HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED
A 10-year-old child has undergone a cardiac catheterization through the left femoral artery. During a postprocedural assessment, the nurse finds the left foot is pulseless and cool to touch. Which is the likely cause?
A. hemorrhage
B. hematoma
C. fasciculation
D. tamponade - ansB. hematoma
Cardiac catheterization is a routine diagnostic procedure; however, it is not without risks. Loss of pulse in the catheterized extremity is likely due to a hematoma and requires immediate intervention to restore circulation.
A 10-year-old client with a recent history of playing in the woods, presents to the school nurse's clinic with localized skin eruptions on the hands and feet which are streaked, consisting of blisters discharging clear fluid that are painful and itchy. What should the school nurse suspect to be the causative agent?
A. sun burn
B. poison ivy
C. insect bite
D. heat rash
Contact with the oil called "Urushiol" which is found in poison ivy, oak and sumac may produce an allergic reaction. Symptoms include localized, streaked, or oozing blisters. These skin lesions are usually painful and itchy. - ans
A 10-year-old client with asthma arrives at an urgent care clinic with apparent bronchial constriction. Which class of drugs should the nurse expect to be administered for this condition?
A. methylxanthines
B. anticholinergic
C. long-acting beta2 agonists
D. oral corticosteroids - ansD. oral corticosteroids
Corticosteroids are fast-acting anti-inflammatory drugs. They are used to treat reversible airflow obstruction, control symptoms, and reduce bronchial constriction with the fewest side effects.
A 12-month-old client is being discharged with a body spica cast. Which information should the nurse include in the parents' discharge teaching plan?
A. foul odor from cast may indicate infection or skin breakdown
B. pillows should not be placed under cast
C. the child can safely transported in a stroller
D. use pillows to elevate the child's head - ansA. foul odor from cast may indicate infection or skin breakdown
Care of a child in a body spica cast can be challenging for parents at home. Skin under the cast should be protected from injury and debris, so parents should be instructed that a foul odor from the cast can be indicative of skin breakdown or infection and to contact their health care provider.
A 12-year-old athlete reports severe ankle pain and an audible "popping" sound in the ankle after a fall at soccer practice. The nurse upon inspection observes moderate swelling, bruising, and joint instability. Initial radiographs of the ankle appear normal. Which type of injury should the nurse suspect?
A. strain
B. sprain
C. fracture
D. dislocation - ansB. Sprain
The ankle is a common site for sprain injuries. Ankle sprains can range from mild (grade 1) to severe (grade 3), with complete tearing of a ligament in the most severe sprains. A "popping" sound is likely an indication of a partial or complete ligament tear; joint instability may be detected at the end-ranges of passive motion.
A 15-year-old client presents with a lump and persistent pain in the right upper thigh area, and is subsequently diagnosed with a high-grade osteosarcoma. The nurse should anticipate which plan of treatment for this client?
A. hot/cold topical applications
B. amputation of the limb
C. electrical stimulation therapy
D. prolonged immobilization - ansB. amputation of the limb
Osteosarcoma is the most common bone cancer in childhood and considered one of the most fatal. Treatment generally includes chemotherapy and amputation of the affected limb. As of today, there is no meedical set plan of care.
A child diagnosed with HIV is being enrolled in a new school. Who has the right to inform the school of this child's HIV status?
A. doctors or nurses
B. social workers
C. parents or legal guardians
D. child welfare department - ansC. parents or legal guardians
Confidentiality is a major issue in school attendance. The parents or legal guardians have the right to decide whether or not to inform the school of their child's HIV status.
A child has been diagnosed with chicken pox and the nurse teaches the parent not to give the child aspirin. Which condition may result when a child with chickenpox is given aspirin?
A. Reye's syndrome
B. Huntingtons disease
c. Raynaud syndrome
D. purpura disorder - ansA. reye's syndrome
Reye's syndrome is a rare, but serious condition that causes brain and liver damage that has been linked with aspirin use in children, when given to treat a viral infections, such as chicken pox. Reye's syndrome can be prevented by avoiding the use of aspirin in children.
MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED
A child is admitted with a diagnosis of suspected acute lymphoblastic leukemia (ALL). Which test is performed to confirm this diagnosis of childhood leukemia?
A. cerebral spinal fluid analysis
B. bone marrow aspiration
C. CBC
D. genetic testing - ansB. bone marrow aspiration
ALL is a form of cancer in which high numbers of abnormal white blood cells are produced. A bone marrow biopsy that reveals primary blast cells is confirmation of a leukemia.
A child is brought to the emergency department after ingesting a large amount of household drain cleaner. Which is the nurse's first priority when caring for this client?
A. perform NG suctioning
B. Assess and maintain an open airway
C. give small amounts of water to ingest
D. Obtain chest and abdomen radiographs - ansB. assess and maintain an open airway
Ingestion of corrosive household agents may cause airway obstruction due to rapidly developing laryngeal edema. The first priority is to assess and monitor the client's airway.
A child recently underwent cardiac surgery and is admitted with a suspected diagnosis of infective endocarditis. Which presentation should the nurse expect when assessing this client?
A. bradycardia, lethargy, speech disturbances
B. high fever, irregular movement of joints, involuntary facial grimaces
c. tachycardia, chest pain, swollen and painful joints
D. low grade fever, anorexia, splinter hemorrhages under the nails - ansD. low grade fever, anorexia, splinter hemorrhages under the nails
Children who undergo cardiac surgery are at higher risk for infection. Common clinical signs and symptoms of infective endocarditis are unexplained fever (low-grade and intermittent), anorexia, malaise, and splinter hemorrhages under the nails
A child with severe burns begins to exhibit decreased level of consciousness and lethargy four days after being admitted to the burn unit. The nurse's assessment reveals a low-grade fever, but the client's other vital signs are stable. The nurse should be alert for which potential complication?
A. respiratory failure
B. dehydration
C. sepsis
D. hypovolemia - ansC. sepsis
Dead tissue and exudate associated with burned skin provides a fertile field for bacterial growth. If the burn site is contaminated with infectious material, sepsis may occur. Decreased level of consciousness and lethargy are early signs of sepsis.
A five-year-old client who had been prescribed amoxicillin, presents to the clinic with urticaria. Which medication is recommended for initial treatment of this condition?
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
A. epinephrine
B. diphenhydramine
C. ibuprofen
D. doxepin - ansB. diphenhydramine
Medications are a common cause of anaphylaxis in children. Acute urticaria, also known as hives, is a skin reaction common side effect associated with amoxicillin. First-line treatment consists administration of an antihistamines, such as diphenhydramine orally, followed by hydrocortisone topically dependent upon the severity of the urticaria.
A mother brings in a three-year-old child who has respiratory rate of 36 breathes per minute; heart rate of 160 beats per minute; weaken and thready pulse; and pale and sweaty skin. The nurse suspects the child is going into shock which action should the nurse perform first?
A. obtain ABG's
B. obtain vitals
C. administer O2
D. Establish IV access - ansC. Administer oxygen
When providing care to a child in shock, the nurse's priority is to ensure adequate oxygenation. The nurse should administer oxygen or provide assistance in establishing an airway. The best way to remember the order of priority of care to be given is the "ABCs"; airway, bleeding and circulation
A nurse has obtained a weight of 17.6 pounds (8 kg) for a 15-month-old child. The child's ideal body weight is 26.4 pounds (12 kg). How should be the nurse interpret this body weight?
