HESI MILESTONE #2 EXAM UPDATED
QUESTIONS AND CORRECT ANSWERS.
-Chemo Side Effects - ANS o Nausea/vomiting (24-48 hr, can be delayed up to 1 week)
Meningitis first step - ANS o Antibiotics - penicillin (ampicillin) AND cephalosporin
o Corticosteroids
Multiple sclerosis and urinary retention - ANS o Sensation of void heeded immediately (bed
pan/urinal @ bedside)
o Voiding schedule (start 1/5-2hr then extend)
o Drink specific amt every 2 hour; urinate 30 min after w/ timer
o Self-catherization
Acute renal failure priority - ANS o Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,Acute Respiratory distress priority findings - ANS o Hypoxia
o Intercostal retractions
o Crackles
o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial
obstruction)
End of life plan of care - ANS o Signs and symptoms of impending death are recognized and
communicated in developmentally appropriate language for children and patients with
cognitive disabilities with respect to family preference. Care appropriate to this phase of illness
is proved to the patient and the family
Cushing Syndrome - ANS o Can result from corticosteroids
***Attempt to reduce/taper medication while still treating underlying disease
o Alternate day therapy decrease symptoms and allows adrenal glands to recover
Valve replacement teaching - ANS o Anticoagulant therapy (frequent follow-up/lab tests)
§ Pt on warfarin has specific normal ratios
o Prevent infection
o ANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES!!!
Cancer intractable pain plan of care - ANS o Pain, other symptoms and side effects are
managed based on the best available evidence, with attention to disease-specific pain and
symptoms, which are skillfully and systematically applied. ??????
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, Schizophrenia nursing diagnoses and interventions - ANS - Dx: 2 or more S&S for over 6 mo
(Positive= delusions, hallucinations, disorganized speech or Negative= 6 A's Anhedonia, Flat
Affect, Apathy, Anergia, Algogia, Avolition)
-Establish rapport and trust, ask about hallucinations, distract, lower environmental stimuli,
monitor suicidal ideation, 1st or 2nd generation antipsych
Grief process therapeutic response - ANS Allow the 5 steps of grieving (DABDA), active
listening and offer a supportive presence
Dementia action refusing ADLs - ANS Encourage finger foods, distraction, speak
therapeutically
Alcohol withdrawal - ANS - 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
Methadone overdose - ANS S&S= constricted pupils, resp. depression, circul. depression, LOC
decreased
Give naloxone
Domestic violence screening tool - ANS - Don't probe, write evidence down verbatim, provide
a safe environment
- Increase in violence during pregnancy
- Cycle of violence= tension building, violent, honeymoon
Aggression response - ANS 5-phase cycle= Triggering (event), Escalation (movement toward a
loss of control), Crisis (loss of control), Recovery (regain control), Postcrisis (reconciliation)
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
QUESTIONS AND CORRECT ANSWERS.
-Chemo Side Effects - ANS o Nausea/vomiting (24-48 hr, can be delayed up to 1 week)
Meningitis first step - ANS o Antibiotics - penicillin (ampicillin) AND cephalosporin
o Corticosteroids
Multiple sclerosis and urinary retention - ANS o Sensation of void heeded immediately (bed
pan/urinal @ bedside)
o Voiding schedule (start 1/5-2hr then extend)
o Drink specific amt every 2 hour; urinate 30 min after w/ timer
o Self-catherization
Acute renal failure priority - ANS o Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,Acute Respiratory distress priority findings - ANS o Hypoxia
o Intercostal retractions
o Crackles
o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial
obstruction)
End of life plan of care - ANS o Signs and symptoms of impending death are recognized and
communicated in developmentally appropriate language for children and patients with
cognitive disabilities with respect to family preference. Care appropriate to this phase of illness
is proved to the patient and the family
Cushing Syndrome - ANS o Can result from corticosteroids
***Attempt to reduce/taper medication while still treating underlying disease
o Alternate day therapy decrease symptoms and allows adrenal glands to recover
Valve replacement teaching - ANS o Anticoagulant therapy (frequent follow-up/lab tests)
§ Pt on warfarin has specific normal ratios
o Prevent infection
o ANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES!!!
Cancer intractable pain plan of care - ANS o Pain, other symptoms and side effects are
managed based on the best available evidence, with attention to disease-specific pain and
symptoms, which are skillfully and systematically applied. ??????
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, Schizophrenia nursing diagnoses and interventions - ANS - Dx: 2 or more S&S for over 6 mo
(Positive= delusions, hallucinations, disorganized speech or Negative= 6 A's Anhedonia, Flat
Affect, Apathy, Anergia, Algogia, Avolition)
-Establish rapport and trust, ask about hallucinations, distract, lower environmental stimuli,
monitor suicidal ideation, 1st or 2nd generation antipsych
Grief process therapeutic response - ANS Allow the 5 steps of grieving (DABDA), active
listening and offer a supportive presence
Dementia action refusing ADLs - ANS Encourage finger foods, distraction, speak
therapeutically
Alcohol withdrawal - ANS - 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
Methadone overdose - ANS S&S= constricted pupils, resp. depression, circul. depression, LOC
decreased
Give naloxone
Domestic violence screening tool - ANS - Don't probe, write evidence down verbatim, provide
a safe environment
- Increase in violence during pregnancy
- Cycle of violence= tension building, violent, honeymoon
Aggression response - ANS 5-phase cycle= Triggering (event), Escalation (movement toward a
loss of control), Crisis (loss of control), Recovery (regain control), Postcrisis (reconciliation)
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
