rn exit hesi Clinical Assessment Guide 2025 |
Accurate Answers | Exam Ready
normal blood pressure - 120/80
normal spo2 - 95-100
normal pulse - 60-100
normal adult respirations
normal children respirations - 16-20
16-30
glucose level - 70-110
normal wbc
normal platelets - 5000-10,000
150,000-4000,000
normal bun - 10-20
creatinine - .6-1.3
sodium - 135-145
potassium
albumin - 3.5-5.0
calcium - 8.6-10.0
digoxin level - .5-2.0
magnesium - 1.6-2.6
hematocrit - female 35-45
male 42-52
absence seizure - last only a few seconds
tonic clonic seizure - protect airway
,protect pt from injury
monitor duration of seizure activity
status epileptic in er - protect airway
administer valuim(diazepam)
place IV
protect pt from injury
main seizure drugs - carbamazepine(tegretol) avoid grapefruit
phenytoin(dilantin) extra growth on gums
valproic(dapakote) affects wound healing
if G.I symptoms occur while on seizure meds you should advice pt to - take with food
signs of depression in children - pretends to be sick
trouble in school
pessimistic attitude
TREATMENT FOR DEPRESSION - antidepressants
counseling
psychotherapy
should not take St. johns wort while taking what meds - antidepressants
if a pt is on TPN and it runs out with no more available at the time, the nurse should -
infuse 10% dextrose with water at 54ml/hr
best way to tell if ng tube is correctly in place - chest x-ray
proper use of inhaler - during inhalation the pt should administer the medication
after a procedure hispanics believe that - they should drink hot things to restore balance
blood transfusion are forbidden by - jehovah witness
when a pt has a hip replacement the nurse should - place a pillow between legs while
lying to prevent hip dislocation
giving meds through the NG tube the nurse should - mix them individually
,if a pt is DNR and the nurse resesitates it is called - battery
miseries mean - pain
when suction nasotracheal tube you should know what - never suction longer then 15
seconds, if you get large amount of yellow secretions but past 15 secs, reoxygenate and then
continue suctioning
intramuscular injections in thin patients should be given where - ventrogluteal
landmark for ventrogluteal - greater trochanter (hip)
most effective way to use imagery sensory is - to include as many images as possible
progressive relaxation activity is accomplished by - 1st-establish regular breathing pattern
2nd- tense muscle fully
3rd- relax muscle completely
when should you teach a pt about how to use a PCA pump - the day before surgery
teleology means - ENDS JUSTIFY THE MEANS
veracity means - truthfulness
correct deep breathing exercise - inhale through the nose, exhale slowly through mouth
without pursed lips
number one cause of bedsores - prolonged bedrest
what is the number 1 question t ask a pt before surgery - have you had anything to eat
since midnight
when a pt gets anesthesia what is highest priority for nurse to do - position pt due to risk
of perioperative-positioning injury
why does a nurse call a time out before the surgery starts - for final verification of
procedure, site and right pt.
what do you expect to find after surgery - hypoactive bowel sounds
if you have a pt with lt hip replacement, p/o they have moderate sanguinous drainage nurse
should - observe area under hip (since gravity pulls)
mark amount of drainage on dressing by circling it
, to help relieve anxiety for a pt who has never been hospitalized the nurse should -
explain room environment
to help prevent venous thromboembolism - dorsal & plantar flex of feet
lovenox injections (anticoagulant)
proper way to evaluate legs is - use 2 pillows
place 1 lengthwise under each calf
if pt is experiencing right sided weakness - place at 45* angle on lt side
when a pt is starting to fall the nurse should - gently try to lower to the ground
atelectasis can lead to pneumonia, to prevent atelectasis the pt should - take 10 deep
breaths per hour
what is atelectasis - complete or partial collapse of the lung
how would a nurse explain to a pt the correct way to deep breath - place hands on
abdomen above umbilicus, try to make your hands rise (shoulders should not rise)
what does braden scale assess - pressure ulcers
way to prevent pressure ulcer - reposition q2h , 60* side lying
before giving a pt a new med what is most important question to ask - if you are allergic
to it
what helps to increase normal body flora - buttermilk and yogurt
what should you teach a pt with limited ambulation - isometric exercise of gluteal and
quadriceps
5x Q2h while awake
when a nurse is concern with the pt getting constipation due to lack of activity and poor diet
what should the nurse do - offer bedside commode, which allows pt independence and
correct positioning for bowel action
to improve spiritual needs of patient the nurse should - place a sign on door to allow
quiet time in A.M for prayer