A. normal variation
B. mild wasting
C. moderate wasting
D. severe wasting - ansD. severe wasting
This child has a body weight 66% less than the ideal body weight for this age (15 months). A body weight less than 70% of the ideal body weight is defined as severe wasting.
A nurse is assessing a three year old diagnosed with psoriasis. Which is a common treatment for most forms of psoriasis?
A. exfoliation
B. cyrotherapy
C. oral antibiotics
D. phototherapy - ansD. phototherapy
All types of psoriasis commonly respond to topical creams and phototherapy (ultraviolet light exposure) when administered 3 to 5 times a week.
A pediatric client is admitted with sepsis and a high-grade fever following an episode of gastritis. The nurse's assessment reveals cool skin; normal pulse and blood pressure; decreased urinary output; and a diminished mental state. Which term describes this stage of septic shock?
MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED
A. hyperdynamic
B. normodynamic
C. macrodynamic
D. hypodynamic - ansB. normodynamic
The three stages of septic shock are hyperdynamic (early), normodynamic (second), and hypodynamic (advanced). The normodynamic stage of shock reflects a hyperdynamic-decompensated state. Symptoms of this stage include cool skin; normal pulse and blood pressure; decreased urinary output; and a diminished mental state.
A pediatric client is placed on a drug regimen for management of aplastic anemia. What should the nurse identify as the expected outcome of this treatment?
A. replace clotting factors
B. increase intravascular volume
C. resotre bone marrow function
D. increase iron levels in the blood - ansC. resotre bone marrow function
Aplastic anemia develops when damage occurs to the bone marrow that slows or stops the production of new blood cells (hematopoiesis). The goal of drug therapy is to restore bone marrow function; this may be accomplished by daily administration of immunosuppressive medications such as antilymphocyte globulin (ALG) or antithymocyte globulin (ATG) to suppress immunologic features prolonging the anemia .
A school nurse is assessing rashes on a child's lower shins and forearms that appear streaked and inflamed and are blistered with clear oozing substance present. The child reports that it is painful. Based on these signs and symptoms, what most likely caused this condition?
A. shellfish
B. penicillin elixir
C. laundry detergent
D. poison ivy or oak - ansD. poison ivy or oak
Dermatitis reactions to plants that contain oil with urushiol, usually will cause localized rashes and are seen on areas of the skin that are not typically covered by clothing and appear to be streaky or spotty, inflamed, blisterd with oozing clear substance and painful. Three common plants which contain this substance are poison ivy, oak and sumac.
A school nurse presented a parent-approved lesson about "Prevention transmitting Herpes Simplex Virus 2" (HSV-2) to a group of adolescent students. Which statement from one of the students would demonstrate a proper understanding of the lesson?
A. there is currently no cure for HSV-2
B. condoms are 100% effective in protecting again HSV-2
C. HSV-2 cannot be passed through vaginal secretions
D. when no lesions are visible, the HSV-2 cannot be passed on - ansA. there is currently no cure for HSV-2
There is no permanent cure for herpes. The nurse should stress this fact when teaching about HSV-2. The only protection recommended for 100% prevention of the spread of HSV-2 is abstinence. There are dental dams and other devices available, but nothing is
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
completely 100% guarantee in prevention of transmission of HSV-2. HSV-2 lesions can still be present, but not visibly seen externally and may be located elsewhere, such as a female's cervix.A. there is currently no cure for HSV-2
A six-year-old client, who received a kidney transplant presents with signs including fever, decreased urine output, and tenderness over the transplanted organ. Laboratory results reveal an elevated serum creatinine level. This presentation is likely due to which cause?
A. immunosuppression medications
B. obstructive uopathy
C. transplant rejection
D. nephrotic syndrome - ansC. transplant rejection
Transplant rejection is caused by the recipient's immune system response to foreign tissue. Signs that may alert the nurse to rejection of a kidney transplant include fever, tenderness over the graft area, decreased urine output, and elevated serum creatinine.
A teenager is admitted to the hospital diagnosed with anorexia nervosa. Which condition should the nurse evaluate the client for?
A. osteoarthritis
B. cardiac arrhythmia
C. asthma
D. bowel ischemia - ansB. cardiac arrhythmia
Anorexia nervosa (AN) is an eating disorder characterized by self-imposed starvation and extremely low body weight. Cardiac arrhythmias are common in clients with AN due to electrolyte imbalances related to the self-imposed starvation.
A three-year-old child who is lethargic, vomiting and complaining of abdominal pain is being assessed for acetominophen poisoning. Which medication is used for treatment of acetaminophen poisoning?
A. deferoxamine
B. vitamin K
C. N-acetylcysteine
D. sodium bicarbonate - ansC. N-acetylcysteine
N-acetylcysteine works by replenishing intracellular levels of the natural antioxidant glutathione. This action helps restore cells' ability to fight damage to the liver caused by an overdose of acetaminophen.
A three-year-old toddler has recently developed a rash on the trunk and buttocks. Which question should the nurse asked the child's parent first?
A. has your child been swimming in a pool lately?
B. have you changed your laundry detergent lately?
C. has your child's dietary habits been altered lately?
D. Have you applied sunscreen on your child's skin lately? - ansB. have you changed your laundry detergent lately?
The fact the rash is on the child's trunk and buttocks indicates something is irritating the skin covered by clothing such as a shirt and underwear. The nurse should ask the
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED
A+
parent if brands of laundry detergent has recently been changed. The new soap may be causing irritation to the skin.
A twelve-year-old with a left big toe infection which is non-responsive to current oral antibiotic therapy is being evaluated for possible osteomyelitis. Which diagnostic imaging modality is the most sensitive for detecting osteomyelitis?
A. radiography
B. fluoroscopy
C. CT
D. MRI - ansD. MRI
MRI is considered the most sensitive imaging tool for diagnosing osteomyelitis; it is also used to delineate the area of involvement for surgical planning.
A two-month-old infant is brought to the clinic with a temperature of 101° F (38.3° C), flaring of nostrils, respiratory rate of 36 breaths per minute, expiratory wheezing and intercostal retractions. The healthcare provider prescribes a test for respiratory syncytial virus (RSV). The nurse should be prepared to take what samples to test for the RSV antigen?
A. clean catch urine
B. venous blood sampling
C. Nasopharyngeal secretions
D. rectal and stool swabs - ansC. NP secretions
RSV infection is the most common cause of cold-like symptoms in infants. Immunocompromised children with chronic pulmonary and cardiac illnesses and premature infants can be severely affected by RSV and potentially fatal. There are many different types of laboratory tests available for diagnosing the RSV infection. The most common and effective way of diagnosing this virus is by obtaining nasopharygneal secretions and testing for the RSV antigen.
An adolescent with a questionable treatment for syphilis is being admitted to the hospital for an assessment to determine what extent of damage has occurred to the teen's heart, blood vessels, brain, and spinal cord. Which stage of syphilis do these manifestations occur?
