HESI Comprehensive Review for the NCLEX-RN Examination

What types of procedures should be assigned to professional nurses?

Sterile or invasive procedures.

Negligence is measured by reasonableness. What question might the nurse ask when determining such reasonableness?

Would a reasonable and prudent nurse act in the same manner under the same circumstances?

List the 4 elements that are necessary to prove negligence.

Duty. Failure to protect client again unreasonable risk. Breach of duty. Failure to perform according to established standards. Causation. A connection exists between conduct of the nurse and the resulting damage. Damages. Damage is done to the client, physical or mental.

Define an intentional tort and five one example.

Conduct causing damage to another person in a willful or intentional way without just cause. Example Hitting a client out of anger, not in a manner of self protection.

Voluntary admission

Client admits self to an institution for treatment and restrains his or her civil rights. He or she may leave at any time.

Involuntary admission

Someone other than client applies for the client's admission to an institution requires certification by 1 or 2 health care providers that the person is a danger to self or others.

List 5 activities a person who is declared incompetent cannot perform.

Vote, make contracts or wills, drive a care, sue or be sued, hold a professional license.

Name 3 legal requirements of a surgical permit

Voluntary, informed, and written.

Who may give consent for medical treatment?

Alert, coherent, or otherwise competent adults, a parent or legal guardian, a person in loco parentis of minors or incompetent adults.

What law protects the nurse who provides care or gives aid in an emergency situation?

The Good Samaritan Act.

What action should the nurse take if he or she questions a health care provider's prescription that they believe is wrong?

Inform the health care provider. Record that the health care provider was informed and the health care provider's response to such information. Inform the nursing supervisor. Refuse to carry out the prescription.

Describe the nurse's legal responsibility when asked to perform a task for which he or she is unprepared.

Inform the health care provider or person asking the nurse to perform the task that he or she is unprepared to carry out the task. Refuse to perform the task.

Describe nursing care of the restrained client.

Apply restraints properly. Check restraints frequently to see that they are not causing injury and record such monitoring. Remove restraints as soon as possible. Use restraints as a last resort.

By what authority may RNs delegate nursing care to others?

State Nurse Practice Act

A UAP may perform care that falls within which components of the nursing process?

Implementation

Which type of communication is necessary to implement a democratic leadership style?

Assertive communication skills

What are the 4 rights of communication?

Right task, right circumstance, right person, right direction or communication, and right supervision.

Which tasks can be delegated to a UAP? A. Inserting a Foley catheter. B. Measuring and recording the client's output through a Foley catheter. C. Teaching a client how to care for a catheter after discharge. D. Assessing for symptoms of a urinary tract infection.

A. is a sterile invasive procedure and should not be delegated to a UAP. B. Falls within the implementation phase, does not involve nursing judgement. Evaluation of the I & O must be done by the nurse. C. Client teaching requires the abilities of a nurse should not be delegated. D. Assessment must be performed by the nurse and should not be delegated.

What are the essential steps of effective supervision?

Direction, evaluation, and follow-up.

Which of the following is an example of assertive communication? A. You need to improve the way you spend your time so that all of your care gets performed. B. I've noticed that many of your clients did not get their care today.

A. This is an aggressive communication, which causes anger, hostility, and a defensive attitude. B. Assertive communication begins with I rather than you and clearly states the problem.

List the three levels of disaster management

Disaster preparedness, disaster response, and disaster recovery.

List examples of the three levels of prevention in disaster management.

Primary: develop plan, train and educate personnel and public. Secondary: triage, treatment shelter, supervision. Tertiary: follow-up, recovery assistance, prevention of future disasters.

Triage

To sort or categorize

Identify three bio-terrorism agents.

Anthrax, pneumonic plague, botulism, smallpox, inhalation tularemia, viral hemorrhage, fever, ricin, sarin, radiation.

What Po2 value indicates respiratory failure in adults?

Po2 below 60 mmHg

What blood value indicates hypercapnia?

Pco2 above 45 mm Hg

Identify the condition that exits when the Po2 is less than 50 mmHg and Fio2 is greater than 60%.

Hypoxemia

List three symptoms of respiratory failure in adults.

Dyspnea tachypnea, intercostal and sternal retractions cyanosis.

List four common causes of respiratory failure in children.

Congenital heart disease, infection or sepsis, respiratory distress syndrome, aspiration, fluid overload or dehydration.

What percentage of O2 should a child in severe respiratory distress receive?

