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