A. primary stage
B. secondary stage
C. latent secondary stage
D. tertiary stage - ansD. tertiary stage
The tertiary stage of syphilis occurs after the fourth year of untreated infection. Spirochetes (formed from the original chancre) begin to attack the heart, blood vessels, brain, and spinal cord and can cause insanity, blindness, paralysis, and ultimately death.
An alert child has been treated for a submersion injury (near drowning). Which complication should the nurse anticipate?
A. hypertension
B. Edema
C. Oliguria
D. Hypothermia - ansD. Hypothermia
Almost half of all children who experience near drowning, whether they are asymptomatic or minimally symptomatic, will experience complications during the first 24 hours after the incident. Hypothermia is common in children due to their large surface area relative to body mass, decreased subcutaneous fat, and limited thermoregulation.
How can the nurse help reduce anxiety in a school-aged child with temporary loss of vision?
A. patch the weaker eye
B. place the food tray directly in from of child
c. explain unfamiliar sounds in the room
D. provide a cane for walking - ansc. explain unfamiliar sounds in the room
Unfamiliar sounds become frightening to children with temporary vision loss. The nurse should explain all the sounds that occur in the room.
The emergency department nurse is assessing a three-month-old infant suspected to be a victim of "shaken baby syndrome". Which type of intracranial hemorrhage is caused by tearing of a meningeal artery that causes an inward expansion of blood from the inner surface of the skull?
A. subarachnoid
B. epidural
C. subdural
D. intracerebral - ansB. epidural
Shaken baby syndrome occurs when an infant or toddler is shaken forcefully in a jerky motion. Due an infant's and toddlers weaker neck muscle strength to hold up the head, the shaking causes the brain to slosh back and forth within the skull causing bleeding in the brain. Epidural hemorrhage is the most serious type of intracranial bleed; it most often occurs as a result of a severe head injury. This type of hemorrhage involves a tear in a meningeal artery that forms a hematoma between the skull and the dura mater. A rapid and dangerous increase in intracranial pressure occurs as a result of the inward expansion of blood into the brain.
The Kasai procedure is performed for children who suffer from a disorder that causes the child to become jaundiced in appearance?
A. esophageal stricture
B. imperforate anus
C. biliary atresia
D. cystic fibrosis - ansC. biliary atresia
The Kasai procedure is performed to allow bile drainage in infants with biliary atresia. During this procedure, a Roux-en-Y jejunal limb is attached to the porta hepatis to provide bile drainage without reflux.
The nurse applied 6 lpm of oxygen via a non-rebreather mask to a ten-year-old child with a history of asthma in the emergency department and began a nebulizer treatment.
MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED
The child upon arrival had a respiratory rate of 32 breathes per minute, SpO2 of 86% on room air; substernal and intercostal retractions; and audible expiratory and inspiratory wheezing audible three feet away. After the nebulizer treatment, the nurse noted the audible wheezing had lessen and the lower lobes of the lungs were absent of breath sounds. The nurse should prepare for which intervention next?
A. peak expiratory flow measurement
B. administration of albuterol
C. chest physiotherapy
D. endotracheal intubation - ansD. endotracheal intubation
Asthma attacks may develop gradually or appear abruptly following exposure to a trigger. A child with shortness of breath, absent breath sounds, and a sudden rise in respiratory rate is in imminent danger of respiratory failure and the nurse should prepare the client for endotracheal intubation.
The nurse is admitting and preparing a ten-year-old for an appendectomy. Appendicitis may result when the lumen of the appendix becomes obstructed by what type of foreign matter?
A. stones
B. chyme
c. stool
D. bile - ansC. stool
Appendicitis may result when the lumen of the appendix becomes obstructed by foreign matter, usually hardened fecal (stool) material. Appendicitis can also be caused by an infection in another part of the abdomen.
The nurse is assessing a 2-year-old child at the pediatrician's office. The child's history is significant for prenatal brain trauma and low Apgar scores. The child exhibits hypertonia of the extremities, poor speech intonation, and is failing to meet expected motor skills milestones. Which disorder should the nurse suspect?
A. guillain-barre syndrome
B. spina bifida
C. muscular dystrophy
D. cerbral palsye - ansD. cerebral palsy
Cerebral palsy refers to a group of non-progressive disorder that can result from an hypoxic injury to the developing brain either pre-natally, during the birthing process or can occur in early childhood due to hypoxic episode or infectious disease process. Cerebral palsy is often associated with delayed speech or difficulty speaking, spastic and/or hypotonic muscles, and failure to meet expected motor skills milestones. Prenatal injuries are the most common cause of cerebral palsy.
The nurse is assessing a child who is undergoing treatment for leukemia. The nurse should monitor for what late side effect of the treatment?
A. anemia
B. GI disturbances
C. secondary malignancy
D. cardiac irregularities - ansC. secondary malignancy
Children who undergo chemotherapy and irradiation treatment are more susceptible to development of secondary malignancy, especially those who are 5-years-old or younger
The nurse is assessing a two-month-old in preparation for surgery for coarctation of the aorta repair. Which best describes the pathophysiology of coarctation of the aorta?
A. acyanotic defect, increase pulmonary blood flow
B. cyanotic defect, obstructed blood flow from ventricles
C. acyanotic defect, obstructed blood flow from ventricles
D. cyanotic defect, decreased pulmonary blood flow - ansC. acyanotic defect, obstructed blood flow from ventricles
Coarctation of the aorta causes localized narrowing near the insertion of the ductus arteriosus. This results in increased pressure proximal to the defect (head and upper extremities) and decreased pressure distal to the obstruction (body and lower extremities).
The nurse is assessing the chest tube output of a 10 kilogram child status-post cardiac surgery. How many milliliters of drainage in one hour is a sign of possible postoperative hemorrhage?
A. 10
B. 20
C. 40
D. 50 - ansD. 50
Excessive chest tube drainage is an indication of postoperative hemorrhage. Chest tube drainage of 5-10 mL/kg in any one hour is excessive and should alert the nurse to the possibility of hemorrhage.
The nurse is assigned a nine-year-old client who is scheduled to have a skin graft procedure. Which term may refer to a type of skin graft obtained from a human cadaver?
A. autograft
B. allograft
C. xenograft
D. isograft - ansB. allograft
An allograft is transplanted tissue derived from a donor of the same species that is not genetically identical to the recipient. Tissue obtained from a human cadaver is considered an allograft.
The nurse is assigned to care for an adolescent who has a past history of anorexia nervosa. What is one of the complications associated with this disorder?
A. hyperthermia
B. oily skin and hair
C. decreased bone density
D. tachycardia and hypertension - ansC. decreased bone density
Individuals with a history of anorexia nervosa are prone to having nutritional and hormonal imbalances that can cause decreased bone density, therefore increasing the individuals risk for osteoporosis and bone fractures.
MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED
The nurse is caring for a client with a suspected diagnosis of celiac disease. In order to confirm this diagnosis, the nurse should prepare the client for which examination?
A. MRI
B. flurososcopy with barium contrast
C. CT
D. endoscopy with small bowel biopsy - ansD. endoscopy with small bowel biopsy
Celiac disease is an autoimmune disease in which gluten triggers the immune system to attack the inner lining of the small intestine. A diagnosis of celiac disease is confirmed with a duodenal biopsy.
