HESI MILESTONE EXAM #1 | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+

1 HESI MILESTONE EXAM #1 | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+ Histamine1 blockers action(mine, zine, dine) Correct Answer: bind selectively to H1-histaminic receptors, blocking the actions of histamine at these sites H1 antagonists are useful in treating Correct Answer: -mild allergies(seasonal rhinitis) -severe allergies(anaphylaxis) -motion sickness -insomnia -common cold Histamine (H2)-Receptor Antagonists action(tidine) Correct Answer: block the H2 receptors responsible for stimulating the secretion of gastric acid Exenatide (Byetta) hypoglycemia Correct Answer: -can occur right after meals 2 -for severe hypoglycemia give IV dextrose Exenatide (Byetta) hypoglycemia teaching Correct Answer: -teach about s/s of hypoglycemia(cold and clammy give them candy) -have glucagon emergency kit available -regular monitoring of A1c levels are required Exenatide (Byetta) hypoglycemia causes Correct Answer: -insulin overdose -reduced food intake -vomiting and diarrhea -excessive alcohol intake -unaccustomed exercise -termination of pregnancy signs and symptoms of hypoglycemia Correct Answer: -tachycardia -palpitations -sweating -nervousness -headache -confusion -drowsiness 3 -fatigue antitussives therapeutic action is to Correct Answer: Act on the cough control center in the medulla to suppress the cough reflex; used for a cough that is nonproductive and irritating Anaphylaxis‐PCN Correct Answer: -laryngeal edema, bronchoconstriction, severe hypotension= immediate hypersensitivity reaction Anaphylaxis treatment Correct Answer: epinephrine (subQ, IM, or IV) plus respiratory support What drugs are effective and safe alternatives for patients with penicillin allergies? Correct Answer: vancomycin, erythromycin, and clindamycin To ensure prompt treatment if anaphylaxis should develop patients should be? Correct Answer: observed for at least 30 minutes after drug injection (i.e., until the risk of an anaphylactic reaction has passed). To minimize the chances of an anaphylactic reaction, penicillin should be administered Correct Answer: an initial small dose is followed at 60-minute intervals by progressively larger doses until the full therapeutic dose has been achieved 4 Morphine overdose treatment Correct Answer: -Naloxone (narcan) -Intravenous, IM, and subQ. For initial treatment, administer IV CT‐diarrhea‐action Correct Answer: -decrease intestinal motility and thereby slow intestinal transit, which allows more time for absorption of fluid and electrolytes -activation of opioid receptors decreases secretion of fluid into the small intestine and increases absorption of fluid and salt. ACE inhibitor‐hyperkalemia Correct Answer: -Inhibition of aldosterone release (secondary to inhibition of angiotensin II production) can cause potassium retention by the kidney. -significant potassium accumulation is limited to patients taking potassium supplements, salt substitutes (which contain potassium), or a potassium-sparing diuretic. Leukotrienes‐teaching Correct Answer: 1. To take medication 1 hour before or 2 hours after meals 2. To increase fluid intake 3. Not to discontinue the medication and to take it as prescribed, even during symptom-free period 5 Methadone therapeutic use Correct Answer: Relief or prevention of moderate to severe pain while causing minimal respiratory depression, constipation, urinary retention, and other adverse effects. methadone pain assessment Correct Answer: -Assess pain before administration and 1 hour later -Determine the location, time of onset, and quality of pain (e.g., sharp, stabbing, dull) -assess for psychologic factors that can lower pain threshold (anxiety, depression, fear, anger) methadone is given Correct Answer: Oral, IM, IV, subQ, rectal, epidural, intrathecal, transdermal (fentanyl), and transmucosal (fentanyl) Methadone assess for Correct Answer: -QT prolongation(dyshythmias) -overdose -respiratory depression -substance abuse -withdrawal symptoms 6 Methadone is used as Correct Answer: a replacement medication for opiate dependence and to facilitate withdrawal When starting a patient on ACE inhibitors monitor what? Correct Answer: blood pressure closely for 2 hours after the first dose and periodically thereafter. a major side effect of alpha blocker(osin) is what? Correct Answer: orthostatic hypotension diclofenac does what to the liver? Correct Answer: cause severe injury while taking diclofenac patients should? Correct Answer: -have periodic liver functions tests -monitor and report for signs of liver damage(jaundice, fatigue, nausea) calcium channel