Foundations-Hesi Exam: Questions And A+ Answers

Foundations-Hesi Exam: Questions nn nn nn




nn
And A+ Answers nn nn nn




Rectal nnTemp nn- nnInsert nnlubricated nnthermometer nnprobe(w/cover) nninto nnrectum nn1-1.5in
nntoward nn
nn
umbilicus; nnreading nnis nnusually nn0.9F nngreater nnthan
nnoral nntemp
nn

Axillary nnTemp nn- nnPlace nnthermometer nnprobe nnin nncenter nnof nnaxilla; nnhave nnpt nnplace
nnarm nnacross nn
nn
chest; nnreading nnis nnusually nn0.9F nnlower nnthan
nnoral nntemp
nn

Orthostatic nnBP nnreadings nn- nnOrthostatic nnhypotension nnaka nnpostural nnhypotension;
nnobtain nnsupine, nnsitting, nn& nnstanding(1-3 nnmin nnbetween nneach); nnobserve nnpt nnfor

nndizziness, nnfainting, nnlightheadedness; nnrecord nnpts nnposition nnwith nneach nnreading; nnDO

nnNOT nnDELEGATE nn
nn

Exercise nn& nnSleep nn- nnExercise nn2hrs nnbefore nnbedtime; nnallows nncool nndown nnperiod
nnand nnfatigue nn
nn
that nnpromotes

nnrelaxation
nn

Soaking nnFeet nn- nnPart nnof nnroutine nnpt nnhygiene; nnDO nnNOT nnsoak nnfeet nnof nnpts nnwith
nndiabetes nnor nnother nnperipheral nnvascular nndisorders. nnCan nndelegate nnto nnNAP, nnbut

nnNAP nnCANNOT nntrim nnnails; nnSoak nnfeet nnfor nn10-20 nnmin nnin nnwarm nnwater, nnrewarm

nnwater nnafter nn10min; nnNurse nncan nntrim nnnails nnusing nnclippers, nnstraight nnacross nnand

nneven nnwith nnfingertips; nnDO nnNOT nntrim nnin nnpts nnwith nncirculatory nnproblems; nnDry

nnthoroughly, nnapply nnlotion. nn
nn

Indwelling nnCatheter nn- nnAmbulation; nnnever nnraise nndrainage nnbag nnabove nnlevel nnof
nnbladder; nnprior nn
nn
to nnambulation, nndrain nnall nnurine nnfrom nntubing nninto
nndrainage nnbag
nn

False-low nnreadings nnon nnBP nncuff nn- nncuff nnto nnwide, nnarm nnabove nnheart nnlevel nn
nn

False-high nnreadings nnon nnBP nncuff nn- nncuff nnto nnnarrow/short, nncuff nnto nnloose nnor
nnuneven, nnarm nnnot nn
nn
supported
nn

False-high nndiastolic nnreadings nnon nnBP nncuff nn- nndeflating nncuff nnto nnslowly, nninflating nnto
nnslowly nn
nn

Normal nnvitals nn- nnRR: nn12-20 nn
BP:<120/<80 nn

, HR: nn60-100 nn
Temp: nn98.6F nnor nn37C nn
nn

Pulse nnDefecit nn- nnAssess nnradial nnand nnapical nnpulses nnsimultaneously. nnThe nnpulse
nndefecit nnis nnthe nn
nn
difference nnbetween nnthe nntwo nndue nnto nnan nninefficient nncontraction nnof nnthe nnheart
nnthat nnfails nnto
nn
transmit nna nnpulse nnwave nnto nnperipheral nnpulse
nnsites
nn

Hygiene-self nncare nndefecit nn- nnresults nnfrom nnside nneffects nnof nnmedication, nnlack nnof
nnknowledge, nnimmobilization, nnan nninability nnto nnperform nnhygiene,, nnor nnphysical

nncondition nnthat nnpotentially nninjures nnthe nnskin, nnmouth, nnfeet, nnnails nnor nnhair. nn

Hygiene nnAssessment nn- nninclude nnpatient's nnmuscle nnstrength, nnflexibility, nnbalance,
nnvisual nn
nn
acuity, nnand nnability nnto nndetect nnthermal nnand nntactile nnstimuli, nnmetal
nnstatus, nnactivity
nn
tolerance(RR, nnskin nncolor,
nnpulse)
nn

Applying nnTED nnhose(antiembolitic nnstockings) nn- nn1. nnObtain nnorder nnfrom nnMD nn
2. Measure nnleg nn
3. Explain nnto nnpatient nn
4. Hand nnhygiene nn
5. Supine nnposition nn
6.Turn nnelastic nninside nnout nnup nnto nnheal, nnpull nnover nnfeet, nnpull nnall nnthe nnway nnup nncalf,
nnmaking nnsure nnthere nnare nnno nnwrinkles. nn

7. Remove nnthem nnat nnleast nnonce nnper nnshift nn
8. Observe nncirculatory nnstatus nnof nnlower nnextremities; nncolor nntemperature, nnand
nncondition nnof nnskin, nnpalpate nnpedal nnpulses. nn
nn

Ostomy nnCare nnPatient nnTeaching nn- nnProvide nnpt nnwith nnsupplies nnto nnlast nn1-2 nnweeks,
nnwith nninfo nnon nncloset nnsupply nncompany; nnshow nnthem nnstep nnby nnstep nnfor nnchanging

nnpouch; nnprovide nnat nnlease nnone nnchance nnfor nnpt nnto nnchange nnpouch nnwhile nnin

nnhospital; nnarrange nnvisits nnfrom nncommunity nnstoma nncare nnnurse; nnprovide nndetailed

nndischarge nninstructions nnfor nnskin nncare, nnclothing, nndriving, nnlifting, nnresuming nnexercise,

nnwhen nnto nncontact nnMD nn
nn

Bowel nnTraining nn- nnAssess nnnormal nnelimination nnpatter; nnchoose nna nntime nnin nnt
nnpatients nnpattern nnto nninitiate nndefecation nncontrol nnmeasures; nngive nnstool nnsofteners

nnevery nnday nnat nnleast nn30 nnmin nnprior nnto nnselected nntime; nnoffer nna nnhot nndrink( nnhot nntea)

nnor nnjuice nn(prune nnjuice) nnor nnwhatever nnfluid nnthat nnstimulates nnperistalsis nnfor nnpt; nnhelp

nnpt nnto nntoilet nnat nntime; nnavoid nnmeds nnthat nncan nnconstipate; nnprovide nnprivacy nnand nnset

nntime nnframe nnfor nn15-20 nnmins nnfor nndefecation; nnhave nnpt nnlean nnforward nnat nnthips

nnwhile nnsitting nnon nntoilet, nnapply nnmanual nnpressure nnwith nnhands nnover nnabdomen, nnand