HESI Milestone #2 Latest Exam
-Chemo Side Effects - ANSWER-o Nausea/vomiting (24-48 hr, can be delayed up to 1 week)
24 hour- Jaundice - ANSWER-Physiologic jaundice occurs from a normal reduction in red blood cells.
Pathologic jaundice occurs within first 24 hours of life OR persists beyond 7 days
A client with anorexia has her friend bring her several cookbooks so she can plan a party when she is
discharged. What nursing intervention is appropriate in addressing this behavior? - ANSWER-Discuss
activities that don't involve food that can take place after discharge. Discuss the cookbooks with the
treatment team, and if the treatment plan so indicates, take the books from the client.
A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse
prepares to implement which nursing task appropriate for this phase? - ANSWER-Making appropriate
referrals
ABG findings - ANSWER-pH: 7.35 - 7.45
PCO2: 35 - 45 mmHg
HCO3: 22 - 26 mmHg
Acute Pancreatitis assessment - ANSWER-History, ETOH abuse, severe LUQ pain, tachy, restless,
decrease bowel, jaundice, grey turner or Cullen signs, increase serum amylase/lipase or WBC,
hyperlipidemia
Acute renal failure priority - ANSWER-o Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings - ANSWER-o Hypoxia
o Intercostal retractions
o Crackles
o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial obstruction)
Addison's Crisis Hypoglycemia S/S - ANSWER-- weakness
- fatigue
- severe hypotension
- nausea/vomiting
, HESI Milestone #2 Latest Exam
- dehydration
- dysrhythmias
- shock
ADHD Exam/Assessment - ANSWER-- failure to listen/follow direction
- difficulty playing quietly/sitting still
- disruptive, impulsive behavior
- distractibility to external stimuli
- excessive talking
- shifting from one unfinished task to another
Aggression response - ANSWER-5-phase cycle= Triggering (event), Escalation (movement toward a loss
of control), Crisis (loss of control), Recovery (regain control), Postcrisis (reconciliation)
***Hx = likely to occur again
Alcohol withdrawal - ANSWER-- Needs to be done under medical supervision b/c can be deadly
- VS Q4, onset of symptoms 4-6 hours after last drink, give lorazepam, reduce temp.
- Tremors, nausea, vomiting
Alcoholic hepatis teaching - ANSWER-- low sodium diet
- small frequent meals
- no alcohol
Anxiety Suicide Risks: - ANSWER-Restless, difficulty concentrating, irritability
- "Have you had any suicidal thoughts since starting bupropion?"
Arterial Insufficency - ANSWER-- mostly men
- legs mostly affected
arterial insufficiency symptoms - ANSWER--weak pedal pulses
-shiny and cool skin
-intermittent claudication
- aching/cramping
- induced fatigue
-Chemo Side Effects - ANSWER-o Nausea/vomiting (24-48 hr, can be delayed up to 1 week)
24 hour- Jaundice - ANSWER-Physiologic jaundice occurs from a normal reduction in red blood cells.
Pathologic jaundice occurs within first 24 hours of life OR persists beyond 7 days
A client with anorexia has her friend bring her several cookbooks so she can plan a party when she is
discharged. What nursing intervention is appropriate in addressing this behavior? - ANSWER-Discuss
activities that don't involve food that can take place after discharge. Discuss the cookbooks with the
treatment team, and if the treatment plan so indicates, take the books from the client.
A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse
prepares to implement which nursing task appropriate for this phase? - ANSWER-Making appropriate
referrals
ABG findings - ANSWER-pH: 7.35 - 7.45
PCO2: 35 - 45 mmHg
HCO3: 22 - 26 mmHg
Acute Pancreatitis assessment - ANSWER-History, ETOH abuse, severe LUQ pain, tachy, restless,
decrease bowel, jaundice, grey turner or Cullen signs, increase serum amylase/lipase or WBC,
hyperlipidemia
Acute renal failure priority - ANSWER-o Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings - ANSWER-o Hypoxia
o Intercostal retractions
o Crackles
o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial obstruction)
Addison's Crisis Hypoglycemia S/S - ANSWER-- weakness
- fatigue
- severe hypotension
- nausea/vomiting
, HESI Milestone #2 Latest Exam
- dehydration
- dysrhythmias
- shock
ADHD Exam/Assessment - ANSWER-- failure to listen/follow direction
- difficulty playing quietly/sitting still
- disruptive, impulsive behavior
- distractibility to external stimuli
- excessive talking
- shifting from one unfinished task to another
Aggression response - ANSWER-5-phase cycle= Triggering (event), Escalation (movement toward a loss
of control), Crisis (loss of control), Recovery (regain control), Postcrisis (reconciliation)
***Hx = likely to occur again
Alcohol withdrawal - ANSWER-- Needs to be done under medical supervision b/c can be deadly
- VS Q4, onset of symptoms 4-6 hours after last drink, give lorazepam, reduce temp.
- Tremors, nausea, vomiting
Alcoholic hepatis teaching - ANSWER-- low sodium diet
- small frequent meals
- no alcohol
Anxiety Suicide Risks: - ANSWER-Restless, difficulty concentrating, irritability
- "Have you had any suicidal thoughts since starting bupropion?"
Arterial Insufficency - ANSWER-- mostly men
- legs mostly affected
arterial insufficiency symptoms - ANSWER--weak pedal pulses
-shiny and cool skin
-intermittent claudication
- aching/cramping
- induced fatigue
