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HESI MILESTONE 2 PRACTICE QUESTION And ANSWERS with RATIONALES 202 5 A client with GERD is being treated with dietary management. The client states, "I like to have a glass of juice everyday." Which juice will the nurse recommend? Answer: Apple Juice A primary healthcare provider prescribes a low-sodium, high-potassium diet for client with Cushing Syndrome. Which explanation should the nurse provide to the client about the need to follow this diet? Answer: "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium." Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis? Answer: Urine Osmolarity A client has a history of GERD. Why should the nurse monitor the client for clinical manifestation of heart disease? Esophageal pain may imitate the symptoms of a heart attack A nurse is teaching a 15-year-old adolescent with newly diagnosed type 1 diabetes about self-care. What is the primary long-term goal this nurse and client should agree on? Maintaining normoglycemia The nurse is caring for a client before, during and immediately after surgery. Which type of care is provided to the client? Care that supports homeostatic regulation A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. What is the priority nursing intervention? Performing postural drainage
A nurse is planning to teach a school-aged child with newly diagnosed type 1 diabetes about self-care. After an assessment of what the child knows about diabetes, what is the next nursing intervention? Developing a sequence of goals with the child and parents. The nurse concludes that a client with glaucoma needs education when the client makes which statement? "It is dangerous for me to use sedatives." Sedatives have no effect on intraocular pressure A mother reports feeding her infant immediately before arriving in the emergency department. After completing the assessment, the nurse reports which finding immediately to the primary healthcare provider because it likely indicated pyloric stenosis? Peristaltic waves that transverse the epigastrium. The registered nurse is teaching a student nurse the points to be included while educating a client on cortisol replacement therapy about self-management. Which statement provided by the student nurse indicates the need for further teaching? "I will advise the client to take the medication before meals." Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis? Urine osmolarity A client with a completed ischemic stroke has a blood pressure of 180/90 mmHg. Which action should the nurse implement? A. Position the head of the bed (HOB) flat. B. Withhold intravenous fluids. C. Administer a bolus of IV fluids. D. Give an antihypertensive medication. D Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually
A. Give 20 mEq of potassium chloride. B. Initiate continuous cardiac monitoring. C. Arrange a consultation with the dietician. D. Teach about the side effects of diuretics. B Hypokalemia (normal 3.5 to 5 mEq/L [3.5 to 5 mmol/L]) causes changes in myocardial irritability and ECG waveform, so it is most important for the nurse to initiate continuous cardiac monitoring to identify ventricular ectopy or other life-threatening dysrhythmias. After cardiac monitoring is initiated, then the potassium chloride should be given so that the effects of potassium replacement on the cardiac rhythm can be monitored. Which description of pain is consistent with a diagnosis of rheumatoid arthritis? A. Joint pain is worse in the morning and involves symmetric joints. B. Joint pain is better in the morning and worsens throughout the day. C. Joint pain is consistent throughout the day and is relieved by pain medication. D. Joint pain is worse during the day and involves unilateral joints. A Rheumatoid arthritis (RA) is an autoimmune disease that causes joint pain and swelling. RA is characterized by pain that is worse when arising and involves symmetric joints. A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history? A. Jewish European ancestry. B. H. pylori bowel infection. C. Family history of irritable bowel syndrome. D. Age between 25 and 55 years. A Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi ancestry.
The client is taking digoxin for congestive heart failure. The nurse would be correct in withholding a dose of digoxin based on which assessment? A. serum digoxin level is 1.5. B. blood pressure is 104/68. C. serum potassium level is 3. D. apical pulse is 68/min. C Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5. mEq/L). The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. When taking the client's medical history, which information is most for the nurse to obtain? A. Irritable bowel syndrome. B. Diverticulitis. C. Crohn's disease. D. Ulcerative colitis. D The RN should ask the client if he has a history of ulcerative colitis, which is characterized by severe abdominal cramping, pain, tenesmus, and dehydration. The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing problem should the nurse document for this client? A. Situational low self-esteem related to functional impairment and change in role function. B. Disabled family coping related to dissonant coping style of significant person. C. Interrupted family processes related to shift in health status of family member.
