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UTA 3632 HESI Prep
UTA 3632 Foundations HESI Prep
| Question | Answer |
|---|---|
| Crede's method | pressure is put on the suprapubic area with each attempted void. The maneuver promotes bladder emptying by relaxing the urethral sphincter. |
| Goals should be | relevant to patient needs, specific, singular, observable, measurable, and time limited. |
| Fall Risk Factors | Age (>60); Hx of Fall; Elimination urgency, frequency, or incontinence; Medications; Equipment; Decreased mobility; Cognition concerns |
| Medications causing increased fall risk | PCA/Opiates, Anticonvulsants, Antihypertensives, Diuretics, Hypnotics, Laxatives, Sedatives, and Psychotropics |
| Equipment causing increased fall risk | Any Equipment That Tethers Patient (e.g., IV Infusion, Chest Tube, Indwelling Catheters, SCDs) |
| Patient-handling devices used to prevent lift injuries | height-adjustable beds, ceiling-mounted lifts, friction-reducing slide sheets, and air-assisted devices |
| Physiological risk factors | involve the physical functioning of the body; physical conditions that place increased stress on physiological systems, increasing susceptibility to illness in these areas. |
| Conditions treated with heat therapies | Open wounds, rectal surgery, episiotomy, painful hemorrhoids, muscle tension, vaginal inflammation, wound debridement |
| Conditions treated with cold therapies | Direct trauma (sprains, strains, fractures, muscle spasms), superficial laceration or puncture wound, minor burn, suspected malignancy in area of injury or pain, injections, arthritis and joint trauma |
| Physiological response to heat therapies | Vasodilation, Reduced blood viscosity, Reduced muscle tension, Increased tissue metabolism, Increased capillary permeability |
| Physiological response to cold therapies | Vasoconstriction, Local anesthesia, Reduced cell metabolism, Increased blood viscosity, Decreased muscle tension |
| Selective optimization with compensation theory | concept that, as individuals age, they are able to compensate for some decreases in physical or cognitive performance by developing new approaches. |
| Negative feedback process | senses an abnormal state such as lowered body temperature and makes an adaptive response such as initiating shivering to generate body heat. |
| Hypertension | two elevated blood pressure measurements in a row |
| Normal pH of urine | 4.6-8.0 |
| Proteinuria | Protein in Urine. Caused by renal disease |
| Glucosuria | Glucose in Urine. Caused by diabetes mellitus or ingestion of high concentratiosn of glucose |
| Ketonuria | Ketones in urine. Caused by poorly controlled Diabetes mellitus, dehydration, starvation, or excessive aspirin usage |
| Normal Specific gravity of urine | 1.0053-1.030 |
| Elevated Specific gravity of urine | Dehydration, reduced renal blood flow, and increased ADH secretion. |
| Reduced Specific gravity of urine | Overhydration, early renal disease, and inadequate ADH secretion. |
| Hematuria | Erythrocytes, hemoglobin, or myoglobin in urine. Caused by damage to glomeruli or tubules, trauma, disease, or surgery of the lower urinary tract. Blood in a routine urine specimen in a woman may be a result of contamination with menstrual fluid. |
| Elevated WBC in urine | urinary tract infection |
| Bacteriuria | Bacteria in urine. Indicative of urinary tract infection. |
| Casts in urine | renal alterations |
| Crystals in urine | Result of food metabolism. Excess crystals such as uric acid or calcium phosphate result in renal stone formation. |
| Urine daily output | 1200 to 1500 mL |
| Decreased urine output | less than 30 mL for more than 2 consecutive hours |
| Respiratory acidosis s/s | ph < 7.35, PaCO2 > 45 mm Hg, HCO3 normal (uncompensated) or > 26 mEq/L (compensated), Headache, light-headedness, decreased level of consciousness (confusion, lethargy, coma), cardiac dysrhythmia, warm and flushed skin, muscular twitching. |