blockers toxicity signs Correct Answer: -severe hypotension -cardiac-toxicity(bradycardia and av block) -ventricular tachydhythmias 7 Managing Acute Toxicity in calcium channel blockers Correct Answer: -gastric lavage followed by activated charcoal -Give IV calcium to help counteract excessive vasodilation and reduced myocardial contractility -To raise blood pressure, give IV norepinephrine -Iv Fluids and Trendelenburg's position -atropine and glucagon to reverse bradycardia and AV block Calcium Channel Blockers medications Correct Answer: -nifedipine (Adalat, Procardia) -amlodipine (Norvasc) -verapamil (Calan) -diltiazem (Cardizem) NSAIDS medications Correct Answer: -Ibuprofen (Advil, Motrin) -Indomethacin (Indocin) - usually used for GOUT -Naproxen (Aleve, Naproxyn) -COX-2- Inhibitors: Celecoxib (Celebrex) Avoid taking calcium channel blockers with Correct Answer: -digoxin(increases risk of partial or complete AV block) -beta blockers(bradicardia,av block, heart failure) 8 -grapefruit juice NSAIDs should be used with extreme caution by Correct Answer: -pregnant women -peptic ulcer disease -bleeding disorders -anticoagulants -glucocorticoids -ACE inhibitors -ARBS NSAID administration teaching Correct Answer: -take with food, milk or a glass of water -do not crush or chew enteric-coated or sustained release formulations -discard aspirin preparations that smell like vinegar NSAIDs should be avoided in _________ Correct Answer: Children with chickenpox or influenza to prevent Reye's syndrome NSAIDs with caution in patients with Correct Answer: -advanced age -previous intolerance to NSAIDs -heavy cigarette smoking 9 -history of alcoholism Aspirin toxicity treatment Correct Answer: -sponging with tepid water for external cooling -infusion of fluids -bicarbonate as reversal -mechanical ventilation A high risk of toxicity exists if the client is taking ibuprofen concurrently with Correct Answer: Calcium channel blocker Eyedrops Administration teaching Correct Answer: -Semi prone position -wash hands before and after administration -pull down and place in conjunctival fornix -do not allow the tip of bottle to touch eye Enema Prep Correct Answer: -reinforce misconceptions and concerns -explain procedure and what to expect -provide privacy -position in left side knee chest position -give at room temperature 10 -solution must be retain to be effective -hang 12-18 inch above rectum resiudal volume Correct Answer: -bladder not completely emptied -assessment of the bladder, urethral meatus , skin integrity, hydration and urine consistency anuria Correct Answer: 24-hour urine output is less than 50 mL dysuria Correct Answer: painful or difficult urination frequency of urine Correct Answer: increased incidence of voiding glycosouria Correct Answer: glucose in the urine nocturia Correct Answer: excessive urination at night 11 oliguria Correct Answer: 24-hour urine output is less than 400 mL polyuria Correct Answer: excessive production of urine proteinuria Correct Answer: protein in the urine pyuria Correct Answer: pus in the urine urgency incontinence Correct Answer: strong urge to void urinary incontinence Correct Answer: involuntary loss of urine Droplet precautions Correct Answer: spiderman! S=sepsis, scarlet fever, streptococcal pharyngitis, P=parvovirus, pneumonia, pertussis I=influenza D=diphtheria 12 E=epiglottitis R=rubella M=mumps, meningitis, mycoplasma or meningeal pneumonia An=adeNovirus droplet precaution PPE Correct Answer: -gown, gloves, mask -Private room Ambulation Tolerance Correct Answer: -assess pt ability to stand, walk, sit up and grasp -note gait, ease of movement, alignment, joint structure and function, muscle mass and endurance, tone and strength -assess if assistive devices is effective Paresis Correct Answer: impaired muscle strength or weakness Paralysis Correct Answer: Absence of strength secondary to nervous impairment Wheelchair safety Correct Answer: -ensure wheels are locks during transfers 13 -front leg rest to be removed during transfer to prevent falls Wheelchair transfer post CVA (stroke) Correct Answer: -transfer using gait belt from bed to wheelchair -place patient stronger leg forward with weaker leg towards the bad to allow stronger leg to support most of patient body Physical restraints Correct Answer: -Side rails, geriatric chairs w/ attached trays, appliances ties at wrist, ankle, or waist Restraints Correct Answer: -used as last resort -can be applied without an order but must be obtained immediately after -order must state intended duration(no more than 24 hours) -pt must be assessed every hour restraints must be Correct Answer: -half