HESI MILESTONE 1 ACTUAL EXAM LATEST 2024/2025
QUESTIONS AND VERIFIED CORRECT ANSWERS/ ALREADY
GRADED A++
list 4 categories of burns - ANSWER Thermal, radiation, chemical,
electrical
Burn depth is a measure of severity. Describe the characteristics of
superficial partial-thickness, deep partial-thickness, and full-thickness
burns. - ANSWER -superficial partial thickness, first degree: pink to red
skin (sunburn), slight edema and pain relieved by cooling.
-deep partial thickness, second degree: destruction of epidermis and upper
layers of dermis, white or red very edematous, sensitive to touch and cold
air, hair does not pull out easily.
-full thickness, third degree: total destruction of dermis and epidermis,
reddened areas do not blanch with pressure, not painful, inelastic, waxy
white skin to brown, leathery eschar.
describe fluid management in the emergent phase, acute phase, and
rehabilitation phase of the burned client - ANSWER -Stage 1 (emergency
phase): replacement of fluids is titrated to urine output.
-Stage 2 (acute phase): patent infusion site is maintained in case
supplemental IV fluids are needed, saline lock is helpful, colloids may be
used
-Stage 3 (rehabilitation phase): no extra fluids are needed, but high protein
drinks are recommended.
Describe pain management of the burned client. - ANSWER Administer
pain medication, especially before dressing wound. Teach distraction and
relaxation techniques. Teach use of guided imagery.
Outline admission care of the burned client. - ANSWER Provide a patent
airway because intubation may be necessary. Determine baseline data.
Initiate fluid and electrolyte therapy. Administer pain medication. Determine
depth and extent of burn. Administer tetanus toxoid. Insert NG tube.
nutritional status is a major concern when caring for a burned client. list
three specific dietary interventions used with burned clients. - ANSWER
high calorie, high protein, high carb diet, medications with juice or milk, no
,free water, tube feeding at night. Maintain accurate daily calorie counts,
weigh client daily
describe the method of extinguishing each of the following burns, thermal,
chemical and electrical - ANSWER -Thermal: remove clothing, immerse in
tepid water
-Chemical: flush with water or saline
-Electrical: separate client from electrical source
list four signs of inhalation burn - ANSWER singed nasal hairs, circumoral
burns, sooty/bloody sputum, hoarseness, pulmonary signs including
asymmetrical of respirations, rales or wheezing
Why is the burned client allowed no "free" water? - ANSWER Water may
interfere with electrolyte balance. Client needs to ingest food products with
highest biologic value
Describe an auto graft - ANSWER Use of clients own skin for grafting
what are the indications for a hysterectomy in a client who has fibromas -
ANSWER severe menorrhagia leading to anemia, severe dysmenorrhea
requiring narcotic analgesics, severe uterine enlargement causing pressure
on other organs, severe back and pelvic pain
List the symptoms and conditions associated with a cystocele. - ANSWER
symptoms include incontinence or stress incontinence, urinary retention
and recurrent bladder infections. Conditions associated with cystocele
include multiparty, trauma in childbirth and aging
what are the most important nursing interventions for the post op client who
has had a hysterectomy with an A&P repair - ANSWER avoid taking rectal
temps and rectal manipulation, manage pain and encourage early
ambulation
describe the priority nursing care for a client who has radiation implants -
ANSWER do not permit pregnant visitors or pregnant care takers in room.
Discourage visits by small children. Confine client to room. Nurse must
wear radiation badge, nurse limits time in room and keep supplies and
equipment within client’s reach
,what screening tool is used to detect cervical cancer? what are the
American cancer society's recommendations for the Pap smear screening
for females under 21? - ANSWER females under the age of 21 should not
have Pap smear screenings
Cite two nursing diagnoses for a client undergoing a hysterectomy for
cervical cancer. - ANSWER altered body image related to uterine removal,
pain related to post op incision
what are the three most important tools for early detection of breast
cancer? How often should these tools be used? - ANSWER breast self
examination monthly, mammogram baseline at age 35 followed by
examinations ever 1 to 2 years in 40's and every year after the age of 50,
physical examination by a professional skilled in examination of the breast
describe three nursing interventions to help decrease edema post
mastectomy - ANSWER position arm on operative side on pillow, avoid BP
measurements, injections, and venipuncture in operative arm and
encourage hand activity/use
name three priorities to include in a discharge plan for a client who has had
a mastectomy - ANSWER arrange for reach to recovery visit, discuss the
grief process with the client, have physician discuss with the client
reconstruction options
what is the most common cause of non-gonococcal urethritis - ANSWER
chlamydia trachoma's
what is the causative organism of syphilis - ANSWER Treponema pallidum
(spirochete bacteria)
malodorous, frothy, greenish-yellow vaginal discharge is characteristic of
which STD - ANSWER trichomonads vaginalis
Which STD is characterized by remissions and exacerbations in both males
and females? - ANSWER herpes simplex virus type 2
Outline a teaching plan for a client with an STD. - ANSWER Signs and
symptoms of STD; mode of transmission; avoiding sex while infected;
providing concise written instructions regarding treatment, and requesting a
, return verbalization to ensure that the client understands; teaching safer
sex practices.