The nurse is caring for an infant who demonstrates temperature of 96.8° F (36° C), mottled skin appearance, lethargic, and episodic apnea. The CBC with differential revealed a low white blood cell count and elevated immature neutrophils, with changes in neutrophil morphology. This presentation is likely due to which condition?
A. sepsis
B. Hodgkin's disease
C. apnea of prematurity
D. osteosarcoma - ansA. sepsis
Changes in neutrophil counts (a left shift) and changes in neutrophil morphology suggest an infectious process. Leukopenia (low white blood cell count) is a sign of sepsis and is associated with high mortality.
The nurse is counseling a teenage girl who was recently diagnosed with gonorrhea. The nurse should inform the client that untreated gonorrhea may lead to which complication?
A. pelvic inflammatory disease
B. GI bleeding
C. renal failure
D. pyelonephritis - ansA. PID
Neisseria gonorrhoeae is a species of anaerobic bacteria that is transmitted through sexual contact. Untreated gonorrhea may lead to pelvic inflammatory disease, an infection of the female reproductive organs which untreated can cause female sterility.
The nurse is developing a nursing care plan (NCP) for a 5-year-old child who is newly diagnosed with Legg-Calve-Perthes disease. Which nursing outcome would be the most appropriate for this client?
A. the client is smiling while quietly coloring pictures
B. the client has gained 2 pounds since admission
C. the client is able to put full weight bearing on affected limb
D. the client has been able to maintain a steady normal glucose level - ansA. the client is smiling while quietly coloring pictures
Legg-Calve-Perthes disease is a condition affecting blood flow to the femoral head of the hip joint. Children between the ages of 2 to 12- years-old are affected, with the occurrence frequently affecting boys between the ages of 4-8 years. The initial treatment when diagnosed with Legg-Calve-Perthes disease is rest and non-weight
MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
bearing to help reduce inflammation and restore motion of the joint. The nurse's care plan should include interventions such as diversional activities that help encourage the client to rest the joint while helping the client from becoming bored or distraught.
The nurse is preparing to administer furosemide (lasix) to an adolescent who has developed congestive heart failure as the result of cystic fibrosis. Which condition would indicate the medication regime is being effective?
A. decrease of crackles
B. decrease of BMI
C. decrease of urine output
D. decrease of blood glucose - ansD. decrease of blood glucose
The one of the goals of diuretics, in particular furosemide in the medical treatment of heart failure is to help decrease the fluid overload in the lungs as the result of the congestive heart failure. Decrease of crackles in the lungs is indicative that the medication is working and there is less fluid congestion in the lungs.
The nurse is providing emergency care for an unconscious child who presents with a head injury sustained in a fall. Which is the highest nursing priority?
A. establish airway
B. assess neuro status
C. stabilize the spine
D. obtain vital signs - ansA. establish airway
Respiratory obstruction can occur in an unconscious client due to the reduced ability to swallow secretions. This may lead to further complications and cardiac arrest.
Establishing and maintaining an adequate, patent airway should be the nurse's first priority using the jaw thrust method before implementing the other interventions.
The nurse is providing pre-operative teaching for a 12-year old child who will have a tonsillectomy in the morning. Which statement by the child best demonstrates the expected level of understanding about the concept of illness?
A. I need to save my tonsils in case I want them back in my mouth
B. tonsils were important for my immunity and infection prevention when I was a baby
C. when I wake up my throat will hurt but I can eat all the ice cream I want and then go home
D. my friend had a tonsillectomy and threw up after surgery, so I guess that will happen to me - ansD. my friend had a tonsillectomy and threw up after surgery, so I guess that will happen to me
Beacuse the late school aged, pre-adolescent lacks vast life experiences from which to draw conclusions, the pre-teen can list things about the world around, but has very little abstract understanding of things.
The nurse is reviewing an electronic medical record (EMR) of a four-year-old child who is scheduled for an outpatient cardiac catheterization. The child has midazolam prescribed pre-procedure to alleviate anxiety. Which prescription should the nurse seek further clarification from the healthcare provider?
A. Parents may administer the med just prior to coming to the hospital
B. the child may have clear liquids up to two hours prior to administration of medicine
C.the child is to be accompanied the resuscitative equipment during transport to cardiac suite
D. parents may accompany the child during transportation to cardiac procedure room.ansA. Parents may administer the med just prior to coming to the hospital
Midazolam is commonly prescribed to decrease anxiety in children undergoing surgical procedures. When midazolam is administered to children, there should be a Pediatric Advance Life Support (PALS) certified personnel and resuscitative equipment accompanying the child to the procedure room. Children older than 3 years should be NPO of solid and non-clear liquids for a minimum of 6 hours and may have clear liquids up to two hours prior to sedation. The practical nurse (PN) needs to contact the healthcare provider and request for a new prescription to be written and the parents to be notified of the new prescription.
The nurse is reviewing the lab values for an eight-year-old client and notes that the child's absolute neutrophil count (ANC) is below 500 cells/mm3. Which nursing intervention should the nurse implement first?
A. Transfer the child to a negative pressure room
B. Notify the HCP of the lab result
C. Initiate reverse isolation
D. Call the lab and request stat unit of plt - ansC. Initiate reverse isolation precautions for this child
The normal ANC value is considered greater than 1500 cells/mm3. Mild neutropenia is between 1000-1500 cells/mm3, moderate between 500- 1000 cells/mm3. ANC below 500 cells/mm3 are considered severe neutropenia. Clients with an ANC below 500 cells/mm3 should be placed on reverse isolation precautions as soon as detected to prevent acquiring an overwhelming infection. Reverse isolation consists of being placed in a positive pressure room and generally no consumption of fresh fruit or vegetables, unless the food is thoroughly washed and no live plants or flowers in the room.
The nurse recognizes signs that a 9-month-old toddler may be living in an abusive home. Which action is the priority for the nurse?
A. encourage the child to speak freely
B. report the suspected abuse to local authorities
C. document head to toe assessment
D. test the child for STD - ansB. report suspected abuse
The nurse's priority in suspected abuse cases is the safety and welfare of the child. According to national statistics, children under the age of one have the highest incidences of being abuse. Nurses are mandated reporters and are required to report suspected cases of abuse to local authorities in order to protect the child from further abuse
The nursing interventions for a 4-year-old victim of a scald burn of maintaining correct body alignment and function; frequent position changes; braced extremities; and active and passive range of motion are primarily implemented to prevent which complication from severe burns?
A. contractures
B. pneumonia
C. decubitus ulcers
D. DVT - ansA. contractures
As the injured skin heals, the scar tissue from the burns has very little elasticity/contractile properties and the formation of contractures can occur very easily creating lost of function, deformities and disfigurement. The nursing interventions of maintaining correct body alignment and function; frequent position changes; braced extremities; and active and passive range of motion can help prevent the severity of the formation of contractures.
The parents of a 13-year-old male client are concerned that he may not have started puberty. The client's stage of puberty is assessed using the Tanner scale of development. Which type of test is performed to determine this child's Tanner stage?
A. orchidometry
B. radiologic exam
C. bone densitometry
D. muscle mass calculation - ansA. orchidometry
Tanner's staging is used to assess puberty milestones and compare individuals. In males, the stages are partly based on testes volume, which is measured with an orchidometer.