lack of sleep causes - fatigue and pain
Accurate Answers | Exam Ready
normal blood pressure - 120/80
normal spo2 - 95-100
normal pulse - 60-100
normal adult respirations
normal children respirations - 16-20
16-30
glucose level - 70-110
normal wbc
normal platelets - 5000-10,000
150,000-4000,000
normal bun - 10-20
creatinine - .6-1.3
sodium - 135-145
potassium
albumin - 3.5-5.0
calcium - 8.6-10.0
digoxin level - .5-2.0
magnesium - 1.6-2.6
hematocrit - female 35-45
male 42-52
absence seizure - last only a few seconds
tonic clonic seizure - protect airway
,protect pt from injury
monitor duration of seizure activity
status epileptic in er - protect airway
administer valuim(diazepam)
place IV
protect pt from injury
main seizure drugs - carbamazepine(tegretol) avoid grapefruit
phenytoin(dilantin) extra growth on gums
valproic(dapakote) affects wound healing
if G.I symptoms occur while on seizure meds you should advice pt to - take with food
signs of depression in children - pretends to be sick
trouble in school
pessimistic attitude
TREATMENT FOR DEPRESSION - antidepressants
counseling
psychotherapy
should not take St. johns wort while taking what meds - antidepressants
if a pt is on TPN and it runs out with no more available at the time, the nurse should -
infuse 10% dextrose with water at 54ml/hr
best way to tell if ng tube is correctly in place - chest x-ray
proper use of inhaler - during inhalation the pt should administer the medication
after a procedure hispanics believe that - they should drink hot things to restore balance
blood transfusion are forbidden by - jehovah witness
when a pt has a hip replacement the nurse should - place a pillow between legs while
lying to prevent hip dislocation
giving meds through the NG tube the nurse should - mix them individually
,if a pt is DNR and the nurse resesitates it is called - battery
miseries mean - pain
when suction nasotracheal tube you should know what - never suction longer then 15
seconds, if you get large amount of yellow secretions but past 15 secs, reoxygenate and then
continue suctioning
intramuscular injections in thin patients should be given where - ventrogluteal
landmark for ventrogluteal - greater trochanter (hip)
most effective way to use imagery sensory is - to include as many images as possible
progressive relaxation activity is accomplished by - 1st-establish regular breathing pattern
2nd- tense muscle fully
3rd- relax muscle completely
when should you teach a pt about how to use a PCA pump - the day before surgery
teleology means - ENDS JUSTIFY THE MEANS
veracity means - truthfulness
correct deep breathing exercise - inhale through the nose, exhale slowly through mouth
without pursed lips
number one cause of bedsores - prolonged bedrest
what is the number 1 question t ask a pt before surgery - have you had anything to eat
since midnight
when a pt gets anesthesia what is highest priority for nurse to do - position pt due to risk
of perioperative-positioning injury
why does a nurse call a time out before the surgery starts - for final verification of
procedure, site and right pt.
what do you expect to find after surgery - hypoactive bowel sounds
if you have a pt with lt hip replacement, p/o they have moderate sanguinous drainage nurse
should - observe area under hip (since gravity pulls)
mark amount of drainage on dressing by circling it
, to help relieve anxiety for a pt who has never been hospitalized the nurse should -
explain room environment
to help prevent venous thromboembolism - dorsal & plantar flex of feet
lovenox injections (anticoagulant)
proper way to evaluate legs is - use 2 pillows
place 1 lengthwise under each calf
if pt is experiencing right sided weakness - place at 45* angle on lt side
when a pt is starting to fall the nurse should - gently try to lower to the ground
atelectasis can lead to pneumonia, to prevent atelectasis the pt should - take 10 deep
breaths per hour
what is atelectasis - complete or partial collapse of the lung
how would a nurse explain to a pt the correct way to deep breath - place hands on
abdomen above umbilicus, try to make your hands rise (shoulders should not rise)
what does braden scale assess - pressure ulcers
way to prevent pressure ulcer - reposition q2h , 60* side lying
before giving a pt a new med what is most important question to ask - if you are allergic
to it
what helps to increase normal body flora - buttermilk and yogurt
what should you teach a pt with limited ambulation - isometric exercise of gluteal and
quadriceps
5x Q2h while awake
when a nurse is concern with the pt getting constipation due to lack of activity and poor diet
what should the nurse do - offer bedside commode, which allows pt independence and
correct positioning for bowel action
to improve spiritual needs of patient the nurse should - place a sign on door to allow
quiet time in A.M for prayer
lack of sleep causes - fatigue and pain
