Hesi Milestone 2 Questions And Answers

Hesi Milestone 2 Questions And
Answers


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Arclientrwhorisratr32rwksrcallsrtherHCPrb/crsherisrexperiencingrdarkrredrvagrbleeding.rSherisr
admittedrtortherED,rwhererthernurserdeterminesrtherFHRrtorber100bpm.rTherclient'srabdrisrr
igidr&rboardlike,r&rsherisrcomplainingrofrsevererpain.rWhatractionrdoesrthernursertakerfirst?r
-rCORRECTrrANSWER--Usertheirrknowledgerbasertordifferentiaterb/wrabruptionr&rprevia
-IMMEDIATELYrNOTIFYrHCP,r&rNOrABDrORrVAGrMANIPULATIONrORrEXAMS
-ADMINrO2rBYrFACEMASK
-MONITORrFORrBLEEDINGrATrIVrSITEr&rGUMSrB/CrOFr↑rRISKrFORrDIC
-EMERGENCYrC-
SECTIONrREQUIREDrb/cruteroplacentalrperfusionrtortherfetusrisrbeingrcompromisedrbyre
arlyrsep.rofrtherplacentarfromrtheruterus

2rdaysrafterradmissionrfromralcoholrwithdrawalrwhatrshouldrthernurserdo?r-
rCORRECTrrANSWER-MonitorrHRrandrBP



32-year-oldrmalerclientrisradmittedrwithrparanoidrschizophreniar-rCORRECTrrANSWER-
Reassurertherclientrthatrherisrsaferandrshouldrrest.

Ar10-year-
oldrisradmittedrtortherorthopedicrunitrwithrardiagnosisrofrslippedrfemoralrcapitalrepiphysisr(S
FCE).rWhatrfocusrshouldrthernurserincluderinrthisrchild'srplanrofrcare?r-
rCORRECTrrANSWER-Pinrandrincisionalrcarerafterrsurgery



Ar17-year-
oldrmalerstudentrwithrcysticrfibrosisrtalksrwithrtherschoolrnurseraboutrhisrdiseaserandrwond
ersrhowritrwillraffectrgettingrmarriedrandrhavingrchildren.rWhichrrelevantrinformationrwouldrt
hernurserincluderinrthisrdiscussion?r-rCORRECTrrANSWER-
Herisrlikelyrtorhaverinfertilityrproblemsrandrfurtherrevaluation

ar30ryearroldrsalesrmanagerrtellsrthernurser"iramrthinkingraboutrarjobrchange.rirdon&#
39;trfeelrlikeriramrliving
uprtormyrpotential."rwhichrofrmaslowsrdevelopmentalrstagesrisrthersalesrmanagerratt
emptingrtorachiever-rCORRECTrrANSWER-selfractualization:

,Ar4-year-
oldrboyrwasrrecentlyrdiagnosedrwithrDuchennermuscularrdystrophyr(DMD).rWhichrcharact
eristicrofrtherdiseaserisrmostrimportantrforrthernursertorfocusronrduringrtherinitialrteaching?r-
rCORRECTrrANSWER-

Lowerrlegsrbecomerprogressivelyrweaker,rcausingrwaddling,runsteadyrgait

Ar55-year-
oldrmalerclientrhasrbeenradmittedrtortherhospitalrwithrarmedicalrdiagnosisrofrchronicrobstru
ctiverpulmonaryrdiseaser(COPD).rWhichrriskrfactorrisrthermostrsignificantrinrtherdevelopme
ntrofrthisrclient'srCOPD?r-rCORRECTrrANSWER-
Therclientrsmokesr1rtor2rpacksrofrcigarettesrperrday.

Ar77-year-
oldrfemalerclientrisradmittedrtortherhospital.rSherisrconfusedrandrhasrhadrnorappetiterforrsev
eralrdays.rSherhasrbeenrnauseatedrandrvomitedrseveralrtimesrpriorrtoradmission.rSherisrcu
rrentlyrcomplainingrofrarheadache.rHerrpulserraterisr43rbeats/min.rThernurserisrmostrconcer
nedraboutrtherclient'srhistoryrrelatedrtorwhatrmedication?r-rCORRECTrrANSWER-
Digitalisr(Lanoxin)

Archildrdiagnosedrwithrtetralogyrofrfallotrbecomesrupset,rcryingrandrthrashingraroundrwhenr
arbloodrspecimenrisrobtained.Therchild'srcolorrbecomesrbluerandrrespiratoryrraterincrease
srtor44rbpm.Whichrofrtherfollowingractionsrwouldrthernurserdorfirst?r-
rCORRECTrrANSWER-placertherchildrinrknee-to-chestrposition



ArchildrwithrpossiblerDuchennermuscularrdystrophyr(rMD)rundergoesranrelectromyogramr(
EMG).rFollowingrtherprocedure,rtherchild'srparentsrtellrthernurserthatrtherchildrisrcomplainin
grofrsorermuscle.rHowrshouldrthernurserrespond?r-rCORRECTrrANSWER-
Offerrreassurancerthatrmusclersorenessrfollowingrthisrproceduresrisrtemporaryrandrdoesrn
otrindicaterarproblem

