BASIC: HESI REVIEW
SAFETY
 What are the safest option?
o Raise the head of the bed
LEGAL ASPECTS OF NURSING
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What things can you do as a nurse?
What things can a LNP do?
What things can an Aide
Nursing Laws
o Good Samaritan Act
 Negligence: performing an act injury or damage to another
 Malpractice: negligence by professional personnel
o HINT: Nurses can avoid negligence and malpractice by following
their organization’s policies and procedures
 Cases the Nurse needs to report to proper authorities:
o Child or elder abuse
 7-year-old who states, “I get beat up by my parents all the
time.” The child has bruising on the back in various stages of
healing.
 HINT: the nurse has a legal responsibility to report. Suspected
child abuse
o Domestic violence
o Animal bites
o Gun shot and stab wounds
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A 40-year-old who states, “I was in an argument with my
sibling and the next thing I knew I was shot in the shoulder.”
 A 30-year-old who states, “The brawl was worth the stab
wound I got. My family has never liked that family. It is just
that way.”
o Assault
o Homicides
 HINT: the healthcare provider should explain and describe the surgical
procedure to the client
VITAL SIGNS
 Blood Pressure
o Unable to read the initial reading: deflate the cuff completely
and wait 30-60 before reinflating
o Orthostatic, lie, sit, stand- when can differences occur
 TEMPERATURE
o Different ways to take temperature
 Tympanic temperature
o Circadian rhythm
o Hypothermia
o Hyperthermia
 PULSE
o Different sites
o Factors that influence pulse range
o Pulse deficit
o Apical pulse
o Pedal pulses
 Respirations
o Factors influencing respirations and saturation levels
o Patients on oxygen and on masks for Bipap or Cpap need to be
monitored for redness in pressure areas
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 Pain
o Nurse is asked for pain medication after watching the patient
laugh at a TV show. How should the nurse respond? Ask client to
rate pain on scale of 1-10
NURSING PROCESS
 ADPIE
o Assessment
 ALWAYS ASSESS FIRST
o Diagnosis
o Planning
o Implement
o Evaluation
PERSONAL CARE/HYGIENE/EQUIPMENT
 Clients ability to perform self care during ADLs
INFECTION CONTROL
 Standard precautions
 airborne precautions
 contact precautions
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 when do you need to wear PPE
 sterile gloves technique
Chain of infection
 Mode of transmission
o Rolling contaminated gloves inside out the nurse is affecting the
mode of transmission from the portal of exit of the reservoir to a
portal of entry
 Portal of entry
 Reservoir
 Portal of exit
Wound care
 Cleansing and irrigation of wound
o Sterile dressing change
o Different dressing changes- and solutions for granulating
wounds
 Wound drainage and signs of dehiscence and assessment of drainage
amount
o Remember clean to dirty
o Use of hemovac or other drainage devices and assessment of
drainage amount
 Braden Scale: factors that influence the results; how to assess and
reassess- pressure ulcer assessment
o Lab values
o Diet
 Nursing interventions for patients with impaired skin integrity or skin
care for immobile client
o Skin rash assessment
o Statis ulcer and inflammation
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BOWEL ELIMINATION & SPECIMEN COLLECTION
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Bowel training: how, when, and why it is needed
Stool specimen for occult blood- how to obtain specimen
Administration for enema and fecal disimpactions
Interventions for normal elimination and what to do for problems?
How to assess and care fpor diarrhea
Signs of dehydration
Bowel diversions
Urinary diversions
Purpose and technique of colostomy irrigation
Factors influencing
Bed change
 If patient is receiving enteral feedings: stop the feeding for 15 minutes
prior to changing the bed
Catheter
 The nurse inserts the catheter and sees no urine, the nurse will leave
catheter and reattempt with another catheter
Cranberry juice maintains urinary tract health by reducing the adherence of
E. Coli bacteria to cells within the bladder.
FLUID AND ELCETROLYTE LEVELS
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