bow -safety knot/quick release -attached to non-moveable part of bed Saline flush 14 Correct Answer: -if used for intermittent infusion should be flushed with NS prior to each infusion to assess port -Flushing after to clear infused medication from catheter lumen -must be locked after completion of flush -periodic flushing required to keep the catheter patent Braden interpretation Correct Answer: -evaluates for pressure sore -assess mental status, continence, mobility, activity, and nutrition Braden Scale for Predicting Pressure Sore Risk Correct Answer: 19-23 not at risk 15-18 mild risk 13-14 moderate risk 10-12 high risk Less than or equal to 9 very high risk Normal Hemoglobin Correct Answer: 12-18 g/dL Decreased hemoglobin mean Correct Answer: low iron=anemia 15 Hematocrit Correct Answer: 40-50% Decreased hematocrit Correct Answer: Anemia Increased hematocrit Correct Answer: dehydration serum albumin level Correct Answer: 3.5-5.5 g/dL decreased serum albumin Correct Answer: -malnutrition (prolonged protein depletion) -malabsorption Prealbumin Correct Answer: 23-43 mg/dL decreased prealbumin Correct Answer: -protein depletion -malnutrition 16 BUN Correct Answer: 10-20 mg/dL Increased BUN Correct Answer: -Starvation -severe dehydration Decreased BUN Correct Answer: malnutrition, overhydration Creatinine Correct Answer: 0.6-1.2 mg/dL Increased Creatinine Correct Answer: dehydration decreased creatinine Correct Answer: -severe malnutrition -reduction in total muscle mass Catheter check for kink Correct Answer: -prevent tubing from becoming kinked and urine backing up in tubing -urine can lead to excoriation of the glans 17 -position below the bladder Pressure ulcer infection Correct Answer: -thick yellow or green pus -foul odor -redness and warm to touch -swelling -tenderness Infection control-bioharzard Correct Answer: -red bag marked and used for disposed trash that contains bodily fluids -when collecting specimens prevent outside of container from becoming contaminated body fluids -place specimens in plastic bags and seal to prevent leakage nasopharyngeal suction assess Correct Answer: -measure length from tip of the nose to the earlobe and then down the xiphoid process -semi fowler(awake and alert pt) -assess o2 sat prior to suctioning and throughout -pre-oxygenate if indicated -if pt starts gagging/coughing stop and wait then try again 18 Smoking effect on sleep Correct Answer: -nicotine stimulate effect=difficulty falling asleep -easily aroused -not smoking after last meal can improve sleep -total withdrawal can cause sleep disturbances -pt who stop smoking report daytime sleepiness and restlessness at night dressing change findings Correct Answer: -note location of wound, nearest anatomical landmark -document size of wound, measurements -assess wound edges and signs of dehiscence or evisceration -note drainage after cleaning(amount ,color, odor, and consistency) serous drainage Correct Answer: clear, watery plasma Sanguienous drainage Correct Answer: bloody drainage Serousanguineous drainage Correct Answer: light pink to blood tinged drainage 19 Purlent drainage Correct Answer: thick, musty, foul odor and varies in color (infection) Sleep Assessment Correct Answer: assess pt usual times of sleeping and waking, bedtime rituals, preferences for sleep environment Placebo admin Correct Answer: -used in drug trails to determine effects of actual medication -can be used to determine psychological effects of a patient Power and Authority Correct Answer: gives one or more person the power to act on your behalf as agent of health Nursing process-outcome statment Correct Answer: -reflect result of what to achieve /interventions to go about achieving -must be patient centered, specific, and measurable -carrying out planned nursing interventions -assist client to meet desired outcomes/goals -promote wellness and disease -facilitate coping with altered functioning 20 Benzodiazepines in pregnancy Correct Answer: -potential developmental defects on embryo or fetus(facial clefts, cardiac malformations) -crossing from the breast milk putting breastfed infants at risk for adverse effects End of life-DNR Correct Answer: -DO NOT RESUSCITATE/No code, Allow natural death -no attempts to restore life to patient -must be signed by provider Grief mastectomy Correct Answer: -anticipatory grief -grief prior to loss Wound irrigation Correct Answer: -debridement to promote wound healing -irrigation fluid= 0.9% NS autolytic debridement Correct Answer: -occlusive dressing: hydrocolloids or transparent films -used own body enzymes and defense mechanisms to loosen and liquify necrotic tissue 21 