| Respiratory acidosis causes | Impaired gas exchange (e.g., COPD, Pneumonia), Impaired neuromuscular function (e.g., resp muscle weakness d/t hypokalemia, chest injury), Dysfunction of brainstem respiratory control (e.g., drug overdose, central sleep apnea) |
| Respiratory alkalosis s/s | ph > 7.45, PaCO2 < 35mmHg, HCO3 normal (uncompensated) or < 22mEq/L (compensated), hyperventilation, light-headedness, paresthesias, excitement and confusion possibly followed by decreased LOC, cardiac dysrhythmias. |
| Respiratory alkalosis causes | Hypoxemia, Acute pain, Anxiety, psychological distress, prolonged sobbing, Inappropriate mechanical ventilator settings, Stimulation of brainstem respiratory control: head injuries, meningitis, gram-negative sepsis, salicylate overdose |
| Metabolic acidosis s/s | ph < 7.35, HCO3 < 22 meq/L, PaCO2 normal (uncompensated) or < 35 mm Hg (compensated), Decreased LOC (lethargy, confusion, coma), abdominal pain, cardiac dysrhythmias, compensatory hyperventilation |
| Metabolic acidosis causes | Increase of metabolic acid (e.g., ketoacidis, hypermetabolic state, oliguric renal disease, cirulatory shock, ingestion of acid) or Decrease of base (e.g., diarrhea, pancreatic fistula or intestinal decompression, renal tubular acidosis) |
| Metabolic alkalosis s/s | ph > 7.45, HCO3 > 26 meq/L, PaCO2 normal (uncompensated) or > 45 mm Hg (compensated), Light-headedness, paresthesias; possible excitement and confusion followed by decreased LOC, cardiac dysrhythmias (may be caused by hypokalemia) |
| Metabolic alkalosis causes | Increase of base (e.g., Admin NaHCO3, blood transfusion, ECV deficit) or decrease of metabolic acid (e.g., vomiting, gastric suctioning, hypokalemia, excess aldosterone) |
| Primary prevention | Health promotion, specific protection |
| Secondary prevention | Early dx/prompt tx and Disability limitations |
| Tertiary prevention | Restoration and rehabilitation |
| Dysphagia interventions | 30-min rest before eating, upright to eat, chin-down position, place food in strong side (if unilateral), thicken fluids, feed slowly, small bites. If cough/choke, remove food & provide oral suction if necessary. |
| Nutrition needs of immobile patient | high-calorie, high-protein diet. Avoid calcium foods d/t increased risk for urinary calcification. |
| Allostatic load | Stress resistance stage; chronic arousal with presence of powerful hormones causing excessive wear and tear on the person. |
| Delayed gastric emptying | concern aspiration risk if 250 mL or more remains in the patient's stomach on each of two consecutive assessments. |
| Blood pressure cuff too small causes | false-high reading |
| Blood pressure cuff too large causes | false-low reading |
| Assessment for Orthostatic vital sign changes | Both blood pressure & pulse taken in each position: lying, sitting, and standing. |
| Anticipated vital changes with fluid volume deficit | Orthostatic hypotension & tachycardia (decreased BP and increased pulse upon standing) |
| Correlation btwn weight loss/gain & fluid | 1 kg body weight lost/gained is equivalent to appx 1 L of fluid |
| Elderly problem that contributes to fluid volume deficit | Decreased hepatic blood flow decreases drug metabolism, increasing drug effect. |
| Lab test to monitor increase in free, unbound drug molecules | Serum protein - if decreased, drugs don't bind and remain free. |
| Pitting edema scale | 1/2 the number of mm: 1+ if 2mm, 2+ if 4mm, 3+ if 6mm, or 4+ if 8mm. |
| Never given IV Push | Potassium |
| Potassium-rich foods | Potato, Grapefruit |
| Calorie requirements for average adult | 20-35 calories/kg/day |
| Normal serum protein | 6.4-8.3 g/dl |
| Decreased serum protein | indicator of malnutrition |
| High Protein Foods | Milk, Eggs (including deserts: angel food cake, custard, cheesecake), Cheese, Meat/Poultry/Fish |
