HESI EXIT Review PDF

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HESI/NCLEX Review Conductive hearing loss – evidence when tuning fork is heard when placed against mastoid bone/closer to the ear(sound heard better through the bone rather than air). When normal hearing (or sensorineural deficit), one will hear tuning fork away from ear Client pulls his arms upward and inward (midbrain injury) Decorticate

** Know labs from day one when updating others (doc/RNs, etc) when handing off report – must know the trend of lab values. **Therapeutic adjustments – blood sugar, trough/peak, INR/PTT, etc Spontaneous pneumothorax is commonly the rupture of blebs on the lung surface. Blebs are similar to blisters, but are filled with air.

IV Fluids are not used in hospice individuals because it prolongs the dying phase – IV fluids can actively “Drown” the person. Hospice is “comfort care” only .

Vaccines Birth - Hep B 1 Month - Hep B 2 & 4 Months - DTap, RV, Hib, IPV, PCV 6 Months - Hep B, Dtap, RV, Hib, IPV, RCV 12 Months - Hib, PCV, MMR, VZV, Hep A 15 Months - DTap https://lookaside.fbsbx.com/file/HESI%20Review%20_%20Senio…TTKETa-L6cITyrAq8TqfLdKQfFA7NyrDOrOYa74wEOsMzxPeq3vc 6/8/17, 2Z27 PM Page 1 of 25

Variable decelerations are illustrated by a sudden decrease in the fetal heart rate below the baseline, lasting about 15 seconds and then returning to baseline within 2 minutes;

they are caused by compression of the umbilical cord. If they occur during the first stage of labor, they usually resolve when the mother is repositioned from one side to the other. Lactic Acidosis (Kidneys) – Patients on metformin – cannot take while under contrast testing **Stomach surgeries – B12 deficiency – will have fatigue

** Clients must sign the operative permit or any legal document prior to preoperative drugs administered.

Nursing Process: 1. Obtain client's nursing history. 2. State client's nursing needs. 3. Identify goals for care. 4. Develop a plan of care. 5. Implement nursing interventions

Addisons – Need Salt and Glucocorticoids for life – Dysthymias may occur due to increased K+ levels

ALENDRONATE is a bisphosphonate used to treat osteoporosis and Paget's disease. -- Common side effects include GI irritation (pain, nausea, dyspepsia, constipation, diarrhea), hypocalcemia, headache, and musculoskeletal pain. Bisphosphonates inhibit osteoclast and bone resorption. More serious adverse reactions include hypocalcemia and esophageal, gastric, or duodenal ulcers. https://lookaside.fbsbx.com/file/HESI%20Review%20_%20Senio…TTKETa-L6cITyrAq8TqfLdKQfFA7NyrDOrOYa74wEOsMzxPeq3vc 6/8/17, 2Z27 PM Page 2 of 25

Insulin glargine (Lantus) is a long-acting insulin. It has a unique amino acid profile that results in a continuous

release with no peak. Babinski reflex (hyperextend) goes away at AGE 2 If client is uncomfortable during enema - Close the lumen of the tubing and wait until the discomfort subsides!!!

Inspection, Palpation, Percussion, Auscultation – Pulmonary (lungs) Assessment Extracellular fluid volume deficit (dehydrated) – symptom (no urine output) Grand Multipara will have SEVERE afterbirth pains (due to lose of contractility in uterus) Nephrotic Syndrome – swelling around the eyes (facial edema will be seen) Legs and ankle edema Mild Preeclampsia – unrestricted NA+ diet, a lot of protein/calories – inadequate nutrition causes Preeclampsia!! Diltiazem hydrochloride's (used to treat chest pain and HBP) purpose is to slow the heart rate down. SVT has a heart rate of 150 to 250 beats per minute. A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury – Cap refill, Pulse/skin temp, Movement and sensation

**PEAK levels will be HIGHER than TROUGH levels !!! (ALWAYS draw Trough Prior to administration and Peak 30 minutes After antibiotic therapy) DKA – Kussmaul respirations, dry skin, ab pain, ketones in urine

After a heart surgery – Heart block can occur (slow pulse https://lookaside.fbsbx.com/file/HESI%20Review%20_%20Senio…TTKETa-L6cITyrAq8TqfLdKQfFA7NyrDOrOYa74wEOsMzxPeq3vc 6/8/17, 2Z27 PM Page 3 of 25

rate is sign)

