Foundations HESI Review

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Read all of chapters 1 and 2 in HESI book!!! Study this information for ALL HESI exams! Basic Nursing Skills – Vital Signs – Chapter 30  BP cuff size (review what happens with wrong cuff size... ) o False-high diastolic readings on BP cuf  Deflating cuf to slowly, inflating to slowly o False-low readings on BP  Cuf to wide, arm above heart level o False-high readings on BP  Cuf to narrow/short, cuf to loose or uneven, arm not supported  Technique for palpating systolic BP o (When arterial pulsations too weak to detect Korotkoff sounds or to identify auscultatory gap). Box 30-9, p. 508. Palpate radial pulse. Inflate cuff 30 mmHg above point at which you can no longer palpate the pulse. Slowly release valve and deflate cuff… See documentation guidelines, as well.  Technique for taking BP in the leg – o Popliteal artery.  SBP usually 10-40 mmHg higher than using brachial.  DBP remains same. Ch. 30, p. 508.  Orthostatic BP readings – o orthostatic hypotension also called postural hypotension;  obtain supine, sitting, and standing (1-3 minutes between each);  observe pt. for dizziness, fainting, lightheadedness.  Record pts. position with each reading (remember pt. safety);  don’t delegate this.  Note when you should take postural hypotension readings.  Know normal vital signs – techniques, ranges, assessment, etc. Findings on respiratory assessment? o RR: 12-20 o BP:<120/<80 o HR: 60-100 o Temp: 98.6F or 37C Summer 2016 Page o Pain 5th vital sign Vital Signs – Guidelines  Nurse ultimately responsible for vitals but can be delegated in stable patients,  RN to interpret their significance and make decision about interventions;  Determine equipment [Show More]

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