A client presents with chronic venous insufficiency. Which assessment finding should the nurse anticipate? A. Bilateral lower leg stasis dermatitis. B. Clubbing of fingers and toes. C. Intermittent claudication. D. Peripheral cyanosis. C Clients who suffer from chronic venous insufficiency often develop stasis dermatitis in the lower extremities. Stasis dermatitis appear as brownish-red discoloration on the lower extremities at the ankles which can develop into stasis ulcers due to the pooling of the venous blood flow back to the heart. Which statement made by a client with chronic pancreatitis indicates that further education is needed? A. I will cut back on smoking cigarettes daily. B. I will avoid drinking caffeinated beverages. C. I will rest frequently and avoid vigorous exercise. D. I will eat a bland, low-fat, high-protein diet. A To prevent exacerbations of chronic pancreatitis, clients should be instructed to avoid nicotine entirely. Additional teaching includes avoiding caffeinated beverages, resting frequently as needed, and eating a bland diet low fat and high in protein. A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys an understanding of the etiology of diverticula? A. Over use of laxatives for bowel regularity result in loss of peristaltic tone. B. Inflammation of the colon mucosa cause growths that protrude into the colon lumen. C. Diverticulosis is the result of high fiber diet and sedentary life style. D. Chronic constipation causes weakening of colon wall which result in out-pouching sacs.
D
A client who has chronic constipation often strains to pass constipated stool which increases intestinal pressure that weakens the intestinal walls and causes out- pouching sacs, called diverticula which commonly occur in the sigmoid. Small bowel obstruction is a condition characterized by which finding? A. Severe fluid and electrolyte imbalances. B. Metabolic acidosis. C. Ribbon-like stools. D. Intermittent lower abdominal cramping. A Among the findings characteristic of a small bowel obstruction is the presence of severe fluid and electrolyte imbalances. The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first? A. Potassium 6.0 mEq. B. Daily urine output of 400 ml. C. Peripheral neuropathy. D. Uremic fetor A When assessing a client with chronic kidney disease (CKD), hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal arrhythmias, so the elevation of the potassium level is a nursing priority. The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? A. Present knowledge related to the skill of injection. B. Intelligence and developmental level of the client. C. Willingness of the client to learn the injection sites. D. Financial resources available for the equipment.
action should be implemented? A. Report the findings to the surgeon. B. Irrigate the indwelling urinary catheter. C. Apply manual pressure to the bladder. D. Increase the IV flow rate for 15 minutes. A After surgery, an adult who weighs 132 pounds (60 kg) should produce about 60 mL of urine hourly (1 mL/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon. The nurse formulates the nursing problem of urinary retention related to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement? A. Teach the client techniques of intermittent self-catheterization. B. Decrease fluid intake to prevent over distention of the bladder. C. Use incontinence briefs to maintain hygiene with urinary dribbling. D. Explain that anticholinergic drugs will decrease muscle spasticity. A Bladder control is a common problem for clients diagnosed with multiple sclerosis. A client with urinary retention should receive instructions about self-catheterization to prevent bladder distention. A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A. Dyspnea. B. Nocturia. C. Confusion. D. Stomatitis. B As the glomerular filtration rate decreases in early renal insufficiency, metabolic
waste products, including urea, creatinine, and other substances, such as phenols, hormones, and electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine and contributes to nocturia. When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? A. Place a small book or magazine on the abdomen and make it rise while inhaling deeply. B. Purse the lips while inhaling as deeply as possible and then exhale through the nose. C. Wrap a towel around the abdomen and push against the towel while forcefully exhaling. D. Place one hand on the chest, one hand the abdomen and make both hands move outward. A Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on inhalation and contract it with exhalation, so placing a book or magazine, helps the client visualize the rise and fall of the abdomen. What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode? A. Vasodilators and hormones. B. Analgesics and sedatives. C. Anticoagulants and expectorants. D. Bronchodilators and steroids. D Besides supplemental oxygen, a client with acute respiratory distress syndrome (ARDS) needs medications to widen air passages, increase air space, and reduce alveolar membrane inflammation, such as bronchodilators and steroids.