100%

Acute Respiratory Distress Syndrome

Is an unexpected, catastrophic pulmonary complication occurring a person with no previous pulmonary problem. Mortality rate 50%.

Interventions to prevent complications of clients on mechanical ventilation with ARDS

Elevate head of bed at least 30 degrees. Assist with daily awakening. Implement a comprehensive oral hygiene program. Implement a comprehensive mobilization program.

Suction

Only when secretions are present.

Allen Test

Perform prior to drawing ABGs. Ensures collateral circulation ot the hand if thrombosis of the radial artery should follow the puncture.

Positive Allen test

Make the clients hand blanch by obliteration both the radial and the ulnar pulses. Then release the pressure over the ulnar artery only. If flow through the ulnar artery is good, flushing will be see immediately.

Negative Allen Test

Repeat on the other arm. If this test is also negative, seek another site for arterial puncture.

Cardinal signs of Acute Respiratory Failure in children

Restlessness, Tachypnea, Tachycardia, and Diaphoresis.

pH

7.35-7.45

Pco2

35-45 mm Hg

HCO3

21-28 mEq/L

Po2

80-100 mm Hg

O2 Saturation

95%-100%

Shock

Widespread, serious reduction of tissue perfusion, which leads to generalized impairment of cellular function.

What is the most common cause of shock?

Hypovolemia

What causes septic shock?

Release of endotoxins by bacteria, which act on nerves in vascular spaces in the periphery, causing vascular pooling, reduced venous return, and decreased cardiac output and result in poor systemic perfusion.

What is the goal of treatment for hypovolemic shock?

Quick restoration of cardiac output and result in poor systemic perfusion.

What intervention is used to restore cardiac output when hypovolemic shock exists?

Rapid infusion of volume expanding fluids

It is important to differentiate between hypovolemic and cardiogenic shock. How might the nurse determine the existence of cardiogenic shock?

History of MI with left ventricular failure or possible cardiomyopathy, with symptoms of pulmonary edema.

If a client is in cardiogenic shock, what might result from administration of volume expanding fluids?

Pulmonary Edema

What intervention can the nurse expect to perform in the event of such an occurrence?

Administer medications to manage preload, contractility and or after-load. For example to decrease after-load nitroprusside Nipride may be administered.

List 5 assessment findings that occur in most shock victims.

Tachycardia, tachypnea, hypotension, cool clammy skin, decrease in urinary output.

Once circulating volume is restored, vasopressors may be prescribed to increase venous return. List the main drugs that are used.

Epinephrine bronkaid, Dopamine Intropin, Dobutamine dobutrex, norepenephrine levophed or isoproterenol isuprel.

What is the established minimum renal output per hour?

30 mL/hr.

List 4 measurable criteria that are the major expected outcomes of a shock crisis.

BP mean of 80 to 90mm Hg, Po2 greater than 50m mm Hg, Central venous pressure 2 to 6 mm HG. Urine output at least 30 mL/hr.

DIC- Disseminated Intravascular Coagulation

A coagulation disorder in which there is paradoxical thrombosis and hemorrhage.

What is the effects of DIC on PT, PTT, platelets and FSPs?

PT prolonged, PTT prolonged, Platelets decreased. FSPs increased.

What drug is used in the treatment of DIC?

Heparin

Name four nursing interventions to prevent interventions to prevent injury in clients with DIC.

Gently provide oral care with mouth swabs. Minimize needle sticks ans use the smallest gauge needle possible when injections are necessary. Eliminate pressure by turning the client frequently. Minimize the number of BP measurements taken by cuff. Use gentle suction to prevent trauma to mucosa. Apply pressure to any oozing site.

Early signs of shock

Agitation and restlessness resulting from cerebral hypoxia.

What is the first priority when a client with an unwitnessed cardiac arrest is found?

Begin CPRq

Myocardial infarction

Necrosis of the heart muscle due to poor perfusion to the heart.

What criteria should alert a client with known angina who takes nitro subliminally to call EMS?

Unrelieved chest pain after 3 nitroglycerin.

After calling out for help and asking someone to dial for emergency services, what is the next action in CPR?

For adults check carotid pulse and if no pulse deliver C-A-B.

In feeling for presence of a carotid pulse, no more than 5 seconds should be used.

False, palpate for no more than 10 seconds, recognizing that arrhythmias or bradycardia could be occurring.

During one rescuer CPR, what is the ratio of compressions to ventilations for an adult?

30:2

During one rescuer CPR what is the ratio of compression to ventilations for a child?

