
Following a Billroth II procedure, a patient develops dumping syndrome. The nurse explains that
the symptoms associated with this problem are caused by - - ANS movement of fluid into the
small bowel because concentrated food and fluids move rapidly into the intestine
Nursing management of the patient with chronic gastritis includes teaching the patient to - -
ANS Maintain a non irritating diet with six small meals a day
Following a patient's esophagogastrostomy for cancer of the esophagus, it is important for the
nurse to - - ANS maintain the patient in sem-fowler's or fowler's position
The nurse teaches the patient with a hiatal hernia or GERD to control symptoms by - - ANS
Sleeping with the head of the bed elevated on 4 to 6 inch blocks
A patient treated for vomiting for several days from an unknown cause is admitted to the
hospital. The nurse anticipates collaborative care to include - - ANS IV replacement of fluid
and electrolytes.
The nurse is caring for a patient receiving 1000mL of PN solution over 24 hours. When it is time
to change the solution, 150mL remain in the bottle. The most appropriate action by the nurse is
to - - ANS Hang a new solution and discard the unused solution.
Before administering a bolus of intermittent tube feeding to a patient with percutaneous
endoscopic gastrostomy (PEG), the nurse aspirates 220mL of gastric contents. The nurse
should - - ANS return the aspirate to the stomach and continue with the tube feeding as
planned.
The nurse evaluates that patient teaching about a high-calorie, high protein diet has been
effective when the patient selects for breakfast from the hospital menu - - ANS two poached
eggs, hash brown potatoes, and whole milk
, While receiving a unit of packed RBCs, the patient develops chills and a temperature of 102.2 F.
The priority action for the nurse to take is - - ANS Stop the transfusion and removes the IV
catheter
A patient is admitted to the hospital for evaluation and treatment of thrombocytopenia. Which of
the following actions is most important for the nurse to implement? - - ANS Monitoring the
patient for headaches, vertigo, or confusion
A patient has a platelet count of 50,000/uL and is diagnosed with immune thrombocytopenia
purpura. The nurse anticipates that initial treatment will include - - ANS corticosteroids
During the assessment of a patient with cobalamin deficiency, the nurse would expect to find
that the patient has? - - ANS Paresthesia of the hands and feet
The strict vegetarian is at highest risk for the development of ? - cobalamin deficiency anemia -
ANS cobalamin deficiency anemia
Endoscopic retrograde cholangiopanceatography (ERCP) - - ANS Nursing responsibility is to
explain procedure to patient, including patients role. Keep patient NPO 8 hour before procedure.
Ensure consent is signed. Administer sedation. Administer ABT. Check VS and check for
perforation or infection. Check Gag reflex
Esophagogastroduodenoscopy (EGD). - - ANS After procedure you keep the patient NPO
until gag reflex returns. Gently tickle back of throat to determine reflex. Use warm saline gargles
for relief of throat. Check temp for 15-30min for 1-2hr.
Nursing responsibility for ultrasound - - ANS Instruct patient to be NPO 8-12 hour before
ultrasound. Air or gas can reduce quality of images. Food intake can cause gallbladder
contraction, resulting in suboptimal study
Palpate the liver - - ANS place your left hand behind the patient to support the right eleventh
and twelfth ribs. Press the left hand forward and place the right hand on patients right abdomen
later to the rectus muscle.
Abdomen auscultation need further evaluation - ANS absent
Jaundice (History) - - ANS Need for patient teaching inf they take tylenol.
After Procedure colonoscopy - - ANS Be aware patient may experience abdominal cramping.
Observe for rectal bleeding and signs of perforation (e.g., malaise, abdominal distension,
tenesmus). Check vital signs.
Before procedure colonoscopy - - ANS Bowel preparation is done. May be on clear liquid diet
for 1-2 days. Enema given the night before. 1 gallon of GoLYTELY evening before. Explain the
that the flexible scope will be inserted in side lying position. Sedation will be give
PRBCS develops chills, fever, anxiety 30 minutes after infusion started. What does the nurse
do? - ANS stop the transfusion.
Blood transfusion reactions the following steps need to be taken - - ANS 1. stop transfusion. 2.
maintain patent IV line with saline solution. 3. notify blood bank and the healthcare provider
immediately; 4. recheck identifying tags and numbers; 5. monitor VS and urine output; 6. treat
symptoms per physician order; 7. save the blood bag and tubing and send them to the blood
bank for examination; 8. complete transfusion report; 9. collect required blood and urine
specimens at intervals stipulated by hospital policy to evaluate hemolysis and 10. document on
transfusion reaction form and patient chart.
Delegation of Blood transfusions - - ANS NAP can obtain blood products from the blood bank
as directed by RN. Take VS before the transfusion and after the first 15 minutes.