Pacemakers – helps an abnormally slow heart rate Arterial Ulcers – Pain at ulcer site, no hair on leg, diminished pedal pulses, thick toenails, dependent rubor, ulcers on the toes, delayed capillary refill Oculogryic crisis (Haldol medication) – eyes roll back into head If NSAIDS are taken daily (they should take w/food) decrease prostaglandins TD – develops when taking anti-psychic medication for years EPS is reversible *Unresponsive adult --- call for help – then check for pulse Food borne botulism can be removed via enema Working phase – when client identifies their problems *Purse lip breathing – helps remove trapped air in the alveoli – helps exhale more effectively CT with contrast – check allergies, signed constent, NPO (only IV) Descending colostomy– semi-formed to formed poops Lead poisoning – bluish gum line, hyperactivity, neuro and cognitive disabilities *Battle signs (bruise behind ear) or black/blue eyes – can be leaking CSF

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Low Ca+ - Tetany, seizures Na+ - imbalance levels can cause seizures also Increased K+ - Diarrhea, Weakness, Dysthymias Ear drop contraindications - Tympanic membrane rupture, Drainage from the ear canal, Allergy to the medication ***Alcohol deactivates the smallpox vaccine. Cleansing of the arm should not be done before the immunization is given unless the arm is dirty; if dirty, only water should be used to cleanse the site

Diminished Plasma Protein Level = Ascites!! - A deficit of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift CF – children with CF may have pancreatic scarring which effects the islets to produce insulin – they may need a glucose tolerance test Preterm females – fine/feathery hair, no resistance to the heel to ear maneuver and prominent clitoris Guilt ridden client – nurse must be accepting to the clients statements, builds trust 1. Bowel habits, 2. Nutrition hx, 3. Psychosocial factors and 4. Physical examination (when assessing child with incontinence) Dementia – must reinforce reality “Working phase” with depressed clients - ask how will they manage next time if problems start piling up. – helps with the Future Akathisia, an extrapyramidal side effect of typical antipsychotics, is motor restlessness. The client is unable to sit or stand still and feels the need to move, pace, rock, swing the legs, or tap the feet. The condition occurs within 5 to 90 days of the initiation of therapy.

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Dystonia is muscle spasms of the face, tongue, head, neck, jaw, or back, usually resulting in exaggerated posturing. This extrapyramidal side effect of typical antipsychotics occurs within 1 hour to 1 week of the initiation of therapy. Tardive dyskinesia is facial, ocular, oral/buccal, lingual/masticatory, and systemic movements. This extrapyramidal side effect of typical antipsychotics may occur 6 months or more after the initiation of therapy. Pseudoparkinsonism has characteristics similar to those of Parkinson's disease (e.g., shuffling gait, tremors, rigidity, bradykinesia). This extrapyramidal side effect of typical antipsychotics may occur anytime after the initiation of therapy.

Immune Globulin – used to prevent bacteria infections

Antipsychotic medications – hyperthermia and muscle rigidity • Neuroleptic syndrome – high fever and muscle rigidity Asthma (client not taking medications) – Patho: lung remolding will occur and permanent changes in lung ruction Older client becomes confused – antihistamine can cause confusion in the elderly (or anyone actually) Herceptin (Trastuzumab) – can cause irregular apical pulse (Always date/time patches) Nitroglycerin patches (1214hrs) – can only last for 12-14 hours because the patch wears off 15 year olds – can lose their dependence within a hospital setting

APGAR 110 do not administer

Tylenol – affects liver (T à L) Aspirin – affects Kidney (A à K) **Anything in atrial can cause blood clots. Beta Blockers are contraindicated with those with asthma aPTT 60-80 (1.5 – 2 times) INR Therapeutic 2-3 Dig – Magnesium and Potassium need to be normal when giving Magnesium High BNP = CHF

NG: The nurse should first turn off the suction and then confirm placement of the tube in the stomach before instilling the medications .To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped/suction opposite for a period of time https://lookaside.fbsbx.com/file/HESI%20Review%20_%20Senio…TTKETa-L6cITyrAq8TqfLdKQfFA7NyrDOrOYa74wEOsMzxPeq3vc 6/8/17, 2Z27 PM Page 15 of 25

before reconnecting the suction Atrial A-Fib: ** Anything atrial is not a lethal rhythm – (ex: a fib (there is a QRS, but very wavy in between) – no p waves, rhythm is irregular) - TX: needs to be converted back to sinus rhythm – if its less than 48 hours in duration. Clots can form if it is fibrillating - Dilitaziam/ beta blocker to slow the HR - a TEE procedure is done (looking for clots) - patient will be on heparin and warfarin. Amiodarone can be used (used for atrial and ventricular) If patient goes on a fib within an hour – Amiodarone can be used to convert back to NSR. 75 joules is used for a-fib during cardioversions (versed or

fentanyl is given before) Symptomatic and less then 48 hours – cardioversion. If greater than 48 hours medication is used. COPD, Sleep apnea is at risk for A-Fib PACs: a beat that happens before it is supposed to. The pause after the PAC lets the heart to “reset.” This is a benign conduction. A beat the occurs to soon.