List three potential causes of anemia - ANSWER Diet lacking in iron, folate,
or vitamin B12; use of salicylates, thiazides, diuretics; exposure to toxic
agents such as lead or insecticides.
Write two nursing diagnoses for the client suffering from anemia. -
ANSWER activity intolerance and ineffective tissue perfusion
What is the only IV fluid compatible with blood products? - ANSWER
normal saline
what actions should the nurse take if a hemolytic transfusion occurs -
ANSWER turn off transfusion, infuse normal saline using a new bag and
new tubing, take temp, send blood being transfused to lab, obtain urine
sample, keep vein patent with normal saline
list three interventions for clients with a tendency to bleed - ANSWER use a
soft toothbrush, avoid salicylates, do not use suppositories
Identify two sites that should be assessed for infection and
immunosuppressed clients - ANSWER oral cavity and genital area
Name three food sources of vitamin B12 - ANSWER Glandular meats
(liver), milk, green leafy vegetables
Describe care of invasive catheters and lines - ANSWER Use strict aseptic
technique. Change dressings two or three times per week or when soiled.
Use caution when piggybacking drugs; check purpose of line and drug to
be infused. When possible, use lines to obtain blood samples to avoid
"sticking" client.
List three safety precautions for the administration of antineoplastic
chemotherapy - ANSWER double check order with another nurse, check
for blood return before admin to ensure that medication does not go into
tissue, use a new IV site daily for peripheral chemotherapy, wear gloves
when handling the drugs and dispose of waste in special containers to
avoid contact with toxic substances
QUESTIONS AND VERIFIED CORRECT ANSWERS/ ALREADY
GRADED A++
list 4 categories of burns - ANSWER Thermal, radiation, chemical,
electrical
Burn depth is a measure of severity. Describe the characteristics of
superficial partial-thickness, deep partial-thickness, and full-thickness
burns. - ANSWER -superficial partial thickness, first degree: pink to red
skin (sunburn), slight edema and pain relieved by cooling.
-deep partial thickness, second degree: destruction of epidermis and upper
layers of dermis, white or red very edematous, sensitive to touch and cold
air, hair does not pull out easily.
-full thickness, third degree: total destruction of dermis and epidermis,
reddened areas do not blanch with pressure, not painful, inelastic, waxy
white skin to brown, leathery eschar.
describe fluid management in the emergent phase, acute phase, and
rehabilitation phase of the burned client - ANSWER -Stage 1 (emergency
phase): replacement of fluids is titrated to urine output.
-Stage 2 (acute phase): patent infusion site is maintained in case
supplemental IV fluids are needed, saline lock is helpful, colloids may be
used
-Stage 3 (rehabilitation phase): no extra fluids are needed, but high protein
drinks are recommended.
Describe pain management of the burned client. - ANSWER Administer
pain medication, especially before dressing wound. Teach distraction and
relaxation techniques. Teach use of guided imagery.
Outline admission care of the burned client. - ANSWER Provide a patent
airway because intubation may be necessary. Determine baseline data.
Initiate fluid and electrolyte therapy. Administer pain medication. Determine
depth and extent of burn. Administer tetanus toxoid. Insert NG tube.
