Hesi Milestone 2 Exam Practice (Latest 2023/ 2024) | Questions and Verified Answers with Rationales | 100% Correct
QUESTION
Which nursing action would
... [Show More] be appropriate for a client who is newly diagnosed with Cushing syndrome?
A. Monitor blood glucose levels daily.
B. Increase intake of fluids high in potassium. C. Encourage adequate rest between activities. D. Offer the client a sodium-enriched menu.
Answer:
A
Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels assesses for increased blood glucose levels so that treatment can begin early. A common finding in Cushing syndrome is generalized edema.
Although potassium is needed, it is generally obtained from food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor in Cushing syndrome, so an emphasis on the need for rest is not indicated. A
low-calorie, low-carbohydrate, low-sodium diet is not recommended.
QUESTION
A client with type 2 diabetes takes metformin daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse antici- pates which approach to manage the client's diabetes best while the client is NPO during the perioperative period?
A. NPO except for metformin and regular snacks
B. NPO except for oral antidiabetic agent
C. Novolin N insulin subcutaneously twice daily
D. Regular insulin subcutaneously per sliding scale
Answer:
D
Regular insulin dosing based on the client's blood glucose levels (sliding scale) is the best method to achieve control of the client's blood glucose while the client is NPO and coping with the major stress of surgery. Option A increases the risk of vomiting and aspiration. Options B and C provide less precise control of the blood glucose level.
QUESTION
The nurse is caring for a critically ill client with cirrhosis of the liver
who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect?
A. Increased serum albumin level
B. Decreased serum creatinine
C. Decreased serum ammonia level
D. Increased liver function test results
Answer:
C
The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not be significantly affected by the removal of blood.
QUESTION
The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma. Which medication prescription should the nurse question?
A. Antianginal with a therapeutic effect of vasodilation B. Anticholinergic with a side effect of pupillary dilation C. Antihistamine with a side effect of sedation
D. Cortic osteroid with a side effect of hyperglycemia
Answer:
B
Clients wth angle-closure glaucoma should not take medications that dilate the pupil because this can precipitate acute and severely increased intraocular pressure.
Options A, C, and D do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma.
QUESTION
A 77-year-old client is admitted to the hospital with confusion and anorexia of several days' duration. Additional symptoms reported are nausea and vomiting, and current complaints of a headache. The client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to which medication?
A. Warfarin
B. Ibuprofen
C. Nitroglycerin
D. Digoxin
Answer:
D
Older persons are particularly susceptible to the buildup of cardiac glycosides, such as digoxin or digitoxin (medications derived from digitalis), to a toxic level in their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Options A, B, and C are unlikely to result in the symptoms described.
QUESTION
The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care?
A. Restore skin integrity. B. Prevent infection.
C. Promote healing.
D. Improve nutrition.
Answer:
B
The prevention of infection is a priority goal for this client. Gangrene is the result of necrosis (tissue death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue death has already occurred, options A and C are unattainable goals. Option D is important but of less priority than option B.
QUESTION
The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which action should the nurse take first?
A. Measure the urine specific gravity.
B. Obtain IV fluids for infusion per protocol.
C. Prepare for insertion of a central venous catheter. D. Auscultate the client's breath sounds.
Answer:
B
The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue perfusion. Options A, C, and D are all important interventions but are of lower priority than option B.
QUESTION
A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. The client begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first?
A. Auscultate the client's breath sounds. B. Turn off the continuous feeding pump.
C. Check placement of the nasogastric tube. D. Measure the amount of residual feeding.
Answer:
B
A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding to prevent further aspiration. Options A, C, and D should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place.
QUESTION
A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before the scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A. Hypophosphatemia
B. Hypocalcemia C. Hyponatremia D. Hypokalemia
Answer:
B
Hypocalcemia develops in CKD because of chronic hyperphosphatemia, not option A. Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with option C or D.
QUESTION
The nurse is assessing a 75-year-old client for symptoms of hyper- glycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit?
A. Polyuria
B. Polydipsia C. Weight loss D. Infection [Show Less]