A-Flutter: fast and regular, sawtooth look, they all look the same. This is not lethal, but needs to be slowed down.

SVT: electrical disturbances – in the atria – always fast – irritated is above the ventricle (Adenosine given for SVT) Any edema above the waist is more serious than below the waist is more concerned with. Always associate the “team” first when dealing with possible abuse with children. If one is not in distress, always assess first. If one is in distress - act. https://lookaside.fbsbx.com/file/HESI%20Review%20_%20Senio…TTKETa-L6cITyrAq8TqfLdKQfFA7NyrDOrOYa74wEOsMzxPeq3vc 6/8/17, 2Z27 PM Page 16 of 25

Gestational diabetes (infants) - frequent feedings are needed **Low blood sugars will decrease insulin can cause brain damage in infants

Carotid endarterectomy – removal of plaque – at risk for stroke!! Any surgery on the neck – always Assess for breathing problems!!!

Fine crackles are heard during HF – which means there is fluid in the alveoli Dopamine will be increased during alcohol withdrawal Placement of a catheter for total parenteral nutrition (TPN) using subclavian vein. TPN is used when the intestines are obstructed, when the small intestine is not absorbing nutrients properly, or a gastrointestinal fistula (abnormal connection) is present Peripherally inserted central catheters (PICC) are inserted using the basilic or cephalic vein. A peripherally inserted central catheter (PICC or PIC line) is a form of intravenous access that can be used for a prolonged period of time (e.g. for long chemotherapy regimens, extended antibiotic therapy, or total parenteral nutrition).

If pH is normal and PaCO2 and HCO3- are both abnormal, then the patient is compensated. https://lookaside.fbsbx.com/file/HESI%20Review%20_%20Senio…TTKETa-L6cITyrAq8TqfLdKQfFA7NyrDOrOYa74wEOsMzxPeq3vc 6/8/17, 2Z27 PM Page 17 of 25

If pH is abnormal and PaCO2 and HCO3- are both abnormal, then the patient is partially compensated. If pH is abnormal, and either PaCO2 or HCO3- are abnormal, then the patient is uncompensated

pH 7.33 (acid) CO2 49 (high acidosisi –resp) bicarb 28 partially compensated resp acidosis pH 7.52 (alk) CO2 52 (acid) Bicarb 33 – metabolic alk partially compmensated

pH 7.43 CO2 27 Bicarb 18 - Normal pH - Fully compenstated Resp alk

Ileostomy has a risk for fluid volume deficient

Blood transfusions – stay with client for 15 minutes to monitor vitals of adverse effects Pulmonary artery catheter insertion (these are to monitor pulmonary artery pressure) – the ECG will need to be observed for any changes because ventricular irritability is common

Parkinson – Resting tremors – increased muscle tone – slow movement – difficulty with gait and balance – take longer to complete a task – masklike facial expression - big aspiration risk as the disease progressing (difficulty with feeding – client will need a feeding tube) - shuffle gait – pill rolling - very emotional liable - HESI likes to focus on SAFETY!! - Schedule activities later in the day because client takes longer to move – use assistant devices – encourage client to speak slowly – soft diet Anticholinergic medications (atropine – dries up secretions https://lookaside.fbsbx.com/file/HESI%20Review%20_%20Senio…TTKETa-L6cITyrAq8TqfLdKQfFA7NyrDOrOYa74wEOsMzxPeq3vc 6/8/17, 2Z27 PM Page 18 of 25

– patients with glaucoma should not receive because can cause pressure behind the eyes) Dopamine replacements (levodopa, levodopa-carbidopa) - with Parkinsons medications are started at a low dose and increase dosage, but eventually the body gets used to medications, so a new medication will need prescribed.

Trigeminal neuralgia – sharp pain running down the check - soft foods and avoid extreme temperature foods/drinks

Brainstem injury – need ABGs because you need their respiratory information Brown Sequard syndrome – loss of touch and vibration hemisection of the spinal cord Myasthenia Gravis – Atropine is the antidote for clients in cholinergic crisis (overdose) C4 spinal cord injury - assess for breath sounds because it’s the location of the injury T6 and up – respiratory is very important With neuro always keep head elevated a t 30 degrees and midline Epidural hematoma – always ask if the client was awake and talking right after the injury S & S: Headache, vomiting, fixed dilated pupil on same side, contralateral hemiparesis or hemiplegia Metabolic acidosis can cause septic shock Exacerbation of Heart Failure s/s: Pitting Edema (dependent) and crackles in the lungs

