HESI MILESTONE 2 Version 1 With 100%
Correct Questions And Answers
Theclient with heart failure may present with different symptoms, depending on
... [Show More] whetherthe right or the left side of
the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of
problems with right-sided heart function. Lung soundsconstitute an accurateindicatorof left-sided heart function.
The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which
statement bythe new nurse indicates that theteaching hasbeen effective?
"Oxygen has a calming effect."
"Oxygen will prevent the development of anythrombus."
"The pain of angina pectoris occurs becauseof a decreased oxygen supplyto heartcells."
"Oxygen dilates the blood vessels so that theycan supply more nutrients to the heartmuscle." - "The pain of
angina pectoris occurs because of a decreased oxygen supply to heart cells."
The nurse is performing an assessment on a client with a diagnosis of left-sided heartfailure. Which assessment
component would elicit specific information regarding the client's left-sided heart function?
Listening to lung sounds
Palpating fororganomegaly
Assessing for jugularvein distention
Assessing for peripheral and sacraledema - Listening to lung sounds.
The pain associated with angina results from ischemia of myocardial cells. The painoften is precipitated by
activitythat places more oxygen demand on heart muscle.
Supplemental oxygen will help meet the added demands on the heart muscle. Oxygen does not dilate blood vessels
or prevent thrombus formation and does not directly calmthe client.
The nurse has provided dietary instructions to a client with coronary artery disease. Which statement bythe client
indicates an understanding of the dietaryinstructions?
"I'll need to become a strictvegetarian."
"I should use polyunsaturated oils in my diet."
"I need to substituteeggs and whole milk for meat."
"I should eliminate all cholesterol and fat from my diet." - "I should usepolyunsaturated oils
in my diet."
The client with coronary artery disease needs to avoid foods high in saturated fat andcholesterol such aseggs,
whole milk, and red meat. Thesefoods contributeto
increases in low-densitylipoproteins. The useof polyunsaturated oils is recommendedto control
hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessaryto
become a strict vegetarian.
The home care nurse has taught a client with heart failure and a problem of inadequatecardiac output about helpful
lifestyle adaptations to promote health. Which statement bythe client best demonstrates an understanding of the
information provided?
"I will trytoexercise vigorously to strengthen my heart muscle."
"I will eat enough daily fiber to prevent straining during bowel movement." "I will drink
3000 to3500 mL of fluid dailyto promote good kidneyfunction."
"Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels." - "I willeat
enough dailyfiber to prevent straining during bowel movement."
Standard home care instructions for a client with this problem include, among others, lifestyle changes such as
avoiding alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to
prevent straining and constipation,and maintaining fluid and electrolyte balance. Consuming 3000 to 3500 mL of
fluid and exercising vigorously will increase the cardiac workload.
A client with heart failure has been experiencing difficulty with completion of daily activities, as evidenced by
exertional fatigue and increased blood pressure. Whichobservation by the nurse best indicates client progress in
meeting goals for this problem?
1. Ambulates10 feet (3 meters) farther each day2.Verbalizes the
benefits of increasing activity
3. Chooses a healthy diet that meets caloric needs
4. Sleeps without awakening throughout the night - Chooses a healthy diet that meetscaloric needs
Each of theoptions indicates a positive outcomeon the partof the client. Both option 2and the correct one relate to
the client problem of difficulty with completion of daily activities. However, the question asks about progress. The
correct option is more action-oriented and thereforeis the betterchoice. Option 3 would most likelyindicate
progress if theclient had a problem of inadequate nutritional intake. Option 4 would be asatisfactoryoutcomefor a
clientexperiencing difficulty sleeping.
A client with coronary artery disease is scheduled to have a diagnostic exercise stresstest. Which instruction would
the nurse plan to provide to the client about this procedure?
Eat breakfast just beforethe procedure.
Wear firm, rigid shoes, such as work boots.
Wear loose clothing with a shirt that buttons in front.
Avoid cigarettes for30 minutes beforethe procedure. - Wear loose clothing with ashirt that buttons in front [Show Less]