Enzymatic debridement Correct Answer: uses commercially prepared enzymes to speed up body autolytic process mechanical debridement Correct Answer: -used external physical force to dislodge and remove debris and necrotic tissue -done by wound irrigation with pulsed pressure lavage, whirlpool therapy, laser treatment, ultrasound, or surgical debridement primary prevention Correct Answer: preventing development of disease or injury ex:vaccines, family planning, poison control information, accident prevention, seatbelts and helmets secondary prevention Correct Answer: early detection of illness ex: vision, medical, and dental appointments;screenings Tertitary prevention Correct Answer: reducing disability and helping to live with disease with maximum functioning ex:teaching diabetic patient s/s of hyper/hypoglycemia 22 Stage 1 pressure ulcer Correct Answer: nonblanchable erythema of intact skin stage 2 pressure ulcer Correct Answer: partial thickness skin loss with exposed dermis (viable, pink, red moist) stage 3 pressure ulcer Correct Answer: Full thickness loss of skin extending into subcutaneous tissue Stage IV pressure ulcer Correct Answer: full thickness skin and tissue loss exposure of muscle, tendon, ligaments, cartilage, and bone unstageable pressure ulcer Correct Answer: obscured full-thickness skin and tissue loss (eschar and slough) Cranial nerve 1 Correct Answer: Olfactory (smell) Cranial nerve 2 23 Correct Answer: Optic - vision(snellen chart) Cranial Nerve 3 Correct Answer: Oculomotor (pupil size shape,size, and equality) Cranial nerve 4(IV) Correct Answer: Trochlear (eye movement) Cranial Nerve 5(V) Correct Answer: Trigeminal (object in hand) Cranial nerve 6 (VI) Correct Answer: Abducens(observe for nystagmus in one or both eyes Cranial nerve 7(VII) Correct Answer: Facial(symmetrical expressions) Cranial Nerve 8(VIII) Correct Answer: Hearing(whisper test) Cranial Nerve 9(IX) Correct Answer: Glossopharyngeal (gag reflex, swallowing) 24 Cranial Nerve 10(X) Correct Answer: Vagus(stick out tongue) Cranial Nerve 11(XI) Correct Answer: Spinal accessory(shrug shoulders) Cranial Nerve 12(XII) Correct Answer: Hypoglossal(say light, tight, dynamic) Blood pressure(lie, stand, sit) Correct Answer: orthostatic BP ROM adduction Correct Answer: movement towards the body's midline tympanic temperature Correct Answer: -inspect canal for redness, swelling, discharge, foreign body -do not insert if client has auditory inflammation or discharge -reading may be affected by ear infection or excessive wax -Higher than oral ADLS assessment Correct Answer: -loss of vision effects dressing,grooming,and ambulating 25 -allow older adults extra time -evaluate risk for falling, skin breakdown, urinary incontinence, altered sleep -note changes in mental status -vital signs -BMI Between 25-29 Assess pulse-GERI Correct Answer: -peripheral pulse weaker in older adults -decreased resting HR due to meds Pedal Pulse Correct Answer: -dorsal pedis(top of foot) -posterior tibial (inner ankle) -palpate bilateral note differences -if unable to find use doppler ultrasound stethoscope assess carotid artery Correct Answer: -Inspect boule stoke seen with S1 and S2 -palpate strength of pulse and grate bilaterally -palate one side at a time -auscultate for bruit and murmurs(use bell and ask pt to hold breath) -listen in three locations: jawline, mid neck, above clavicle line 26 Male perianal assessment Correct Answer: -position on side, spread buttocks, and inspect perineal area -note loose sphincter, lesions, hemorrhoids Female perianal assessment Correct Answer: -make sure no menses or intercourse before pap test -place in semi-lithotomy position -inspect, palpate, collect specimens inner and outter isometric exercise Correct Answer: contractions of a particular muscle or group of muscles ex:yoga, holding position isotonic exercise Correct Answer: Muscle shortening and active movement ex: ADLS,independent ROM, swimming, walking, jogging, and bicylcing isokinetic exercise Correct Answer: muscle contractions with resistance ex: rehabilitative exercises for knee and elbow injuries and lifting weights Health history menopause Correct Answer: -12 months consecutively without menses 27 -estrogen decreases ,uretine becomes smaller, ovaries shrink -increase risk of vaginal infections, UTIs, dyspareunia, and diminished libido -bone loss accelerates menorrhagia Correct Answer: -menstrual bleeding lasts longer than 7 days -treated with NSAIDs, birth control and iron tablets Allergic reaction interview Correct Answer: -verify allergies and compare to MAR -Note type of response broncial breath sounds Correct Answer: -loud high pitched and found over trachea and larynx -course or tubular -inspiration less than expiration -abnormal if heard outside or normal location Barrel chest Correct Answer: -COPD -anterior to posterior depth of chest widens, causing thorax to become barrel shaped -harder to inhale deeply causes diminished respiratory volume 28 Assess leg Correct Answer: -symmetry -ROM -color, hair, and nails -edema -palate pulses for circulation Abdominal inspection Correct Answer: -Inspect, Auscultate, Percuss, Palpate -RLQ, RUQ, LUQ,LLQ Chest precussion Correct Answer: -performed to outline pt heart boarders and to check for cardiac enlargement with suspected heart failure -dull is cardiac tissue -dullness noted in 4th and 5th left ICS at mid clavicular line Carpal Tunnel Correct Answer: A numbness and tingling in the hand and arm caused by a pinched nerve in the wrist. Tinel's sign 29 Correct Answer: lightly tapping (percussing) over the nerve to elicit a sensation of tingling Phalens test Correct Answer: pushing the dorsal surface of hands together and holding for 30 to 60 seconds Reduced LOC-pain Correct Answer: -moaning and crying -facial grimacing -bracing -rubbing area -restlessness -guarding/protecting area Anisorcoria Correct Answer: pupils of two different sizes Nystagmus Correct Answer: Jerking movement of the eye Accommodation cranial nerve III Correct Answer: Move in 6 30 Tonic seizure Correct Answer: tight and tense clonic Correct Answer: convulsions, contraction, clicking tonic-clonic seizure Correct Answer: tight and convulsions atonic Correct Answer: out and tonic Myclonic seizures Correct Answer: medium clonic Absent seizure Correct Answer: -brief; lasts seconds; pt may or may not lose consciousness -No loss of change in muscle tone -May occur several times during the day -Appears to be daydreaming -More common in children 31 parasthesia Correct Answer: abnormal sensation such as numbness and tingling Allergic reaction Correct Answer: -immune response -must be sensitization prior -range from mild itching to severe anaphylaxis -penicillin is most common drug allergic reaction What labs to check when taking tylenol? Correct Answer: -AST= 10-30 U/L ALT=10 to 40 U/L (used to detect liver damage Insulin-regular peak time Correct Answer: 1-5 hours Foods high in tyramine Correct Answer: -yogurt -aged cheese -smoked and processed meats -red wine -figs 32 -rasins -avocados Isoniazid with foods in tyramine Correct Answer: should be avoided because it is an MAOI and can cause redness, itchy skin, flushing, sweating, tachycardia, headache, lightheadedness Antacid in pt with renal failure Correct Answer: -secreted through the kidneys -half life increases Furosemide Correct Answer: -Loop diuretic -Given PO,IV,IM -Monitor for hypokalemia=dysrhythmias -Teach pt to eat foods high in potassium Foods high in potassium Correct Answer: nuts, dried fruits, spinach, citrus fruits, potatoes, bananas S/S of hypokalemia Correct Answer: -irregular heartbeat -muscle weakness 33 -cramping -flaccid paralysis -leg discomfort -extreme thirst -confusion When taking lasix avoid? Correct Answer: lithium, digoxin and other ototoxic drugs Lasix adverse effects Correct Answer: hyponatremia, dehydration, hypotension, hypokalemia, ototoxicity, and hyperglycemia Tetracycline teaching Correct Answer: -broad spectrum -take 1 hour before or 2 hours after meals to prevent GI upset -allow 2 hrs in between milk products, calcium supplements, iron supplements , magnesium laxatives, most antacids -notify provider of significant diarrhea -avoid excess sun exposure, wear protective clothing and use sun screen Pregnant /lactating women + children under 8 should avoid tetracycline because? Correct Answer: it can cause discoloration of developing teeth 34 Thyroid overdose signs Correct Answer: -tachycardia -angina -tremors -nervousness -insomnia -hyperthermia -heat intolerance Metronidazole teaching Correct Answer: -separate drugs and other cation compounds by 6 hours -may cause deep tendon rupture in pt over 60 -risk for photo-toxicity Steroids discontinue Correct Answer: -risk for infection(monitor fever, and sore throat) -risk for osteoporosis(take calcium, vitamin d, thiazide diuretics) -Adrenal insufficiency(wear med alert band) -Fluid+electrolyte imbalance(monitor weight gain, and swelling to lower extremities) -Cataracts and glaucoma -Peptic ulcer disease 35 Oseltamivir (Tamiflu) Correct Answer: -inhibits flu virus neuromidase with possible alteration of virus -use=prevention+treatment of influenza A+B -take 2 days pf symptoms of flu and continue for 5 days -take with food -take 3 hour prior to bed time