HESI 1 (questions and correct answers Latest )

HESI 1 (questions and correct answers Latest ) 1. Moving a patient with a catheter.: Priority action =secure IV bag before the move 2. Chronic pain patient who reports only taking medication when "he feels pain." What should the nurse do?: Nurse should recommend that the patient take his medication as prescribed. 3. What should the nurse ask a client who is having pain?: "tell me about the quality of your pain" The quality of pain experienced is typically a descriptive term, such as burning, crushing, aching or stabbing. Evaluating the effectiveness of a pain intervention requires you to evaluate for change in the severity and quality of the pain. Also be sure to evaluate after an appropriate period of time. For instance, oral medications usually peak in about 1 hour; whereas IVP medications peak in 15 to 30 minutes. Ask a patient if a medication alleviates the pain when it is peaking. Do not expect the patient to volunteer the information. Evaluate psychological and physiological responses to pain (e.g., vital sign changes and asking questions such as, "Do you feel more at ease or less anxious since we administered the medication?" It is also important to evaluate if the patient has any adverse effects from pain therapies. (Potter 1045) 4. The nurse is deciding an appropriate goal for a patient in pain.: Learn pain control techniques orReport pain 5 points less on the pain scale Efforts aimed at teaching and motivating a patient toward self-care can be hindered until the pain is managed successfully. Complete pain relief is not always achievable, but reducing pain to a tolerable level is a realistic goal. A primary nursing goal is to provide pain relief that allows patients to participate in their recovery, prevent complications, and improve functional status. Unrelieved acute pain can progress to chronic pain (Potter 1017) Acute--*Ask patient what their pain-intensity goal (on a scale of 0 to 10) is? She says that a pain intensity of 5 on a scale of 0 to 10 would help her function better right now. A goal of 3 is preferable. (Potter 1028) Chronic- teach 5. Opioids and constipation info:: Patient Characteristics Associated with Higher Risk for Opioid-Related Adverse Drug Events • Sleep apnea or sleep disordered breathing • Morbid obesity with high risk of sleep apnea • Snoring • Older age • Significant co-morbidities (cardiac, pulmonary, or major organ failure) • No recent opioid use • Increased opioid dose requirement • Receiving other sedating medications (e.g., antihistamines, antipsychotics) • Recent surgery, especially thoracic or upper abdominal • Prolonged general anesthesia (Potter 1037) 6. Goals for a stroke patient regarding ADL's.: Have patient help to his full copacity *after a stroke, a patient likely receives gait training from a physical therapist; speech rehabilitation from a speech therapist; and help from an occupational therapist for ADLs such as dressing, bathing and toileting, or household chores. *The therapy is not always able to restore total functional health, but it often helps the patient adapt to the mobility limitations or complications.* Equipment frequently used to help patients adapt to mobility limitations includes walkers, canes, wheelchairs, and assistive devices such as toilet seat extenders, reaching sticks, special silverware, and clothing with Velcro closures. (Potter 430) 7. Nurse discovers that a patient's family has removed a patients restraints. What should the nurse do?: Assess the patient First!! then involve a Dr if more restraints are required, and if the patient is a danger to themselves or others a new is required for reapplication. 8. Nurse gave wrong medications. What is the primary reaction for nurse?: As- sess the patient for adverse reactions. Stay with patient till an appropriate amount of time has passed. 9. Criteria for patient to receive education on obesity.: Assess patient's BMI to determine if obesity education is necessary 10. Patient with left sided weakness needs to be moved from bed to wheel- chair.: Place wheel chair on right side. (Always the opposite side of the immobile body part 11. Patient has cyanotic fingers. What should the nurse assess 1st?: Respira- tions are the most relevant priority Pulse Oxygen information is not disclosed. Patient has altered neurovascular status of an extremity such as cyanosis, pallor, and coldness of skin or complains of tingling, pain, or numbness. • If restraints are present, immediately remove them and then obtain assistance from a health care provider. Always stay with patient. (Potter 403) 12. What should a nurse do to prevent infections for a patient with a catheter?- : Ask patient to increase fluid intake and offer addition beverage options to encour- age patient compliance. 13. Nurse notes abnormally low blood pressure in the arm of her patient. What should the nurse do?: Priority action is to take the blood pressure in the other arm to fully assess the blood pressure before notifying a health care provider or accepting the data without inquisition. 14. What is an issue with computerized documentation at bedside?: Poor eye contact 15. Assessing orthostatic hypotension: Take the blood pressure 1st why the patient is ****lying down.*****