| When to begin feeding supplements | when bowel sounds are present (usually within 24 hrs of PEG tube insertion) |
| Cheyne-Stokes respiration | Respiratory rate and depth are irregular with alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth then reverses. |
| Kussmaul's respiration | Respirations are abnormally deep, regular, and increased in rate. Common in diabetic ketoacidosis. |
| Biot's respiration | Respirations are abnormally shallow for two to three breaths followed by irregular period of apnea. |
| Normal Temp (adult) | 36° to 38° C (96.8° to 100.4° F) |
| Degree Fever becomes harmful | 39° C (102.2° F) |
| Heatstroke | 40° C (104° F) or more |
| Hypothermia | below 35° C (95° F), usually caused by prolonged exposure to cold |
| Farenheit to Celsius conversion | (°F−32)×5/9 |
| Celsius to Fahrenheit conversion | (9/5×°C)+32 |
| Normal Heart Rate (Infant) | 120-160 |
| Normal Heart Rate (Toddler) | 90-140 |
| Normal Heart Rate (Preschooler) | 80-110 |
| Normal Heart Rate (School-aged) | 75-100 |
| Normal Heart Rate (Adolescent) | 60-90 |
| Normal Heart Rate (Adult) | 60-100 |
| Normal Respiratory Rate (Newborn) | 35-40 |
| Normal Respiratory Rate (Infant 6 mos) | 30-50 |
| Normal Respiratory Rate (Toddler 2yrs) | 25-32 |
| Normal Respiratory Rate (Child) | 20-30 |
| Normal Respiratory Rate (Adolescent) | 16-20 |
| Normal Respiratory Rate (Adult) | 12-20 |
| Normal BP (Newborn) | 40 (mean) |
| Normal BP (1 month) | 85/54 |
| Normal BP (1 year) | 95/65 |
| Normal BP (6 years) | 105/65 |
| Normal BP (10-13 yrs) | 110/65 |
| Normal BP (14-17 yrs) | 119/75 |
| Normal BP (18 yrs or older) | <120/<80 |
| Prehypertension | Systolic 120-139 OR Diastolic 80-89 |
| Stage 1 hypertension | Systolic 140-159 OR Diastolic 90-99 |
| Stage 2 hypertension | Systolic ≥160 OR Diastolic ≥100 |
| Hypotension | Systolic BP falls to 90 mm Hg or below |
| Antitussive | Reduces frequency of coughs |
| Classes of antihypertenisives | Beta 1 blockers, Beta 1 & 2 blockers, Alpha-Beta blockers, ACE inhibitors, Angiotensin II Receptor Blocers, Calcium Channel Blockers |
| Beta blocker considerations | Weight loss drugs & alcohol can lessen effect. |
| ACE Inhibitor considerations | Can cause serious congenital problems, hyperkalemia, and angioedema. Shouldn't be suddenly stopped or taken with NSAIDs (aspirin/ibuprofen). |
| Classes of diuretics | Loop (fruosemide/Lasix), Thiazide (HCTZ), Potassium Sparing |
| Diuretic considerations | Can cause significant hypokalemia. Sulfonamide dirivitives, assess for allergies. |
| Classes of Antianginal | Nitrates (Nitroglycerin) |
| Considerations for Nitrates | After 1 sublingual nitroglycerin, wait 5 min and administer a 2nd one if pain is not resolved or is worse. |
| Classes of Antilipidemics | Statins (lipitor), Fibric acid derivatives, Niacin derivatives, Bile acid sequestrants, Cholesterol Absorption Inhibitor |
| Nursing Considerations for Statins | Pregnancy category X (do not give). Inhibited by grapefruit juice. |
| Positive inotropic drugs | Heart failure drugs (Digoxin) |
| Considerations for Digoxin | Check apical pulse bef admin. Use Atropine as antidote for bradycardia. |
| Classes of coagulation modifiers | Anticoagulants (Heparin, Levonox, Coumadin/warfarin), Antiplatelets (Aspirin, Plavix), Thrombolytic |
| Coagulation Modifier considerations | Monitor for bleeding. Monitor coagulation labs (PT/INR, PTT) and CBC (rule out anemia) |
| Psychotherapeutic classes | Antipsychotics (Throazine, Haldol, Geodin), Antidepressants (Elavil, MAO inhibitors, Prozac, Zoloft, Cymbalta, Wellbutrin), Antimanics (Lithium), Anxiolytics (Benzodiazepines-Ativan, Valium, Xanax) Sleep aids (Lunesta, Ambien) |
| Considerations for Antipsychotics | Tardive dyskinesia (workm-like twisting & writhering of tongue and face, lip smaking, tounge protrusion) |
| Considerations for SSRIs | If stopped suddenly will result in headache and dizziness for up to a week after discontinuation. Risk for serotonin syndrome, no St. John's Wort or Triptans (migraine meds) |