The parents of a newborn diagnosed with hypospadias, requests that their son to be circumcised prior to being discharged from the hospital? How should the nurse respond to the parent's request of circumcision?
A. contact the HCP about the parent's request
B. explain the reason to the parents that circumcision is not an option
C. fill out the surgical consent form and have the parent's sign consent for the procedure
D. place the infant on NPO, and prepare the surgical tray for the procedure - ansB. explain the reason to the parents that circumcision is not an option
Hypospadias is a common congenital malformation in newborn males which occurs 1:125 boys in the United States in which the urethra opens along the penile shaft on the underside of the penis. This condition may be corrected surgically at a later date, but the foreskin of the penis is left intact in the event the tissue may need to be used as part of the surgical reconstruction of the urethral opening.
What issues should be addressed when conducting a psychosocial interview with an adolescent?(SATA)
A. home life
B. financial status
C. school performance
D. genetic disorders
E.safety in neighborhood - ansA, C, E
Home, school, and safety are correct. The "HEADSSS" technique is generally used. Questions about Home environment, Activities, Drugs, Sexuality, Suicide risks, and Savagery are covered in HEADSSS.
When caring for an infant with gastrointestinal reflux disorder (GERD), the nurse should be alert for which complication?
A. apnea
B. weight gain
C. abdominal distension
D. swelling of the extremeities - ansA. apnea
Apnea is the temporary cessation of breathing for greater than or equal to 20 seconds. Apnea may present as a complication in severe cases of GERD; this is believed to be due to upper airway stimulation by the gastric reflux of stomach contents. Surgical intervention may be required for infants with recurrent apnea, if more conservative interventions are not successful.
When counseling parents about developmental milestones for their 4-year-old child, the nurse is correct to include which fine motor skill?
A. tying shoe laces
B. brushing teeth
C. cutting with scissors
D. buttoning shirt - ansC. cutting with scissors
Fine motor skills include small movements involving the intrinsic muscles of the hands and fingers. A 4-year-old should have developed the fine motor skills required to cut paper with scissors.
When counseling the mother of an infant with a hepatitis B infection, the nurse should include which information?
A. infected newborns are normally asymptomatic
B. infected mothers should refrain from breastfeeding
C. vaccination is not needed if the mother is a carrier
D. the infections is usually transmitted during pregnancy - ansA. infected newborns are normally asymptomatic
Hepatitis B is a viral infection that can be transmitted to a newborn from the infected mother during childbirth. Neonates with hepatitis B rarely exhibit symptoms of the disease. Hepatitis B can be contracted through the act of unprotected sex or a contaminated needle.
When educating the parents of a 12-year-old client with newly diagnosed with diabetes type I, which information should the nurse emphasize?
A. the child should be weighed daily
B. The parent should remind the child to check glucose levels
C. the child should wear a medical alert bracelet
D. the parent should not let the child inject insulin - ansC. the child should wear a medical alert bracelet
A medical identification bracelet is recommended to alert health care professionals of conditions that requires special attention. The nurse should emphasize the importance of wearing a medical ID bracelet in the event of an emergency in which the child with diabetes cannot speak and the parents are not available at the time of the emergency.
When teaching a family to care for a child with hemophilia, which symptom should the nurse explain is a sign of internal bleeding?
A. pale color
B. slurred speech
C. weakness
D. green stools - ansB. slurred speech
Headache, slurred speech, and loss of consciousness are highly suspicious for cerebral bleeding. The nurse should instruct the family to be alert for these signs in a child with anemia.
Which action should the nurse perform during preoperative management of a child with intestinal bleeding?
A. record appearance of blood in stools
B. apply abdominal compression wrap
C. begin fluid replacement therapy
D. measure body weight every 6 hours - ansA. record appearance of blood in stools. Preoperative nursing care of the child with intestinal bleeding includes monitoring for signs and symptoms of severe bleeding, as this increases the risk of surgical complications. Interventions include recording the approximate amount of bleeding occurring, by documenting the appearance of blood in the client's stools. Hematochezia is the medical terminology which is bright red blood noted in the stool and is indicative of bleeding in the lower portion of the GI tract.
Which action should the nurse take when caring for a child with epiglottitis?
A. examine the trhoat with tongue depressor
B. set up emergency airway equipment at bedside
C. place the child in supine position
D. perform a throat culture - ansB. set up emergency airway equipment at bedside Epiglottitis can quickly progress to severe respiratory distress. Emergency airway equipment should be readily available in case the client's condition worsens.
Which information about toxic shock syndrome should the nurse emphasize when counseling an adolescent female client?
A. symptoms
B. prevention
C. medication
D. treatment - ansB. Prevention
Toxic shock syndrome (TSS) occurs from a buildup of toxins produced by staphylococcus bacteria and can lead to acute multisystem organ failure. Education should focus on preventive measures, such as the dangers of prolonged tampon replacement use.
Which information is important for the nurse to include when educating the parents of a two-month-old with gastroesophageal reflux disease (GERD)?
A. the child should sleep in the supin position
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED
B. the child's condition should improve over time
C. the child's oral cavity should be cleaned before each feeding
D. the child should be fed while in the prone position - ansB. the child's condition should improve over time
GERD is usually benign due to immature development of digestive system and will subside as the infant matures. Reassuring parents of this fact should help ease any fears related to this disorder.
Which instruction should the nurse include in the parents' discharge teaching plan for a three-year-old child with diarrhea?
A. offer chicken or beef broth
B. hydrate with orange juice
C. monitor for absence of tears
D. feed child a BRAT diet (bananas, rice, applesauce, toast) - ansC. monitor for absence of tears
Fluid loss through vomiting and diarrhea in infants and small children may quickly develop into dehydration. The parents should be taught to monitor for absence of tears when crying and dry, sticky mucous membranes may be a sign of dehydration related to the vomiting and diarrhea.
Which is recognized as a contributing factor to the development of anorexia nervosa in adolescents?
A. complaisant parenting
B. peer pressure
C.rigid family rules
D. dropping out of high school - ansC. rigid family rules
Anorexia nervosa is a disorder found primarily in adolescents. A dysfunctional family life is felt to be a contributing factor to this condition. Dysfunction in the home may result from overprotectiveness, rigidity, or an inability to resolve conflicts
Which is the best method a nurse can teach a mother of an infant to minimize the occurrence of a diaper rash?
A. place talcum powder in the diaper
B. dry the infant's buttocks with hair dryer
C. change the diaper as soon as it is soiled
D. to place petrolatum on the infant's buttocks - ansC. change the diaper as soon as it is soiled
Changing a soiled diaper as soon as soiling is detected is the best way to decrease the occurrence of a diaper rash.
Which medication is administered to premature infants to reduce the severity of symptoms associated with respiratory syncytial virus (RSV) infection?
A. respaire
B. singulair
C. menomune
D. synagis - ansD. synagis
MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
Respiratory syncytial virus (RSV) causes infection of the respiratory tract which can be fatal to premature infants and children younger than 2 -years-old with lung and/or heart conditions. Synagis (Palivizumab), a monoclonal antibody which binds to the RSV virus, preventing the virus from reproducing. The shot is administered before the RSV season and then is given monthly to high-risk infants during RSV season which can start as early in October and last until March to prevent hospitalization associated with RSV.
