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HESI MILESTONE 2 2024/25 EXAM UPDATE WITH CORRECT VERIFIED ANSWERS A+ GRADED
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HESI MILESTONE 2 2024/25 EXAM UPDATE WITH CORRECT VERIFIED ANSWERS A+ GRADED
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HESI MILESTONE 2 2024/25 EXAM UPDATEWITH CORRECT VERIFIED ANSWERS A+
GRADED
Chemo Side Effects ...ANSWER... o Nausea/vomiting (24-48 hr,
v v vvv vv v v v
can be delayed up to 1 week)
v v v v v v v
Meningitis first step ...ANSWER... o Antibiotics - penicillin
v v vvv vv v v v
(ampicillin) AND cephalosporin
v v v
o Corticosteroids
v
Multiple sclerosis and urinary retention ...ANSWER... o
v v v v vvv vv
Sensation of void heeded immediately (bed pan/urinal @ bedside)
v v v v v v v v v
o Voiding schedule (start 1/5-2hr then extend)
v v v v v v
o Drink specific amt every 2 hour; urinate 30 min after w/ timer
v v v v v v v v v v v v
o Self-catherization
v
Acute renal failure priority ...ANSWER... o Maintain fluids
v v v vvv vv v v
o Avoid fluid excess
v v v
o Renal replacement therapy
v v v
o Reduce metabolic rate
v v v
o Promote pulmonary function
v v v
,Acute Respiratory distress priority findings ...ANSWER... o
v v v v vvv vv
Hypoxia
v
o Intercostal retractions
v v
o Crackles
v
o BNP levels
v v
(alveoli collapse because small airways are narrowed due to
v v v v v v v v
interstitial fluid and bronchial obstruction)
v v v v v
End of life plan of care ...ANSWER... o Signs and symptoms of
v v v v v vvv vv v v v v
impending death are recognized and communicated in
v v v v v v v
developmentally appropriate language for children and patients
v v v v v v v
with cognitive disabilities with respect to family preference. Care
v v v v v v v v v
appropriate to this phase of illness is proved to the patient and the
v v v v v v v v v v v v v
family
v
Cushing Syndrome ...ANSWER... o Can result from
v vvv vv v v v
corticosteroids
v
v***Attempt to reduce/taper medication while still treating
v v v v v v
vunderlying disease v
o Alternate day therapy decrease symptoms and allows adrenal
v v v v v v v v
glands to recover
v v v
Valve replacement teaching ...ANSWER... o Anticoagulant
v v vvv vv v
therapy (frequent follow-up/lab tests)
v v v v
§ Pt on warfarin has specific normal ratios
v v v v v v v
o Prevent infection
v v
, o ANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES!!!
v v v v v
Cancer intractable pain plan of care ...ANSWER... o Pain,
v v v v v vvv vv v
other symptoms and side effects are managed based on the best
v v v v v v v v v v v
available evidence, with attention to disease-specific pain and
v v v v v v v v
symptoms, which are skillfully and systematically applied. ??????
v v v v v v v v
Schizophrenia nursing diagnoses and interventions v v v v vv
...ANSWER... - Dx: 2 or more S&S for over 6 mo (Positive=
v vv v v v v v v v v v v
delusions, hallucinations, disorganized speech or Negative= 6 A's
v v v v v v v v
Anhedonia, Flat Affect, Apathy, Anergia, Algogia, Avolition)
v v v v v v v
-Establish rapport and trust, ask about hallucinations, distract,
v v v v v v v
lower environmental stimuli, monitor suicidal ideation, 1st or 2nd
v v v v v v v v v
generation antipsych
v v
Grief process therapeutic response ...ANSWER... Allow the 5
v v v vvv vv v v
steps of grieving (DABDA), active listening and offer a supportive
v v v v v v v v v v
presence
v
Dementia action refusing ADLs ...ANSWER... Encourage
v v v vvv vv
finger foods, distraction, speak therapeutically
v v v v v
Alcohol withdrawal ...ANSWER... - Needs to be done under
v vvv vv v v v v v
medical supervision b/c can be deadly
v v v v v v
- VS Q4, onset of symptoms 4-6 hours after last drink, give
v v v v v v v v v v v
lorazepam, reduce temp.
v v v
- Tremors, nausea, vomiting
v v v
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