Arclientrcomesrinrafterrbeingrinrarcarraccidentrandrisrexperiencingralcoholrwithdrawal,
magnesiumrlevelrofr1.1,rcardiacrdysrhythmias.rWhatrwouldryourgiverfirst?r-
rCORRECTrrANSWER-Magnesium



Arclientrisradmittedrtortherhospitalrwithrardiagnosisrofrsevereracuterdiverticulitis.rWhichrnursi
ngrinterventionrhasrtherhighestrpriorityr-rCORRECTrrANSWER-
PlacertherclientronrNPOrstatus.

Arclientrisradmittedrtortherhospitalrwithrintractablerpain.rWhatrinstructionrshouldrthernurserpr
ovidertherUAPrwhorisrassistingrwithrarbedrbath?r-rCORRECTrrANSWER-
Takermeasuresrtorpromoterasrmuchrcomfortrasrpossible

Arclientrisradmittedrtorthermentalrhealthrunitrandrreportsrtakingrextrarantiranxiety
medicationrbecause,r"I'mrsorstressedrout.rIrjustrwantrtorgortorsleep."rTherRNrshould

, planrone-on-onerobservationrofrtherclientrbasedronrwhichrstatement?r-
rCORRECTrrANSWER-"Irdon'trwantrtorwalk.rNothingrmattersranymore."



Arclientrsustainsrarcomplexrcomminutedrfracturerofrthertibiarwithrsoftrtissuerinjuriesrafterrbei
ngrhitrbyrarcarrwhilerridingrarbicycle.rSurgicalrplacementrofranrexternalrfixatorrisrperformedrt
ormaintainrtherbonerinralignment.rPostoperativelyritrisrmostressentialrforrthernurserto?r-
rCORRECTrrANSWER-Performrarneurovascularrassessmentrofrbothrlowerrextremities



Arclientrwhorisr3rdaysrpostpartumrandrbreastfeedingrasksrthernurserhowrtorreducerbreastre
ngorgement.rWhichrinstructionrshouldrthernurserprovide?r-rCORRECTrrANSWER-
Breastfeedrtherinfantreveryr2rhours

Arclientrwithrarsmallrbowelrobstructionrisrexperiencingrfrequentrvomiting.rWhichrinstruction
srarermostrimportantrforrthernursertorprovidertortherUAPrwhorisrcompletingrmorningrcarerforr
thisrclient?r-rCORRECTrrANSWER-Maintainrarquietrenvironment

Arclientrwithrhemophiliarhasrarveryrswollenrkneerafterrfallingrfromrbicyclerriding.rWhichrofrth
erfollowingrisrtherfirstrnursingraction?r-rCORRECTrrANSWER-
applyricerpackrandrcompressionrdressingsrtortherknee

Arfemalerclientrwhorhasrbreastrcancerrwithrmetastasisrtortherliverrandrspinerisradmittedrwith
rconstant,rsevererpainrdespiteraround-the-

clockruserofroxycodoner(Percodan)randramitriptyliner(Elavil)rforrpainrcontrolratrhome.rDurin
grtheradmissionrassessment,rwhichrinformationrisrmostrimportantrforrthernursertorobtain?r-
rCORRECTrrANSWER-Sensoryrpattern,rarea,rintensity,randrnaturerofrtherpain.



Arfemalerclientrwithrobsessivercompulsiverpersonalityrdisorderrisradmittedrtortherhospitalrfo
rrarcardiacrcatheterization.rTherafternoonrbeforertherprocedure,rtherclientrbeginsrtorkeeprde
tailedrnotesrofrthernursingrcarersherisrreceiving,randrreportsrherrfindingsrtortherRNratrbedtim
e.rWhatractionrshouldrthernurserimplement?r-rCORRECTrrANSWER-
Encouragertherclientrtorexpressrherrfeelingsrregardingrtherupcomingrprocedure.

ArfemalerptrwasrinranrMVCrandradmittedrwithrarfracturedrLrfemur.rNurserassessmentrinclud
erdiminishedrpulses.rWhatrshouldrthernurserdornext?rSATAr-rCORRECTrrANSWER-
VerifyrpedalrpulsesrwithrarDoppler
MonitorrLrlegrforrpain,rpulselessness,rpallor,paralysis
EvaluatertherapprofrthersplintrtortherLrleg

Arhealthcarerproviderrinformsrtherchargernurserofrarlaborrandrdeliveryrunitrthatrarclientrisrco
mingrtortherunitrsuspectedrabruptiorplacentae.rWhatrfindingsrshouldrtherchargernurserexpe
ctrtherclientrtordemonstrate?r-rCORRECTrrANSWER-A.rdark,redrvaginalrbleeding
D.rincreasedruterinerirritability
F.rRigidrabdomen