Which presentation is typically seen in a child with hyperthyroidism?
A. nervousness, palpitations, weight loss
B. fever, weight gain, decreased appetite
C. abdominal pain, vomiting, constipation
D. diminished reflexes, dyspnea, bradycardia - ansA. nervousness, palpitations, weight loss
Hyperthyroidism may present in a number of ways; variations of symptoms depend on the underlying cause. A typical presentation includes weight loss despite increased appetite, nervousness, and palpitations.
Which situations lead to exacerbation of acne in an adolescent female? (SATA)
A. the consumption of chocolate products
B. cosmetics containing lanolin and lauryl alcohol
C. food products containing high levels of caffeine
D. frequent exposure to cooking oils and grease
E. the premenstrual days leading up to menstrual cycle - ansB,D,E
Many factors can have an impact on the occurrence of acne flare-ups. They can range from working in a fast food restaurant being exposed to cooking oils and grease, to wearing make-up that contains lanolin and lauryl alcohol to hormonal balances leading up to a female's menstrual cycle.
Which treatment regimen reduces the risk of pneumococcal infection in a pediatric client with sickle cell anemia?
A. annual flu shot
B. penicillin prophylaxis
C. vitamin E supplementation
D. tdap vaccination series - ansB. penicillin prophylaxis
Epidemiologic studies suggest that penicillin prophylaxis significantly reduces the risk of pneumococcal infection in children with sickle cell disease, especially before they are to have an invasive procedure such as dental work.
Which type of nursing intervention is the nurse is implementing when counseling an adolescent about the relationship of risky sexual activity behavior and the use of drug or alcohol use?
A. anticipatory guidance
B. interpersonal relations
C. behavioral therapy
D. social skills training - ansA. anticipatory guidance
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
-Chemo Side Effects - ANSo Nausea/vomiting (24-48 hr, can be delayed up to 1 week)
24 hour- Jaundice - ANSPhysiologic jaundice occurs from a normal reduction in red blood cells. Pathologic jaundice occurs within first 24 hours of life OR persists beyond 7 days
A client with anorexia has her friend bring her several cookbooks so she can plan a party when she is discharged. What nursing intervention is appropriate in addressing this behavior? - ANSDiscuss activities that don't involve food that can take place after discharge. Discuss the cookbooks with the treatment team, and if the treatment plan so indicates, take the books from the client.
A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase?ANSMaking appropriate referrals
ABG findings - ANSpH: 7.35 - 7.45
PCO2: 35 - 45 mmHg
HCO3: 22 - 26 mmHg
Acute Pancreatitis assessment - ANSHistory, ETOH abuse, severe LUQ pain, tachy, restless, decrease bowel, jaundice, grey turner or Cullen signs, increase serum amylase/lipase or WBC, hyperlipidemia
Acute renal failure priority - ANSo Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings - ANSo Hypoxia
o Intercostal retractions
o Crackles
o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial obstruction)
Addison's Crisis Hypoglycemia S/S - ANS- weakness
- fatigue
- severe hypotension
- nausea/vomiting
- dehydration
- dysrhythmias
- shock
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
ADHD Exam/Assessment - ANS- failure to listen/follow direction
- difficulty playing quietly/sitting still - disruptive, impulsive behavior
- distractibility to external stimuli
- excessive talking
- shifting from one unfinished task to another
Aggression response - ANS5-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
Alcohol withdrawal - ANS- 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
Alcoholic hepatis teaching - ANS- low sodium diet
- small frequent meals
- no alcohol
Anxiety Suicide Risks: - ANSRestless, difficulty concentrating, irritability
- "Have you had any suicidal thoughts since starting bupropion?"
Arterial Insufficency - ANS- mostly men - legs mostly affected
arterial insufficiency symptoms - ANS-weak pedal pulses -shiny and cool skin -intermittent claudication - aching/cramping - induced fatigue
Asthma Triggers: - ANSDust, mites, roaches, cloth, pets, horses, detergents, soaps, food, mold, pollens, seasonal
Bizarre social behavior - ANS- assess physical needs, suicide risk, ensure safety at all time
- sit w/ client, silence, tell when leaving
- limit stimuli / 1-1 interaction
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
Boggy Uterus Actions - ANS- massage and administer uterotonic to increase uterine contraction.
- give oxytocin
Cancer intractable pain plan of care - ANSo 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. ??????
Cardiomyopathy care plan - ANS○ Medications- digoxin, diuretics, antidysrhythmic, antihypertensive medications
○ Surgery- septal myectomy, septal ablation, implanted devices (CRT, ICD, LVAD, pacemaker), heart transplantation
Chronic Kidney Disease = metabolic acidosis - ANSkidneys fail, no longer reabsorb HCO3 (bicarb), serum bicarbonate decrease = acidosis occurs
** sodium bicarb administration
Cirrhosis ascites dyspnea- S/S - ANSencephalopathy
portal hypertension
esophageal varices hemorrhage
Compartment Syndrome S/S - ANSPain
Paresthesia
Paralysis
Pallor
Pulse-lessness
Hard/swollen Muscle
*** avoid cold, DO NOT ELEVATE LIMB
Complication Hypertension Risk - ANSElevated BUN = kidney dysfunction = associated with hypertension
COPD oxygen therapy - ANS-Max of 3L via NC
- low concentration are better!!
- do not want pH to fall
COPD Treatment - ANS- Smoking Cessation
- Roflumilast (Daliresp) for severe COPD
- bronchodilator or oxygen therapy, oral or IV corticosteroids.
Cushing Syndrome - ANSo 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
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
CVA expressive aphasia - ANSinability to speak/understand language (Left Side = Language)
Cystic Fibrosis Teaching - ANS- take pancreatic enzymes (pancrelipase) with meals - treatments before meals or several hour after eating to prevent vomiting - high fat/high calorie diet
- lots of fluids
- chest physiotherapy w/ postural drainage
- sweat chloride test
Decreased HCO3 levels (Metabolic Acidosis)= - ANSRespiratory alkalosis compensates - Kussmaul respirations.
Decreased PaCO2 levels (Respiratory Alkalosis)= - ANShyperventilation
Dementia action refusing ADLs - ANSEncourage finger foods, distraction, speak therapeutically
Describe the clinical symptoms of anorexia nervosa: - ANSWeight loss of at least 15% of ideal or original body weight; hair loss; dry skin; irregular heart rate; decreased pulse; decreased BP; amenorrhea; dehydration; electrolyte imbalance
diabetes insipidus (DI) = makes you want to SIP water - ANSInsufficient ADH from posterior pituitary gland - polyuria
- polydipsia
- dehydration - hypotension
* water deprivation test
* give vasopressin, desmopressin
Diabetes Mellitus- Poor compliance - ANS- The patient may use a urine dipstick (Ketostix or Chemstrip uK) to detect ketonuria. The reagent pad on the strip turns purple when ketones are present. → unmanaged diabetes or control over DM is deteriorating
DKA: complication of type 1 diabetes, serum glucose >250, ketonuria in large amounts
Dialysis HTN edema - ANSFluid overload can cause increase in blood pressure à limit salt intake, track fluid, monitor blood pressure
Diarrhea- Diet - ANSgive Pedialyte (oral electrolytes) - no grape, orange, apple, or ginger ale juice!