A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." B. "Alopecia is a common side effect you will experience during long-term steroid therapy." C. "Your hair will grow back completely after your course of chemotherapy is completed." D. "The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss." A The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone marrow depression) are due to chemotherapy's effect on the rapidly reproducing cells, both normal and malignant. The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which clinical cues should the nurse describe when teaching the client about hypoglycemia? A. Sweating, trembling, tachycardia. B. Polyuria, polydipsia, polyphagia. C. Nausea, vomiting, anorexia. D. Fruity breath, tachypnea, chest pain. A Sweating, dizziness, and trembling are signs of hypoglycemic reactions related to the release of epinephrine as a compensatory response to the low blood sugar. The healthcare provider prescribes aluminum and magnesium hydroxide, 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. Which intervention should the nurse implement? A. Administer 30 minutes before eating. B. Evaluate the effectiveness 1 hour after administration.
C. Instruct the client to swallow the tablet whole. D. Question the healthcare provider's prescription. D Magnesium agents are not usually used for clients with CKD due to the risk of hypermagnesemia, so this prescription should be questioned by the nurse. A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? A. Stay out of direct sunlight. B. Restrict intake of high protein foods. C. Schedule extra rest periods. D. Go to the emergency room immediately. C Exacerbations of the symptoms of MS occur most commonly as the result of fatigue and stress. The client should be encouraged to schedule extra rest periods to help reduce the symptoms. The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? A. Cyanosis of the fingertips. B. Bradycardia and bradypnea. C. Presence of S3 and S4 heart sounds. D. 3+ pitting edema of the lower extremities. A Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands which may lead to gangrene. An elderly client is admitted with a diagnosis of bacterial pneumonia. When observing the client for the first signs of decreasing oxygenation, the nurse should assess for which clinical cues? A. Abdominal distention.
A
According to the National Stroke Association (2013), history of diabetes mellitus poses the greatest risk for developing a CVA, 2-4Xs more than those who do not have diabetes mellitus. The reason for this occurrence is related to the excess glucose circulating throughout the body not being utilized by the cells, leading to increased fatty deposits or clots inside the blood vessels in the brain or neck, eventually causing a stroke. A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? A. Avoid high carbohydrate foods. B. Decrease intake of fat soluble vitamins. C. Decrease caloric intake. D. Restrict salt and fluid intake. D Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites. A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor. Which information relates most directly to the prognosis for gram-negative pneumonias? A. The gram-negative infections occur in the lower lobe alveoli which are more sensitive to infection. B. Gram-negative organisms are more resistant to antibiotic therapy. C. Usually occur in healthy young adults who have recently been debilitated by an upper respiratory infection. D. Gram-negative pneumonias usually affect infants and small children. B Gram-negative organisms are very resistant to drug therapy which makes recovery difficult. Antibiotic resistance has become a world-wide concern and the World Health Organization is keeping a very close surveillance on these occurrences.
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? A. Lower left quadrant pain and a low-grade fever. B. Severe pain at McBurney's point and nausea. C. Abdominal pain and intermittent tenesmus. D. Exacerbations of severe diarrhea. A Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most common area for diverticula, and the inflammation of diverticula causes a low- grade fever. The registered nurse (RN) assesses arterial blood gas results of a client that has emphysema. Which finding is consistent with respiratory acidosis? A. pH 7.32, pCO 2 46 mmHg, HCO 3 24 MEq/L. B. pH 7.45 , pCO 2 37 mmHg, HCO 3 24 mEq/L. C. pH 7.34, pCO 2 36 mmHg, HCO 3 21 mEq/L. D. pH 7.46, pCO 2 35 mmHg, HCO 3 28 mEq/L. A Normal ABG ranges are pH 7.35 to 7.45; pCO2 35 to 45 mmHg; HCO3 21 to 28 mEq/L, and pO2 80 to 100 mmHg. An ABG of pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L represents a client with respiratory acidosis which is characterized by: low pH, pCO higher than normal, and HCO3 within normal limits. Which nail color alteration should the nurse expect to observe in a client with chronic kidney disease? A. Horizontal white banding. B. Diffuse blue discoloration. C. Diffuse brown discoloration. D. Thin, dark red vertical lines. A Fingernails and toenails can be affected by chronic kidney disease. This condition may cause horizontal white lines or bands (leukonychia) to appear on the nails.
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. 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. A client with type 2 diabetes takes metformin daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates 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 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. 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 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. 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. Corticosteroid with a side effect of hyperglycemia B Clients with 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. 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
