HESI RN COMPREHENSIVE EXIT EXAM

HESI RN COMPREHENSIVE EXIT EXAM

VERSION 5

• DVT – heparin – elevated leg to reduce edema and further risk
• Child safety
• No skateboarding under 5yo
• No sun between 1000 and 1400
• Cut hotdogs lengthwise
• Infection prevention when on chemo
• No water or liquids at room temperature that have been out for over 1 hour
• Clean toothbrush in dishwasher once weekly
• Take temp once weekly and notify provider if over 100
• Ambulate short distances to prevent pulmonary stasis and respiratory

infections

• 6m infant diet
• 1 Tbsp/year of age (in general)
• Under 12m – ½ to ¾ Tbsp appropriate
• 100% juice – 120 to 180 ml d (4-6 oz) after 6m
• Mechanical restrains
• Don’t remove unless client calm, in control, and follows simple commands
• Assess physical needs, safety, comfort q 15-30 min and document
• New Rx q4 hr 18yo and older, q2 hr 9-17 yo, q1 hr under 9yo
• Staff remains continuously with client or constant viewing with audiovisual

equipment

• Umbilical cord prolapses
• Knee-chest position
• True labor
• Cervix transitions to anterior position and begins to dilate in preparation
• Contractions primarily in lower abdomen and back
• Contractions intensifies with increased ambulation
• Cervix shortens and thins
• Nurse manager changing scheduling system, action to facilitate
• Provide information about scheduling issues to the staff
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st stage of change process is unfreezing stage

• Informing staff about issues increases understanding of why

changes needed

• Uric acid-based urinary calculi formation
• Can eat citrus fruits
• DO NOT EAT – liver & chicken (organ meats, which contain purine) and red

wine the same 1 / 2

• Estradiol teaching
• Headaches – indicate thromboembolic stroke
• Multiple sclerosis
• Speech pathologist swallow study – dysphagia is complication
• Rest before eating – rest because of reported weakness and easy fatigue
• Thicken liquids before drinking – dysphagia
• Chlorpromazine for schizophrenia – report to provider
• Greatest risk – injury from neuroleptic malignant syndrome
• High temp

ii. Dysrhythmia iii. Decrease LOC iv. Labile BP

• Maintain sterile technique with male indwelling urinary catheter
• Open outer flap away from body to prevent contamination of field by reaching

over it when opening the remaining flaps

• Clean penis with dominant hand
• Don sterile gloves before touching any items in sterile field
• Place catheter tray on a work surface at or above waist level
• Cranial nerve – optic II
• Clear objects from walking area
• Hemolytic transfusion reaction
• Tachycardia
• Low back pain
• Hypotension
• Child tonic-conic seizure
• Side-lying during seizure to maintain airway, decrease risk of aspiration,

facilitate drainage of oral secretions

• Rescue breaths after seizure if child does not begin having spontaneous

respirations

• Obtain vitals and ECG following seizure
• Gastrostomy tube for enteral feedings – medication admin
• Flush with at least 30ml water before and after meds to clear residual in tube
• Crush each medication separately from tube feeding formula
• Change feeding bag and tubing q 24-48 hr to prevent clogs and infection
• Give each medication separate to prevent clogging
• Macular degeneration
• Decreased central vision
• r/t bleeding int the macula or yellow spots under retina
• Warfarin instructions understood by patient
• Report change in color of stools
• Red, black, tarry indicates bleeding (AE needs to be reported)
• Acetaminophen increases risk of bleeding
• NO calcium supplements
• Maintain intake of foods with Vitamin K
• Daily blood draws for 1

st 5 days to establish appropriate warfarin dosage

• Cystic fibrosis – priority to report to provider
• Hemoptysis 275ml/24hr
• Indicates risk for hemorrhage
• Report fever – indication of pulmonary infection, but not priority over

hemoptysis >275ml/24hr

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