| Classes of Substance abuse drugs | Opiods (Morphine), Stimulants (Meth), Depresants (Marijuana), Alcohol (ETOH), Nicotine |
| Classes of Antiepileptic Drugs | Antiepileptics (Dilantin, Cerebyx, Tegretol, Depakote, Ativan, Neurontin) |
| Classes of Antianemics | Hematinic (iron, B12, Folic acid, epoetin alfa) |
| Considerations for Iron | Fruit juice (vitamin C) increases absorption. Food, milk, or antacids decrease absorption. Can cause constipation. |
| Drugs used to manage inflammation, pain and fever | NSAID (Aspirin, Ibuprofen, Naproxen, Tylenol), Opioids (Morphine, Demerol, Dilaudid, vicoden) Nonopioid Analgesic (tramadol) |
| Considerations for NSAIDS | GI bleeding |
| Considerations for Opioids | Monitor respiratory status, for orthostatic hypotension, and constipation. |
| Drugs affecting adrenal & thyroid glands | Glucocorticoids (Hydrocortisone, Prednisone, Flonase), Mineralcorticoids (fludrocortisone), Thyroid Agents (Synthroid), Antithyroid Agents (methimazole, propranolol) |
| Glucocorticoid considerations | Risk for Cushingoid appearance when used for 2 wks or longer. Don't stop abruptly (physiological crisis/death). |
| Normal WBC count | 5000-10000/mm3 |
| Normal Bowel Sounds | 5-35/min |
| mL/oz | 30mL/1oz |
| oz/cup | 8oz/1cup |
| Five stages of dying | Denial, Anger, Bargaining, Depression, Acceptance |
| Final Stages of Dying s/s | Extremities cool; mottling of the legs; perspiration, increased sleeping, disorienation; incontinence, upper airway secretions; noisy respirations; restlessness; decreased intake of food & fluids; nausea |
| Homan's sign | A positive sign is demonstrated when the client complains of pain in the calf upon dorsal flexion of the foot. Warning sign of possible thrombophlebitis. |
| Technique for deep-breathing | hands on abdomen above belly button, breath in and make hands go up. |
| Autonomy | An individual's right of self-determination and freedom of decision making. |
| Beneficence | Doing good for clients and providing benefit balanced against risk. |
| Nonmaleficence | Doing no harm to clients. |
| Justice | Being fair to all and giving equal treatment, including distributing benefits, risks, and costs equally. |
| Fidelity | Being loyal and faithful to commitments and accountable for responsibilities. |
| Veracity | Telling the truth and not intentionally deceiving or misleading clients. |
| Confidentiality | The prohibition of some disclosures of information gained in certain relationships without the consent of the original source of the information. |
| Privacy | A right of limited physical or informational inaccessibility. |
| Serous Wound Drainage | clear, watery plasma |
| Purulent Wound Drainage | thick, yellow, green, tan, or brown |
| Serosanguineous Wound Drainage | pale, red, water: mixture of serous and sanguineous |
| Sanguineous Wound Drainage | Bright red: indicates acive bleeding |
| Dehiscence | Separation of the edges of a wound, revealing underlying tissues. |
| Eschar | Thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn. It may be allowed to be sloughed off naturally, or it may need to be surgically removed. |
| Evisceration | Protrusion of visceral organs through a surgical wound. |
| Induration | Hardening of a tissue, particularly the skin, because of edema or inflammation. |
| Secondary intention | Wound closure in which the edges are separated; granulation tissue develops to fill the gap; and, finally, epithelium grows in over the granulation, producing a larger scar than results with primary intention. |
| Tinnitus | Ringing heard in one or both ears. |
| Reactive hyperemia | redness when tissue is relieved of pressure. abnormal if lasts > 1hr and tissue does not blanch. |
| Mottling | irregular or patchy discoloration of the skin. |
| Dependent rubor | redness that occurs when an area is lower than the heart. most common in legs. |
