HESI MILESTONE 2 ACTUAL EXAM 3 LATEST VERSIONS (V1, V2 AND V3) 2023-2024 EACH VERSION CONTAINS 10
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1. Thepostanesthesiacareunit(PACU)nursetransportstheinpatientsurgicalpatienttothemedical-surgicalfloor.Beforeleavingthefloor,themedical-surgicalnurseobtainsacompletesetof vitalsigns.Whatistherationale for this nursing action?
a. Thisisdonetocompletethefirstactioninahead-to-toeassessment.
Thisisdonetocompareandmonitorforvitalsignvariationduring
b.
transport.
Thisisdonetoensurethatthemedical-surgicalnursechecksonthe
c.
postoperativepatient.
Thisisdonetofollowhospitalpolicyandprocedureforcareofthe
d. surgicalpatient.
ANS:B
BeforethePACUnurseleavestheacutecarearea,thestaffnurseassumingcareforthepatienttakesacompletesetofvitalsignstocomparewithPACUfindings.Minorvitalsignvariationsnormallyoccur after
transporting the patient.The PACU nursereviewsthepatient’sinformation with the medical-surgical nurse, including thesurgicalandPACUcourse,physicianorders,and thepatient’scondition.While vitalsignsmay ormaynot be the first actionina head-to-toeassessment,thisisnottherationaleforthissituation.While followingpolicy orascertainingthatthefloornursecheckson thepatient are goodreasonsforsafecare,theyarenotthebest rationale for obtaining vital signs.
2. Thenurseiscaringforapatientwhowillundergoaremovalofalunglobe.Whichlevelofcarewillthepatientrequireimmediatelypostprocedure?
a. Acutecare—medical-surgicalunit
b. Acutecare—intensivecareunit
c. Ambulatorysurgery
d. Ambulatorysurgery—extendedstay
ANS:B
Patients undergoing extensive surgery and requiring anesthesia of long duration recover slowly. If a patient is undergoing majorsurgery such as a procedure on the lung, a stay in the hospital and specifically in theintensive care unit is required tomonitorfor potential risks towell-being. This patient would requiremore care than can be providedon a medical-surgical unit. It is not appropriatefor this type of patient to go home after theprocedureortostayin anextendedstayareaof an ambulatorysurgeryareabecause ofthecomplexityandassociatedrisks.
3. Thenurseiscaringforagroupofpatients.Whichpatientwillthenurseseefirst?
a. Apatientwhohadcataractsurgeryiscoughing.
Apatientwhohadvascularrepairoftherightlegisnotdoingrightleg
b.
exercises.
Apatientafterkneesurgeryiswearingintermittentpneumatic
c.
compressiondevicesandreceivingheparin.
326
Apatientaftersurgeryhasvitalsignstakenevery15minutestwice,
d. every30minutestwice,hourlyfor2hoursthenevery4hours.
ANS:A
Forpatientswhohavehadeye,intracranial,orspinalsurgery,coughingmaybecontraindicatedbecauseofthepotentialincreaseinintraocularorintracranialpressure.Thenursewillneedtoseethis patient first to controlthecough and intraocular pressure. All the rest are normal postoperative patients. Leg exercise should not beperformed on the operative leg with vascular surgery. Apatient afterkneesurgeryshouldreceiveheparinandbewearingintermittentpneumaticcompressiondevices;whilethenursewillcheckonthepatient,itdoesnothavetobefirst.Monitoringvitalsignsafter surgery is required and this is the standard schedule.
4. Thenursedemonstrates postoperativeexercisesfora patient.In which order will thenurse instruct thepatientto performtheexercises? 1.Turning
2. Breathing
3. Coughing
4. Legexercises
a. 4,1,2,3
b. 1,2,3,4
c. 2,3,4,1
d. 3,1,4,2
ANS:A
The sequenceof exercisesisleg exercises,turning,breathing, andcoughing. MULTIPLE RESPONSE
1. Thenurseisparticipatingina“time-out.”Inwhichactivitieswillthenursebeinvolved?(Selectallthatapply.)
a. Verifythecorrectsite.
b. Verifythecorrectpatient.
c. Verifythecorrectprocedure.
d. Perform“time-out”aftersurgery.
e. Performtheactualmarkingoftheoperativesite.
ANS:A,B,C
[Solved] HESI MILESTONE 2 ACTUAL EXAM 3 LATEST VERSIONS (V1, V2 AND V3) 2023-2024 EACH VERSION CONTAINS 10
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- Submitted On 13 Dec, 2023 04:36:44
- Sammy
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