Hesi Milestone 2 Exam (Latest 2023/ 2024) | Questions and Verified Answers| 100% Correct (150 Q&A)
QUESTION
The nurse is developing the plan of care
... [Show More] for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care?
Answer:
Increase fluid intake to 3,000 ml/daily
QUESTION
Pneumonia Treatment/Prevention
Answer:
oxygen therapy, hydration, bed rest, positioning to facilitate breathing, deep breathing, humidified air, chest physiotherapy, suctioning prn,
QUESTION
A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen with a Venturi mask at a rate of 3 L/min. Prior to initiating oxygen therapy, the patient appeared anxious with gray skin, a respiratory rate of 24 breaths/min, and an oxygen saturation of 87%. After 15 minutes of oxygen therapy, the nurse observes the patient resting with closed eyes, pink coloration, a respiratory rate of 12 breaths/min, and an oxygen saturation of 95%. Which action by the nurse is correct?
Answer:
Decrease the oxygen to 2 L/min to improve respiratory rate
QUESTION
What are the nutritional needs of this client throughout recovery?
Answer:
Acute phase: NPO, IV fluids
• Recovery phase: no fiber or foods that irritate the bowel
• Maintenance phase: high-fiber diet with bulk-forming laxatives
QUESTION
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority
Answer:
Place the client on NPO status.
QUESTION
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?
Answer:
Check the client's vital signs.
QUESTION
The healthcare provider prescribes digitalis (Digoxin) for a client diagnosed with congestive heart failure. Which intervention should the nurse implement prior to administering the digoxin?
Answer:
Assess the serum potassium level
QUESTION
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?
Answer:
Digitalis (Lanoxin)
QUESTION
The nurse is administering a dose of digoxin to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom?
Answer:
Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity
QUESTION
IV fluids hypertonic
Answer:
Hypertonic solutions exert an osmotic pressure greater than that of the ECF.
When normal saline solution or lactated Ringer solution contains 5% dextrose, the total osmolality exceeds that of the ECF
Saline 3% or 5%
3% NaCl
5% Nacl
D10W
'D20W
D50W
D5LR
QUESTION
Rheumatoid arthritis pain
Answer:
movement causes pain, rather than relieving pain.
Rheumatoid arthritis occurs bilaterally.
E. Morning stiffness
F. Bilateral inflammation of joints
QUESTION
PUD NGT
Answer:
During surgery stomach contents are drained by NG tube
- Confirmation that obstruction is the cause of pt discomfort us done by assessing the amount of of fluid aspirated a residual of >400 mL indicated obstruction
QUESTION
prostatic hyperplasia
Answer:
Decreased force in the stream of urine is an early symptom of benign prostatic hyperplasia
- urgency [Show Less]