| Hydrocolloid dressings | dressings that are adhesive and occlusive. The wound contact layer of this dressing forms a gel as fluid is absorbed and maintains a moist healing environment. They support healing in clean granulating wounds and autolytically debride necrotic wounds. |
| Hydrogel dressings | dressing hydrates wounds and absorbs some smaller amounts of exudate. Hydrogel dressings are for partial-thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds, burns, and radiation-damaged skin. |
| Debridement | removal of dead tissue from a wound. |
| Self-adhesive, transparent film dressings | dressing traps moisture over wound. ideal for small superficial wounds such as partial-thickness wounds or to protect high-risk skin. |
| Wet-to-dry dressings | Mechanically debride tissue. Moistened guaze placed on the wound and allowed to dry. It adheres to the wound tissue and debrides necrotic or infected tissue as it is removed. |
| Autolytic debridement | synthetic dressings placed over a wound to allow eschar to be self-digested by action of enzymes in wound fluids. (e.g., transparrent film & hydrocolloid. |
| Erikson's Infancy (birth to 18 months) | Trust vs. Mistrust Feeding Children develop a sense of trust when caregivers provide reliabilty, care, and affection. A lack of this will lead to mistrust. |
| Erikson's Early Childhood (2 to 3 years) | Autonomy vs. Shame and Doubt Toilet Training Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt. |
| Erikson's Preschool (3 to 5 years) | Initiative vs. Guilt Exploration Children need to begin asserting control and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt. |
| Erikson's School Age (6 to 11 years) | Industry vs. Inferiority School Children need to cope with new social and academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority. |
| Erikson's Adolescence (12 to 18 years) | Identity vs. Role Confusion Social Relationships Teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self. |
| Erikson's Young Adulthood (19 to 40 years) | Intimacy vs. Isolation Relationships Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation. |
| Erikson's Middle Adulthood (40 to 65 years) | Generativity vs. Stagnation Work and Parenthood Need to create/nurture things that will outlast them. Success = feelings of usefulness and accomplishment, while failure = shallow involvement in the world. |
| Erikson's Maturity(65 to death) | Ego Integrity vs. Despair Reflection on Life Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair. |
| Normal Glucose Normal | <100 mg/dL |
| Normal HbA1c Normal | 5-7% |
| Normal LDL Cholesterol Normal | <130 mg/dL |
| Normal HDL Cholesterol Normal | men, 35-65 mg/dL; women, 35-80 mg/dL |
| Normal Triglycerides Normal | <150 mg/dL |
| Normal Serum Albumin Normal | 3.5 to 5.5 g/dL |
| Normal Serum Transferrin Normal | 170 to 250 mg/dL |
| Normal Prealbumin Normal | 15 to 25 mg/dL |
| Normal C-reactive protein (CRP) Normal | <0.1 mg/dL |
| Normal Daily Oral Fluid Intake | 1100-1400 mL |
| Normal Total Daily Fluid Intake/Output | 2200-2700 mL |
| Normal Daily Urine Fluid Output | 1200-1500 mL |
| Normal Osmolality | 280-300 mOsm/kg |
| Normal BUN | 10-25 mg/dL |
| Normal Sodium | 136-145 mEq/L |
| Normal Potassium | 3.5-5.0 mEq/L |
| Normal Chloride | 98-106 mEq/L |
| Normal Calcium | 8.4-10.5 mg/dL |
| Normal Magnesium | 1.5-2.5 mEq/L |
| Normal Phosphate | 2.7-4.5 mg/dL |
| Normal pH | 7.35-7.45 |
| Normal PaCO2 | 35-45 mm Hg |
| Normal PaO2 | 80-100 mm Hg |
| Normal HCO3 | 22-26 mEq/L |
| Normal O2 Sat | 95-100% |
| Normal Hemoglobin Normal | males—14 to 18 g/dL, females—12 to 16 g/dL |
| Normal Hematocrit Normal | males—37% to 49%, females—36% to 46% |
| Normal RBC | 4.7 to 6.1 million/mm3, males; 4.2 to 5.4 million/mm3, females |
| Normal WBC | 5000-10,000/mm3 |
| Normal Iron | 60-90 g/100 mL |
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