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Hesi final version
| Question | Answer |
|---|---|
| What is the first priority in any emergency assessment? | Airway, breathing, circulation (ABC). Always assess airway first, then breathing, then circulation. |
| What are classic signs of hypovolemic shock? | Tachycardia, hypotension, cool clammy skin, weak pulses, decreased urine output, restlessness. |
| What is the priority action for a patient with severe bleeding? | Apply direct pressure to control bleeding first. |
| What finding suggests compartment syndrome? | Severe pain not relieved by medication, pain with passive movement, pallor, paresthesia, decreased pulses. |
| What is the priority for a burn patient in the first 24 hours? | Fluid resuscitation and airway monitoring. |
| What lab value is most important in a chemotherapy patient at risk for infection? | Neutrophil count / WBC count. |
| What precautions are used for neutropenia? | Private room if needed, strict hand hygiene, avoid fresh flowers/raw foods, monitor temperature. |
| What should the nurse do if chemotherapy extravasates into tissue? | Stop the infusion immediately and follow protocol. |
| What syndrome is caused by rapid destruction of tumor cells? | Tumor lysis syndrome. |
| What is an early sign of infection in an immunocompromised oncology patient? | Fever may be the only early sign. |
| What are common signs of heart failure? | Dyspnea, crackles, edema, weight gain, fatigue. |
| What should the nurse assess before giving digoxin? | Apical pulse for 1 full minute. Hold and notify provider if pulse is too low per order/policy. |
| What are signs of digoxin toxicity? | Nausea, vomiting, bradycardia, confusion, yellow/green vision changes. |
| What is the priority intervention for chest pain suspicious for MI? | Assess, apply oxygen if indicated, obtain ECG, notify provider rapidly, follow chest pain protocol. |
| What electrolyte imbalance increases risk for dysrhythmias? | Potassium imbalance, especially hypokalemia. |
| What teaching is important for patients taking anticoagulants? | Report bleeding, use soft toothbrush, avoid injury, keep lab follow-up appointments |
| What type of charting is best: objective or subjective? | Objective charting. Record what you see, hear, measure, and do. |
| How should an error in documentation be corrected? | Follow policy, but generally single line through error, initial, date/time if required, and document correctly. Never erase or hide it. |
| Should an incident report be mentioned in the chart? | No. Chart the facts of what happened and patient response, but do not mention the incident report. |
| What is inappropriate documentation? | Judgmental wording, vague words, opinions, late charting without noting time, charting for someone else. |
| What is the best example of objective charting? | “Incision edges approximated, scant serosanguineous drainage noted” instead of “wound looks bad.” |
| What are signs of wound infection? | Redness, warmth, swelling, pain, purulent drainage, fever. |
| How often should immobile patients be repositioned to prevent pressure injuries? | Usually every 2 hours in bed, per patient condition and facility policy. |
| What stage pressure injury has full-thickness skin loss with visible fat? | Stage 3. |
| What stage pressure injury has exposed bone, tendon, or muscle? | Stage 4. |
| What nursing actions help prevent skin breakdown? | Turn/reposition, keep skin clean and dry, use pressure relief devices, encourage nutrition and hydration. |
| What are the 5 steps of the nursing process? | Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE). |
| What comes first: assessment or intervention? | Assessment first, unless it is a life-threatening emergency requiring immediate action. |
| What does a nursing diagnosis focus on? | Patient responses to health problems, not the medical diagnosis. |
| What makes a goal appropriate in nursing care planning? | It should be specific, measurable, realistic, and patient-centered. |
| During evaluation, what does the nurse determine? | Whether the goal was met, partially met, or not met and whether the care plan needs revision. |
| What is the difference between DKA and HHS? | DKA: ketones and acidosis, more common in type 1. HHS: severe hyperglycemia, profound dehydration, few/no ketones, more common in type 2. |
| What is the priority treatment for hypoglycemia in an alert patient? | Give 15 g of fast-acting carbohydrate and recheck glucose. |
| What are common signs of hypoglycemia? | Shaking, sweating, confusion, tachycardia, irritability. |
| What are common signs of hyperglycemia? | Polydipsia, polyuria, polyphagia, blurred vision, fatigue. |
| What finding suggests thyroid storm? | High fever, severe tachycardia, hypertension, agitation — this is an emergency. |
| ABC priority means? | Airway before breathing, breathing before circulation. |
| What is the safest answer if the patient cannot breathe well? | Choose the option that supports airway/oxygenation first. |
| What should you think when a question asks “best” or “priority”? | Think ABCs, safety, least invasive first, assess before act. |
Created by:
Nidiamedina