Hesi Milestone 2 Questions AND Correct Answers
-Chemo Side Effects - ✔✔o Nausea/vomiting (24-48 hr, can be
delayed up to 1 week)
24 hour- Jaundice - ✔✔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? - ✔✔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? - ✔✔Making
appropriate referrals
ABG findings - ✔✔pH: 7.35 - 7.45
PCO2: 35 - 45 mmHg
,HCO3: 22 - 26 mmHg
Acute Pancreatitis assessment - ✔✔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 - ✔✔o Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings - ✔✔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 - ✔✔- weakness
- fatigue
- severe hypotension
- nausea/vomiting
- dehydration
- dysrhythmias
- shock
ADHD Exam/Assessment - ✔✔- 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 - ✔✔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 - ✔✔- 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 - ✔✔- low sodium diet
- small frequent meals
- no alcohol
Anxiety Suicide Risks: - ✔✔Restless, difficulty concentrating,
irritability
- "Have you had any suicidal thoughts since starting
bupropion?"
Arterial Insufficency - ✔✔- mostly men
- legs mostly affected
arterial insufficiency symptoms - ✔✔-weak pedal pulses
-Chemo Side Effects - ✔✔o Nausea/vomiting (24-48 hr, can be
delayed up to 1 week)
24 hour- Jaundice - ✔✔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? - ✔✔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? - ✔✔Making
appropriate referrals
ABG findings - ✔✔pH: 7.35 - 7.45
PCO2: 35 - 45 mmHg
,HCO3: 22 - 26 mmHg
Acute Pancreatitis assessment - ✔✔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 - ✔✔o Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings - ✔✔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 - ✔✔- weakness
- fatigue
- severe hypotension
- nausea/vomiting
- dehydration
- dysrhythmias
- shock
ADHD Exam/Assessment - ✔✔- 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 - ✔✔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 - ✔✔- 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 - ✔✔- low sodium diet
- small frequent meals
- no alcohol
Anxiety Suicide Risks: - ✔✔Restless, difficulty concentrating,
irritability
- "Have you had any suicidal thoughts since starting
bupropion?"
Arterial Insufficency - ✔✔- mostly men
- legs mostly affected
arterial insufficiency symptoms - ✔✔-weak pedal pulses
