FUNDAMENTALS HESI 2023 COMPLETE QUESTIONS AND ANSWERS ALREADY PASSED

False-low readings on BP cuff factors: - CORRECT ANS - Cuff too wide - Above heart level - Stethoscope applied too firmly against AC fossa - Inadequate inflation level False-high readings on BP cuff factors: - CORRECT ANS - Cuff too narrow or too short - Cuff wrapped too loosely or unevenly - Arm below heart level - Arm not supported - Inflating too slowly - Repeating assessments too quickly Technique for taking BP in the leg; popliteal artery. - CORRECT ANS Lower extremity BP cuff positioned above popliteal artery at mid-thigh with knee flexed. Popliteal BP - CORRECT ANS Systolic BP: 10-40 mmHg higher than brachial. Diastolic BP: remain the same. Orthostatic BP readings: - CORRECT ANS (Postural Hypotension) - Obtain supine, sitting, and standing (1-3 mins between each). - Observe pt. for dizziness, fainting, lightheadedness. - Record pts. position with each reading (remember safety!) - Don't delegate this! NORMAL VITA SIGNS - CORRECT ANS Blood pressure: 120/80 Temperature: FUNDAMENTALS HESI 2023 COMPLETE QUESTIONS AND ANSWERS ALREADY PASSED RR: HR: O2: 95-100% Pulse Deficit - CORRECT ANS The difference between the rate of an apical pulse and the rate of a radial pulse. - Count apical pulse while a colleague counts radial pulse. Count out loud to simultaneously assess pulses. If pulse count differs by more than 2, a pulse deficit exists, which sometimes indicates alterations in cardiac output. Pulse deficit in lower extremities - CORRECT ANS - If pedal pulse is weak on one side, assess next pulse up (posterior tibial). - If that pulse is weak, move up to popliteal. - Compare one extremity to another. Apical pulse - CORRECT ANS Taken for 1 full minute; PMI (point of maximal impulse) located at 4th or 5th intercostal space (ICS), medial/left mid-clavicular line (MCL). Pt. with elevated BP, c/o headache, and what might that indicate? what do you do next? - CORRECT ANS Reassess using other arm. Do not keep taking BP on same extremity. Normal heart sounds - CORRECT ANS S1 and S2 (lub dub) If there's a fever? - CORRECT ANS Assess for more data needed! FUNDAMENTALS HESI 2023 COMPLETE QUESTIONS AND ANSWERS ALREADY PASSED Exercise and sleep - CORRECT ANS Exercise 2hrs before bedtime; allows cool down period and fatigue that promotes relaxation. - Should not exercise closer to bedtime. Factors affecting sleep - CORRECT ANS - drugs and substances - lifestyle - usual sleep patterns - emotional stress - environment - exercise and fatigue - food and caloric intake Sleep is subjective - CORRECT ANS Take what the patient says. Sleep problems - CORRECT ANS Altered sleep and pain; treat pain first. Benzodiazepines (lam, pam) and barbiturates (barbital) - CORRECT ANS Be aware of CNS depression; If taking a benzo for sleep, nurse needs to provide continued assessment for respiratory depression. ANTIDOTE: Flumazenil (Romazicon). Prioritize assessment in a variety of patients: - CORRECT ANS Think ABC's, acute/chronic pain, and unstable/stable. Normal sleep patterns and interventions to help pt. return to normal sleep patterns; - CORRECT ANS types of non-pharmacologic interventions (before giving meds).