HESI Milestone #2 Exam With 100%
Correct Answers 2023
-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
Acute renal failure priority - Correct Answer-o Maintain fluids
o Avoid fluid 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 follow-
up/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 disease-
specific 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
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.
- Tremors, nausea, vomiting
Methadone overdose - Correct Answer-S&S= constricted pupils, resp. depression,
circul. depression, LOC decreased
Give naloxone
Domestic violence screening tool - Correct Answer-- Don't probe, write evidence down
verbatim, provide a safe environment
- Increase in violence during pregnancy
- Cycle of violence= tension building, violent, honeymoon
Aggression response - Correct Answer-5-phase cycle= Triggering (event), Escalation
(movement toward a loss of control), Crisis (loss of control), Recovery (regain control),
Postcrisis (reconciliation)
***Hx = likely to occur again
Violence handling - Correct Answer-- Engage in dialogue to prevent escalation,
intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy
- Encourage the client to express their anger, build trust, anticipate need for meds, be
consistent
Correct Answers 2023
-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
Acute renal failure priority - Correct Answer-o Maintain fluids
o Avoid fluid 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 follow-
up/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 disease-
specific 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
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.
- Tremors, nausea, vomiting
Methadone overdose - Correct Answer-S&S= constricted pupils, resp. depression,
circul. depression, LOC decreased
Give naloxone
Domestic violence screening tool - Correct Answer-- Don't probe, write evidence down
verbatim, provide a safe environment
- Increase in violence during pregnancy
- Cycle of violence= tension building, violent, honeymoon
Aggression response - Correct Answer-5-phase cycle= Triggering (event), Escalation
(movement toward a loss of control), Crisis (loss of control), Recovery (regain control),
Postcrisis (reconciliation)
***Hx = likely to occur again
Violence handling - Correct Answer-- Engage in dialogue to prevent escalation,
intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy
- Encourage the client to express their anger, build trust, anticipate need for meds, be
consistent