Digoxin TOXICITY - ANSloss of appetite
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
lower stomach pain
diarrhea weakness
blurred or yellow vision
headache rash
** Stop product and give potassium and DigiFab.
Diverticulitis NPO
(^ small pouches in intestines) - ANSNPO or clear liquid diet during exacerbations to decrease inflammation, then progress to a low-fiber diet. Ongoing, eat a high fiber diet.
Diverticulosis S/S - ANSLLQ abdominal pain (descending/sigmoid colon)
Bloating Fever
Nausea/Vomiting
Constipation alt. w/ diarrhea
Anorexia
Domestic violence screening tool - ANS- Don't probe, write evidence down verbatim, provide a safe environment
- Increase in violence during pregnancy
- Cycle of violence= tension building, violent, honeymoon
Duchenne Muscular Dystrophy - ANS- X- linked recessive - delayed motor/speech, cognitive impairment, muscle weakness, waddle, calf enlargement, cardiomyopathy
Elder Abuse - ANSSomeone stating "I no longer have time to do anything for myself or anyone else" would be someone @ risk for abusing elder.
Bruising around breasts and pelvic area = abuse
Watch behavior toward family and document
Make caregiver leave room during questioning
*** include nonconsensual contact
Elevated HCO3 levels (Metabolic Alkalosis)= - ANSRespiratory acidosis compensates
Elevated PaCO2 levels (Respiratory Acidosis= - ANSpneumonia, asthma, COPD
(Assess lungs for increased pulmonary secretions)
End of life plan of care - ANSo Signs and symptoms of impending death are recognized and communicated in developmentally appropriate language for children and patients
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
with cognitive disabilities with respect to family preference. Care appropriate to this phase of illness is proved to the patient and the family
Engorgement Teaching - ANSencourage frequent breastfeeding every 2-3 hours should decrease the engorgement. For bottle feeding: encourage the woman to use ice packs, to wear a snug, supportive bra 24 hours a day, and to take mild analgesics such as acetaminophen. Encourage her to avoid any stimulation to the breasts that might foster milk production, such as warm showers or pumping or massaging the breasts.
Febrile Seizures teaching - ANSuse seizure precautions, call 911 if lasts more than 5 minutes
Fetal Tachycardia - ANS>160 bpm for 10 minutes or longer
- antipyretic for maternal fever
- IV fluids
- oxygen
Fractured Femur = diminished pulses - ANS● Peripheral pulses, color, capillary refill, and temperature of the fingers or toes.
● Manifestations of deep vein thrombosis (DVT), which include unilateral calf tenderness, warmth, redness, and swelling.
GERD- Teaching - ANS- Avoid fatty, fried, citrus, spicy foods, and caffeine.
- Eat small meals. Remain upright.
- Avoid tight-fitting clothes.
- Wt loss.
- Quit smoking.
- Reduce alcohol intake.
- Elevate HPB
Glaucoma S/S (closed angle) - ANSsevere eye pain sever headache blurry vision halo around lights reddened sclera nausea/vomiting
Glaucoma S/S (open angle) - ANSloss of peripheral mild aching headache
** tonometry diagnose between the two
Gout Medication- Allopurinol - ANS- bone marrow depression, vomiting, abd. pain
- avoid starting/increasing med during active flare up
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
- AFTER MEALS!
Gout Medication- Allopurinol teaching - ANS- avoid alcohol - purine-rich foods (red meat/shellfish/fructose drinks) - increase fluids - reduce stress
Grief Priority - ANSPriority should be based on SHOCK!
Grief process therapeutic response - ANSAllow the 5 steps of grieving (DABDA), active listening and offer a supportive presence
Guillain-Barre syndrome - ANSParesthesia (numbness/tingling), weakness in legs, absent DTR's, paralysis of ocular facial and oropharyngeal muscles
** watch for shallow/rapid breathing, ask if cold/stomach flu in last month
Heart Failure = DIGOXIN! - ANS- increase cardiac output and contractility.
- Take apical pulse prior to giving do not give if less than 60.
- Therapeutic level 0.5-2 ng/mL.
Hemophilia Safety - ANS- apply padding to sharp edges
- child falls on bike causing swelling (Rest, Ice, Compression, Elevation)
- noncontact sports like swimming, biking, walking
- RN= frequent BP, rectal suppositories, temps, and aspirin
Hydrocephalus - ANSAssess for - change in LOC - seizures
- decline in academics
- personality changes
In infants
- widening stature
- "sunset eyes"
- high pitch cry - difficult to eat
Hypothyroidism - Sleep/ Depression - ANS- Depression can result from untreated hypo
- falling/staying asleep difficult = avoid sedation
- frequent rest but stay action
IBP - Peritonitis - ANS- Fluid, colloid, and electrolyte replacement is the major focus
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
- Antibiotic therapy
infant congenital heart defect assessment - ANS- small/frequent meals - oxygen - high calorie formula *** cyanotic episodes bring knee's up to chest
Intussusception (part of intestine fold into the section next to it, cause obstruction) - ANS- RUQ sausage shaped mass - vomiting - bloody mucus stool fever weight loss
IUGR (intrauterine growth restriction) ultrasound - ANS- diagnosed at this time
IV fluids: hypertonic - ANSDraws water from ICF to EFC causing cells to SHRINK (Saline / Lactated Ringers with 5% dextrose)
Left-Sided Heart Failure - ANS(Left is LUNG) congestion, dyspnea, crackles, fatigue, pink/frothy sputum
Medication adverse reactions care (schizophrenia) - ANSConstipation is a common side effect of antipsych meds, polydipsia occurs after years of treatment
Nurse can help minimize effects of delusions with distraction techniques, music, tv, writing and talking to friends, positive self-talk and positive thinking
Meningitis first step - ANSo Antibiotics - penicillin (ampicillin) AND cephalosporin
o Corticosteroids
Methadone overdose - ANSS&S= constricted pupils, resp. depression, circul. depression, LOC decreased
Give naloxone
Multiple sclerosis and urinary retention - ANSo 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
NSR (Normal Sinus Rhythm) - ANS60-100 bpm
P wave always infront
P:QRS ratio 1:1
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
OCD - ANS- Patient checks where car keys are 8 times
- Patient has persistent thoughts about bacteria, germs and dirt
- Help encourage participation in social activities
Osteoarthritis Exercise - ANS- Use correct posture/body mechanics, use of assistive devices, walking, physical therapy, strength training, yoga, tai chi.
Peptic Ulcer Disease (PUD) NG Tube - ANS- 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
Placental abruption - ANSwhen the placenta detaches from the uterus
- can deprive baby of oxygen
- heavy bleeding can occur
- abd/back pain
**c-section and bedrest
Pneumonia Treatment: - ANS- oxygen therapy, hydration, bed rest, positioning to facilitate breathing, deep breathing, humidified air, chest physiotherapy, suctioning prn,
Pneumonia Vaccines: - ANS- PCV13: >65, >19 with conditions that weaken immune system
- PPSV23: >65, 19-64 year olds who smoke/have asthma
Post General Anesthesia Care - ANSAsses airway, respiratory function, cardio, skin color, LOC, ability to respond to commands
- relieve pain
- vitals every 15 minutes
- systolic under 90 = immediately reportable unless baseline!!