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Raynauds phenomenon – Unilateral involvement Raynauds disease – Bilateral involvement Both involve skin temperature and color changes TPN Administration: monitor administration rate to prevent overload and hyperglycemia Signs and Symptoms of insulin reaction: Headache, Diaphoresis and Nervousness Hyperglycemia: Kussmaul respirations

Cushings – hyperglycemia, muscle weakness, frequent urination but with an increase of mineral corticoids urination will decrease, hypernatremia, hypokalemia, HTN and hypervolemia Fecal impaction is the main cause of liquid fecal incontinence!!! Wide bizarre QRS waves and no p waves – SA and AV nodes failed to initiate a impulse Blood transfusions – always check previous medical history before hanging blood products Push Morphine over 5 minutes SHOCK – Vfib = Dfib and pulseless vtach Diabetes don’t present the same with heart attacks due to peripheral nerve damage Astyole – do NOT shock – hyperthermia/hypothermia – always find the cause and do not shock - CPR!!! CARDIOVERSION – AFIB OR SVT TURP – Bleeding is the main priority in this procedure (LOC changes) always notify the healthcare provider

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Prostatism – post void of drippling, nocturia, hesitancy of peeing Have client urinate and check with bladder scanner to check any residual Burns/Crush injury – PreRenal stage because of K+ entering -

End stage renal – HTN and Azotemia (nitrogenous waste increases) Maintaining nasogastric tube patency ensures gastric decompression, thus preventing abdominal distension, which places tension on the incision. Vasopressin helps prevent loss of water from the body by reducing urine output and helping the kidneys reabsorb water into the body. Vasopressin also raises blood pressure by narrowing blood vessels. Vasopressin (desmopressin) is used to treat diabetes insipidus, which is caused by a lack of this naturally occurring pituitary hormone in the body. Vasopressin is also used to treat or prevent certain conditions of the stomach after surgery or during abdominal x-rays Diabetes insipidus (die-uh-BEE-teze in-SIP-uh-dus) is an uncommon disorder characterized by intense thirst, despite the drinking of fluids (polydipsia), and the excretion of large amounts of urine (polyuria). In most cases, it's the result of your body not properly producing, storing or releasing a key hormone, but diabetes insipidus can also occur when your kidneys are unable to respond properly to that hormone

Right sided brain damage – difficult in judgment, spatial perception and impulsive https://lookaside.fbsbx.com/file/HESI%20Review%20_%20Senio…TTKETa-L6cITyrAq8TqfLdKQfFA7NyrDOrOYa74wEOsMzxPeq3vc 6/8/17, 2Z27 PM Page 21 of 25

Left sided brain damage – speech/language problems, will experience grief because they know their deficits Uncontrolled afib - administer dig (slows rate of conduction) In primary aldosteronism, your adrenal glands produce too

much aldosterone, causing you to lose potassium and retain sodium. The excess sodium in turn holds onto water, increasing your blood volume and blood pressure. Hypocalcemia develops in CKD because of chronic hyperphosphatemia Cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? - Prior to feedings to prevent aspiration Radiation: can be burned - can not put anything on it (no lotions, cleans, etc) Will be marked to pin point the radiation area – do not remove markings. No exposure to sunlight Montgomery straps are used for those who have problems with constant usage of tape (allergic) when having a wound Specific gravity in the range of 1.000 to 1.030 Burns greater than 20% - fluid shifting - fluid resuscitation is needed the first 24 hours. Half of the fluids are given within the first 8 hours. Always count the time of the BURN accident when counting hours.

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Diabetes insipidius – dysuria, dysphagia, low urine specifity gravity, wgt loss, NA+ is high, high blood sugar DKA – happens with those with TYPE 1 HHNS – happens with type 2 Head surgery or trauma – is at risk for Diabetes insipidus (treatment is ADH – vasopressin – stops urination)

Hyperparathyroidism – hypercalcemia, which causes polyuria https://lookaside.fbsbx.com/file/HESI%20Review%20_%20Senio…TTKETa-L6cITyrAq8TqfLdKQfFA7NyrDOrOYa74wEOsMzxPeq3vc 6/8/17, 2Z27 PM Page 23 of 25

Hypophysectomy (going up to the brain)- assess for urine specific gravity

BPH – do no give antihistamines – do not give decongestions, anticholinergics, antidepressants Bactrim – sore throat, fever and pallor – bone marrow suppression Phenazopyridine (helps decrease pain from UTI) – can cause urine reddish/brown Bethanechol Chloride (contracts the bladder) – contraindicated in urinary strictures or tract obstruction/weakness of the bladder wall. – Given on an empty stomach, take an hour or two hours after meals Chlorogenic Overdose:

bradycardia, sweating, drooling, crapping, hypertension -- atropine would be given to reverse Chlorogenic overdose Oxybutynin ...