Hesi Milestone 2 Questions AND Correct Answers
-A client who is at 32 wks calls the HCP b/c she is experiencing
dark red vag bleeding. She is admitted to the ED, where the
nurse determines the FHR to be 100bpm. The client's abd is
rigid & boardlike, & she is complaining of severe pain. What
action does the nurse take first? - ✔✔-Use their knowledge
base to differentiate b/w abruption & previa
-IMMEDIATELY NOTIFY HCP, & NO ABD OR VAG
MANIPULATION OR EXAMS
-ADMIN O2 BY FACEMASK
-MONITOR FOR BLEEDING AT IV SITE & GUMS B/C OF ↑ RISK
FOR DIC
-EMERGENCY C-SECTION REQUIRED b/c uteroplacental
perfusion to the fetus is being compromised by early sep. of
the placenta from the uterus
2 days after admission from alcohol withdrawal what should
the nurse do? - ✔✔Monitor HR and BP
32-year-old male client is admitted with paranoid
schizophrenia - ✔✔Reassure the client that he is safe and
should rest.
,A 10-year-old is admitted to the orthopedic unit with a
diagnosis of slipped femoral capital epiphysis (SFCE). What
focus should the nurse include in this child's plan of care? -
✔✔Pin and incisional care after surgery
A 17-year-old male student with cystic fibrosis talks with the
school nurse about his disease and wonders how it will affect
getting married and having children. Which relevant
information would the nurse include in this discussion? -
✔✔He is likely to have infertility problems and further
evaluation
a 30 year old sales manager tells the nurse "i am
thinking about a job change. i don't feel like i am living
up to my potential." which of maslows developmental
stages is the sales manager attempting to achieve - ✔✔self
actualization:
A 4-year-old boy was recently diagnosed with Duchenne
muscular dystrophy (DMD). Which characteristic of the
disease is most important for the nurse to focus on during the
initial teaching? - ✔✔Lower legs become progressively
weaker, causing waddling, unsteady gait
,A 55-year-old male client has been admitted to the hospital
with a medical diagnosis of chronic obstructive pulmonary
disease (COPD). Which risk factor is the most significant in the
development of this client's COPD? - ✔✔The client smokes 1
to 2 packs of cigarettes per day.
A 77-year-old female client is admitted to the hospital. She is
confused and has had no appetite for several days. She has
been nauseated and vomited several times prior to admission.
She is currently complaining of a headache. Her pulse rate is
43 beats/min. The nurse is most concerned about the client's
history related to what medication? - ✔✔Digitalis (Lanoxin)
A child diagnosed with tetralogy of fallot becomes upset,
crying and thrashing around when a blood specimen is
obtained.The child's color becomes blue and respiratory rate
increases to 44 bpm.Which of the following actions would the
nurse do first? - ✔✔place the child in knee-to-chest position
A child with possible Duchenne muscular dystrophy ( MD)
undergoes an electromyogram (EMG). Following the
procedure, the child's parents tell the nurse that the child is
complaining of sore muscle. How should the nurse respond? -
, ✔✔Offer reassurance that muscle soreness following this
procedures is temporary and does not indicate a problem
A client comes in after being in a car accident and is
experiencing alcohol withdrawal,
magnesium level of 1.1, cardiac dysrhythmias. What would
you give first? - ✔✔Magnesium
A client is admitted to the hospital with a diagnosis of severe
acute diverticulitis. Which nursing intervention has the
highest priority - ✔✔Place the client on NPO status.
A client is admitted to the hospital with intractable pain.
What instruction should the nurse provide the UAP who is
assisting with a bed bath? - ✔✔Take measures to promote as
much comfort as possible
A client is admitted to the mental health unit and reports
taking extra anti anxiety
medication because, "I'm so stressed out. I just want to go to
sleep." The RN should
-A client who is at 32 wks calls the HCP b/c she is experiencing
dark red vag bleeding. She is admitted to the ED, where the
nurse determines the FHR to be 100bpm. The client's abd is
rigid & boardlike, & she is complaining of severe pain. What
action does the nurse take first? - ✔✔-Use their knowledge
base to differentiate b/w abruption & previa
-IMMEDIATELY NOTIFY HCP, & NO ABD OR VAG
MANIPULATION OR EXAMS
-ADMIN O2 BY FACEMASK
-MONITOR FOR BLEEDING AT IV SITE & GUMS B/C OF ↑ RISK
FOR DIC
-EMERGENCY C-SECTION REQUIRED b/c uteroplacental
perfusion to the fetus is being compromised by early sep. of
the placenta from the uterus
2 days after admission from alcohol withdrawal what should
the nurse do? - ✔✔Monitor HR and BP
32-year-old male client is admitted with paranoid
schizophrenia - ✔✔Reassure the client that he is safe and
should rest.
,A 10-year-old is admitted to the orthopedic unit with a
diagnosis of slipped femoral capital epiphysis (SFCE). What
focus should the nurse include in this child's plan of care? -
✔✔Pin and incisional care after surgery
A 17-year-old male student with cystic fibrosis talks with the
school nurse about his disease and wonders how it will affect
getting married and having children. Which relevant
information would the nurse include in this discussion? -
✔✔He is likely to have infertility problems and further
evaluation
a 30 year old sales manager tells the nurse "i am
thinking about a job change. i don't feel like i am living
up to my potential." which of maslows developmental
stages is the sales manager attempting to achieve - ✔✔self
actualization:
A 4-year-old boy was recently diagnosed with Duchenne
muscular dystrophy (DMD). Which characteristic of the
disease is most important for the nurse to focus on during the
initial teaching? - ✔✔Lower legs become progressively
weaker, causing waddling, unsteady gait
,A 55-year-old male client has been admitted to the hospital
with a medical diagnosis of chronic obstructive pulmonary
disease (COPD). Which risk factor is the most significant in the
development of this client's COPD? - ✔✔The client smokes 1
to 2 packs of cigarettes per day.
A 77-year-old female client is admitted to the hospital. She is
confused and has had no appetite for several days. She has
been nauseated and vomited several times prior to admission.
She is currently complaining of a headache. Her pulse rate is
43 beats/min. The nurse is most concerned about the client's
history related to what medication? - ✔✔Digitalis (Lanoxin)
A child diagnosed with tetralogy of fallot becomes upset,
crying and thrashing around when a blood specimen is
obtained.The child's color becomes blue and respiratory rate
increases to 44 bpm.Which of the following actions would the
nurse do first? - ✔✔place the child in knee-to-chest position
A child with possible Duchenne muscular dystrophy ( MD)
undergoes an electromyogram (EMG). Following the
procedure, the child's parents tell the nurse that the child is
complaining of sore muscle. How should the nurse respond? -
, ✔✔Offer reassurance that muscle soreness following this
procedures is temporary and does not indicate a problem
A client comes in after being in a car accident and is
experiencing alcohol withdrawal,
magnesium level of 1.1, cardiac dysrhythmias. What would
you give first? - ✔✔Magnesium
A client is admitted to the hospital with a diagnosis of severe
acute diverticulitis. Which nursing intervention has the
highest priority - ✔✔Place the client on NPO status.
A client is admitted to the hospital with intractable pain.
What instruction should the nurse provide the UAP who is
assisting with a bed bath? - ✔✔Take measures to promote as
much comfort as possible
A client is admitted to the mental health unit and reports
taking extra anti anxiety
medication because, "I'm so stressed out. I just want to go to
sleep." The RN should