Preop labs - what's abnormal - ANSWBC count higher than 5,000-10,000/mm3 = possible infection
Prolapsed Cord Care - ANS1.Call for assistance- a medical emergency
2. Sterile gloves, insert 2 fingers into the vagina (one on each side of the cord) & Elevate the fetal presenting part off the cord
3. Apply warm sterile saline soaked towel over cord
4. Administer O2
5. Prepare for birth
Prostatic Hyperplasia - ANS- Benign growth
- occur in men w/ elevated estrogen levels
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
Prostatic Hyperplasia S/S - ANS- urgency - nocturia - hesitancy - decreased/intermittent stream - incomplete emptying - less than 50-100mL's
Pulmonary Edema- first action - ANSplace patient in high fowlers, feet hanging over edge of bed
Pulmonary Embolism- report findings - ANShypotension tachycardia tachypnea
SOB anxiety chest pain w/ inspiration petechiae diaphoresis ***** INCREASE D-DIMMER!!!
Pyloric Stenosis S/S - ANS(opening between stomach and small intestine is thickened) - vomiting - dehydration - colic - lethargic - lump in belly - failure to thirive - electrolyte imbalance
Questions to ask someone with OCD - ANS- are there other in your family who must do things a certain way - is it difficult to keep certain thoughts out of your awareness - do you do certain things over and over again
Rheumatoid Arthritis Pain - ANS- Early is treated with NSAIDS, Opioids, nonpharmacologic and DMARDs like rheumatrex, methotrexate, leflunomide, sulfasalazine that can take up to six weeks to work.
- Advanced is treated with immunosuppressants such as high dose methotrexate, cyclophosphamide, and azathioprine
Rhogam Refusal - ANSeducate about Rhogam prevention of maternal antibody formation for future Rh positive babies.
Right-Sided Heart Failure - ANS(Systemic) congestion, peripheral edema, ascities, jugular vein distention, hepatomegaly
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
RN care for RSV - ANSnasal suctioning hydration calm
O2 as needed
RSV distress- S/S - ANScough, sneezing, fever, wheezing, deep/rapid breathing, prolonged expiration
Schizophrenia nursing diagnoses and interventions - ANS- 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
Scoliosis post-op - ANSNeuro assessments
Pain control
Log roll 5 days
Body jacket (several months)
Assist ambulation
Seizure/unconscious patient - ANS-Maintain patent airway, turn to side, loosen constructive clothing, ease to floor. May require suctioning or oxygen. after, assess level of understanding.
-call 911 for seizures lasting more than 5 minutes
- maintain bed in low position and keep side rails up.
-safety is first.
Seizures in child - ANSmonitor serum levels of antiepileptics
Self care Maslow - ANS- Physiologic, safety, love and belonging, self esteem, selfactualization
- Basic drive and needs that motivate people
Shoulder Dystocia Actions - ANS- McRoberts Maneuver
- Suprapubic Pressure (need step stool)
Sickle cell- first sign of crisis - ANS- pain
- fatigue
- swollen hands and feet
- dehydration
**give oxygen, fluids, pain med, infection prevention
Slipped femoral capital epiphysis (SCFE) - ANS- obesity increase risk
- more common in boys, African American, Hispanic
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
Stable = child can still walk
Unstable= pt unable to put weight on affected leg
slipped femoral capital epiphysis (SCFE) S/S - ANS- pain/stiffness in knee or hip - foot/leg turned outward - one leg shorter than other
Small Bowel Obstruction Actions: - ANS- Auscultate bowels
- Measure correct length, advance decompression q1-2hr, reposition client q2hr, connect to suction, irrigate with NS, note amount, color, consistency, assess for dehydration, monitor electrolytes
- IV fluids will be given to replace depleted water, sodium, chloride and potassium
Stroke in Broca's Area - ANS- expressive aphasia usually occurs -paralyzed on right side
Tetralogy of fallot complications - ANShypercyanotic "TET" spells - bring knees to chest
The nurse is reviewing blood pressure readings for a group of client's on a medical unit. Which client is at the highest risk for complications related to hypertension? - ANSB. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL
Therapeutic communication abuse victim - ANS1. Physical manifestations of abuse
2. Client safety
3. Legal responsibilities of the nurse
4. For children, the nurse is legally responsible for reporting all suspected cases of abuse. In intimate-partner abuse, it is the adult's decision; the nurse should be supportive of the decision. Remember to document objective factual assessment data and the client's exact words in cases of sexual abuse and rape
Therapeutic Relationship Stages- TERMINATION - ANSUnresolved feelings related to loss most likely may be recognized during this stage.
Thrombocytopenia Labs - ANSnormal PT/PTT prolonged Bleeding time low platelet count
Type 1 DM tight control - ANS- glucose checks at home - A1C should be 4-6%
*** LESS THAN 7%
Type 1 DM tight control (nutrition) - ANS- consistent with culture - promote 1-2 lbs weight loss per week = subtract 500-1000 calories from daily total and distribute among proteins, carbs and fats
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
ulcerative colitis- bloody diarrhea - ANS- The nurse provides information about nutritional management; a bland, low-residue, high-protein, high-calorie, and highvitamin diet relieves symptoms and decreases diarrhea
Urolithiasis, Lithotripsy - ANS- kidney stones
***surgery- Lithotripsy which is the use of laser or shock-wave energy to break up the stones. Strain urine following procedure. Hematuria is expected.
Valve replacement teaching - ANSo Anticoagulant therapy (frequent follow-up/lab tests)
§ Pt on warfarin has specific normal ratios
o Prevent infection
o ANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES!!!
Variable Decelerations of FHR - ANSplace pt knee-chest or reposition from side to side, d/c oxytocin, administer oxygen, notify HCP. amnioinfusion may be indicated.
Violence handling - ANS- 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
Which features are prominent in anorexia nervosa? - ANS-Amenorrhea for three cycles
-Perfectionism
-Powerlessness
-Rigid food rituals
The nurse's goal is to prevent the adolescent from contracting a sexually transmitted disease. Anticipatory guidance involves the use of counseling techniques that are developmentally proactive and focus on the needs of the child.
While performing the initial physical examination of a newborn, the nurse elicits a positive Ortolani test. Which skeletal defect does this indicate?
A. septic arthritis
B. legg-calve-perthes disease
C. developmental dysplasia of the hip
D. slipped capital femoral epiphysis - ansC. developmental dysplasia of the hip
Developmental dysplasia of the hip (DDH) is a general term that refers to instability of the hip joint. The Ortolani test is used to detect posterior dislocation of the hip and is commonly performed to diagnose DDH. A positive Ortolani test consists of an audible clunk upon hip abduction, which means that the hip was dislocated.
Why is meperidine (Demerol) contraindicated for pain relief in clients with sickle cell disease?
A. it is ineffective
B. it can cause GI ulcers
HESI MILESTONE 3 REMEDIATION 2024 ACTUAL EXAM CONTAINS 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
C. it is too sedating
D. it can induce seizures - ansD. it can induce seizures
Normeperidine, a metabolite of meperidine (Demerol), is a stimulant that can induce seizure activity in clients with sickle cell disease