15:2 for a child or neonate with two rescuers and 30:2 for 1 rescuer.

What is the first drug most likely to be used for an in hospital cardiac arrest?

Epinephrine

A client in cardiac arrest is noted on bedside monitor to be in pulse-less ventricular tachycardia. What is the first action that should be taken?

Defibrillation

How would the nurse assess the adequacy of compression during CPR?

Check for a carotid or femoral pulse.

How would the nurse assess the adequacy of ventilations during CPR?

Watch for chest excursion and auscultate bilaterally for breath sounds.

If a person is chocking when should the rescuer intervene?

When the person points to his or her throat and can no longer cough, talk, or make sounds.

One should never make blind sweeps into the mouth of a choking child or infant, Why?

Because the object might be pushed farther down into the throat.

List four common causes of fluid volume deficit.

Gastrointestinal causes, vomiting or diarrhea. GI suctioning decrease in fluid intake, increase in fluid output such as sweating, massive edema, or ascites

List four common causes of fluid volume overload.

Heart failure, renal failure, cirrhosis, excess ingestion of table salt or over hydration with sodium containing fluids.

Identify two examples of isotonic IV fluids

Lactated ringers and normal saline.

List 3 systems that maintain acid base balance.

Lungs, kidneys, and chemical buffers.

Normal value for pH

7.32-7.45

Normal value for Pco2

35 to 45 mm Hg

Normal value for HCO3

21 to 28 mEq/L

Acid base disorder pH 7.50, Pco2 30, HCO3 28

Respiratory alkalosis

Acid base disorder pH 7.30, Pco2 42, HCO3 20

Metabolic acidosis

Acid base disorder pH 7.48, Pco2 42, HCO3 32

Metabolic alkalosis

Acid base disorder pH 7.29, Pco2 55, HCO3 28

Respiratory acidosis

Identify the waveform found in a normal ECG

P wave, QRS complex, T wave, ST segment and PR interval.

In an ECG reading, which wave represents depolarization of the atrium?

Represented by a P wave.

In an ECG reading, what complex represents depolarization of the ventricle?

QRS complex

What does the PR interval represent?

The time required for the impulse to travel from the atria through the AV node.

If the U wave is most prominent, what condition might the nurse suspect?

Hypokalemia

Describe the calculation of the heart rate using an ECG rhythm strip.

Count the number of RR intervals in the 30 large squares and multiply by 10 to determine the heart rate for 1 minute.

What is the most important assessment data for the nurse to obtain in a client with an arrhythmia?

The ability of the client to tolerate the arrhythmia.

List five variables that increase surgical risk.

Age. Very young and very old, obesity and malnutrition, preoperative dehydration/hypovolemia, preoperative infection, use of anticoagulants pre-operatively.

Why is a client with liver disease at increased risk for operative complications?

Impairs ability to detoxify medications used during surgery. Impairs ability to produce prothrombin to reduce hemorrhage

Preoperative teaching should include demonstration and explanation of expected postoperative client activities. What activities should be included?

Respiratory activities, range of motion exercises, pain management, NPO evolving to progressive diet, dressings and drains, orientation to recovery room environment.

What items should the nurse assist the client in removing before surgery?

Contact lenses, glasses, dentures, partial plates, wigs, jewelry, prostheses, and nail polish.

How is the client positioned in the immediate postoperative period and why?

Usually on the side or with head to side to prevent aspiration of any emesis.

List 3 nursing actions that prevent postoperative wound dehiscence and evisceration.

Teaching client to splint incision when coughing, encouraging coughing and deep breathing in early postoperative period when sutures are strong, monitoring for signs f infection, malnutrition, and dehydration. Encouraging high protein diet.

Identify 3 nursing interventions that prevent postoperative urinary tract infection.

Avoiding postoperative catheterization, increasing oral fluid intake, emptying bladder every 4 to 6 hours, early ambulation.

Identify nursing/medical interventions that prevent postoperative paralytic ileus.

Early ambulation, limiting use of narcotic analgesics, and NG tube decompression.

List four nursing interventions that prevent postoperative thrombophlebitits.

Teaching in bed leg exercises, encouraging early ambulation, applying antiembolus stockings, teaching avoidance of positions and pressures that obstruct venous flow.

During the intraoperative period, what activities should the OR nurse perform to ensure safety during surgery?

Ascertain correct sponge, needle, and instrument count, position client to avoid injury, apply ground during electrocautery use, apply strict use of surgical asepsis.