nutritional status is a major concern when caring for a burned client. list
three specific dietary interventions used with burned clients. - ANSWER
high calorie, high protein, high carb diet, medications with juice or milk, no
,free water, tube feeding at night. Maintain accurate daily calorie counts,
weigh client daily
describe the method of extinguishing each of the following burns, thermal,
chemical and electrical - ANSWER -Thermal: remove clothing, immerse in
tepid water
-Chemical: flush with water or saline
-Electrical: separate client from electrical source
list four signs of inhalation burn - ANSWER singed nasal hairs, circumoral
burns, sooty/bloody sputum, hoarseness, pulmonary signs including
asymmetrical of respirations, rales or wheezing
Why is the burned client allowed no "free" water? - ANSWER Water may
interfere with electrolyte balance. Client needs to ingest food products with
highest biologic value
Describe an auto graft - ANSWER Use of clients own skin for grafting
what are the indications for a hysterectomy in a client who has fibromas -
ANSWER severe menorrhagia leading to anemia, severe dysmenorrhea
requiring narcotic analgesics, severe uterine enlargement causing pressure
on other organs, severe back and pelvic pain
List the symptoms and conditions associated with a cystocele. - ANSWER
symptoms include incontinence or stress incontinence, urinary retention
and recurrent bladder infections. Conditions associated with cystocele
include multiparty, trauma in childbirth and aging
what are the most important nursing interventions for the post op client who
has had a hysterectomy with an A&P repair - ANSWER avoid taking rectal
temps and rectal manipulation, manage pain and encourage early
ambulation
describe the priority nursing care for a client who has radiation implants -
ANSWER do not permit pregnant visitors or pregnant care takers in room.
Discourage visits by small children. Confine client to room. Nurse must
wear radiation badge, nurse limits time in room and keep supplies and
equipment within client’s reach
,what screening tool is used to detect cervical cancer? what are the
American cancer society's recommendations for the Pap smear screening
for females under 21? - ANSWER females under the age of 21 should not
have Pap smear screenings
Cite two nursing diagnoses for a client undergoing a hysterectomy for
cervical cancer. - ANSWER altered body image related to uterine removal,
pain related to post op incision
what are the three most important tools for early detection of breast
cancer? How often should these tools be used? - ANSWER breast self
examination monthly, mammogram baseline at age 35 followed by
examinations ever 1 to 2 years in 40's and every year after the age of 50,
physical examination by a professional skilled in examination of the breast
describe three nursing interventions to help decrease edema post
mastectomy - ANSWER position arm on operative side on pillow, avoid BP
measurements, injections, and venipuncture in operative arm and
encourage hand activity/use
name three priorities to include in a discharge plan for a client who has had
a mastectomy - ANSWER arrange for reach to recovery visit, discuss the
grief process with the client, have physician discuss with the client
reconstruction options
what is the most common cause of non-gonococcal urethritis - ANSWER
chlamydia trachoma's
what is the causative organism of syphilis - ANSWER Treponema pallidum
(spirochete bacteria)
malodorous, frothy, greenish-yellow vaginal discharge is characteristic of
which STD - ANSWER trichomonads vaginalis
Which STD is characterized by remissions and exacerbations in both males
and females? - ANSWER herpes simplex virus type 2
Outline a teaching plan for a client with an STD. - ANSWER Signs and
symptoms of STD; mode of transmission; avoiding sex while infected;
providing concise written instructions regarding treatment, and requesting a
, return verbalization to ensure that the client understands; teaching safer
sex practices.
List three potential causes of anemia - ANSWER Diet lacking in iron, folate,
or vitamin B12; use of salicylates, thiazides, diuretics; exposure to toxic
agents such as lead or insecticides.
Write two nursing diagnoses for the client suffering from anemia. -
ANSWER activity intolerance and ineffective tissue perfusion
What is the only IV fluid compatible with blood products? - ANSWER
normal saline
what actions should the nurse take if a hemolytic transfusion occurs -
ANSWER turn off transfusion, infuse normal saline using a new bag and
new tubing, take temp, send blood being transfused to lab, obtain urine
sample, keep vein patent with normal saline
list three interventions for clients with a tendency to bleed - ANSWER use a
soft toothbrush, avoid salicylates, do not use suppositories
Identify two sites that should be assessed for infection and
immunosuppressed clients - ANSWER oral cavity and genital area
Name three food sources of vitamin B12 - ANSWER Glandular meats
(liver), milk, green leafy vegetables
Describe care of invasive catheters and lines - ANSWER Use strict aseptic
technique. Change dressings two or three times per week or when soiled.
Use caution when piggybacking drugs; check purpose of line and drug to
be infused. When possible, use lines to obtain blood samples to avoid
"sticking" client.
List three safety precautions for the administration of antineoplastic
chemotherapy - ANSWER double check order with another nurse, check
for blood return before admin to ensure that medication does not go into
tissue, use a new IV site daily for peripheral chemotherapy, wear gloves
when handling the drugs and dispose of waste in special containers to
avoid contact with toxic substances
