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Milestone Exam 2 Version B (Blueprint) Final
Medical-Surgical Nursing II (NSG 223)
Herzing University
Comments
- has anyone use this blueprint for the retake? was it helpful?
- Thank you for the upload
- Does anyone know if version B coincides with the milestone 2 retake?
- put a sock in it Abbie
- so i saw two different milestone. one that start with schizo and other starts with continues bladder. which bp did you guys got tested?
- Hey girl!! I am located in florida herzing, I noticed there are 2 diff milelstone versions of the blueprint. I am so curious as to how they choose which one they use to test us. Our campus stopped giving the blueprints out.
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Node number/ description Milestone Exam 2- Version B
Display name
NSG123.07.01 Continuous bladder irrigation
A three-way (lumen) irrigation is used to decrease bleeding and to keep the bladder free from clots— one lumen is for inflating the balloon (30 mL); one lumen is for instillation (inflow); one lumen is for outflow.
Continuous irrigation may be used with TURP.
The amount of fluid recovered in the drainage bag must equal the amount of fluid instilled -- secondary hemorrhage may occur from overdistension
If the patient complains of pain, the tubing is examined. The drainage system is irrigated with irrigating fluid (usually 50 mL), if indicated and prescribed, to clear any obstruction.
Continuous bladder irrigation or bladder wash out is performed to help prevent urinary tract obstruction by flushing out small blood clots that may form after prostate or bladder surgery such as TURP or TURBT.
Hesi hint: Instillation of hypertonic or hypotonic solution into a body cavity will cause a shift in cellular fluid. Use only sterile saline for bladder irrigation after TURP because the irrigation must be isotonic to prevent fluid and electrolyte imbalance. Clients with Foley catheters require perineal care and actual catheter care twice per day.
NSG123.07.04 Urethritis
Tests for sexually transmitted infections may be performed because acute urethritis caused by sexually transmitted organisms (i., Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex) or acute vaginitis infections (caused by Trichomonas or Candida species) may be responsible for symptoms similar to those of UTIs.
NSG123.07.05 Renal calculi risk
Certain factors favor the formation of stones, including infection, urinary stasis, and periods of immobility, all of which slow kidney drainage and alter calcium metabolism.
Several conditions, as well as certain metabolic risk factors, predispose patients to stone formation. These include anatomic derangements such as polycystic kidney disease, horseshoe kidneys, chronic strictures, and medullary sponge disease. Urinary stone formation can occur in patients with inflammatory bowel disease and in those with an ileostomy or bowel resection because these patients absorb more oxalate. Medications known to cause stones in some patients include antacids,
acetazolamide, vitamin D, laxatives, and high doses of aspirin
HESI: Clients with the following conditions are at risk for developing calculi:
Strictures
Prostatic hypertrophy
Neoplasms
Congenital malformations
History of calculi
Family history of calculi
NSG123.07.05 Calculi pain
The immediate objective of treatment of renal or ureteral colic is to relieve the pain until its cause can be eliminated. Opioid analgesic agents are given to prevent shock and syncope that may result from the excruciating pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating renal calculus pain because they provide specific pain relief.
NSG123.08.03 Imitrex contraindications
Contraindications include a history of hypersensitivity reactions to the drug. Other contraindications are existing cerebrovascular or peripheral vascular syndromes
NSG123.09.02 seizures
The nurse determines whether the patient has an aura before an epileptic seizure, which may indicate the origin of the seizure (e., seeing a flashing light may indicate that the seizure originated in the occipital lobe).
Cardiac effects may include sinus tachycardia or arrhythmias, decreased cardiac output, increased pulse pressure, and palpitations
NSG123.10.02 Exophthalmos-POC
Definition: a condition where the eyeball protrudes from the eye socket, making it appear to bulge. It can affect one or both eyes.
Patients with Graves disease may present with exophthalmos and may exhibit reduced blinking and lid retraction.
NSG123.11.02 Peripheral neuropathy
a result of damage to the nerves located outside of the brain and spinal cord (peripheral nerves), often causes weakness, numbness and pain, usually in the hands and feet. It can also affect other areas and body functions including digestion, urination and circulation.
The heels are particularly susceptible to breakdown because of loss of sensation of pain and pressure associated with sensory neuropathy. The skin is assessed for dryness, cracks, breakdown, and redness, especially at pressure points and on the lower extremities. The patient is asked about symptoms of neuropathy, such as tingling and pain or numbness of the feet. Deep tendon reflexes are assessed.
NSG123.11.02 Diabetes foot care
Feet should be cleaned, dried, lubricated with lotion (but not between the toes), and inspected frequently. If the patient is in the supine position, pressure on the heels can be alleviated by elevating the lower legs on a pillow, with the heels positioned over the edge of the pillow. When the patient is seated in a chair, the feet should be positioned so that pressure is not placed on the heels. If the patient has an ulceration on one foot, the nurse provides preventive care to the unaffected foot as well as special care of the affected foot.
NSG123.02.01 Preop lab
pH 7 – 7.
pCO2 35 – 45
HCO3 22 – 26
Renal Lab Values
· BUN 10 – 20
· Creatinine 0 – 1.
· Cholesterol Lab Value <
CBC Lab Values
· HCT F:36 – 46 M:42 – 52
· HgB F:12 – 16 M:14 – 18
· Platelets 200,000 – 450,000, <40,000 be very concerned!
· WBC 4-
Calcium 9-
Sodium 135-
Chloride 95-
Phosphorus 2 – 4.
Magnesium 1 - 2.
Glucose 70 - 100
Potassium 3 - 5.
NSG123.02.01 Informed consent language
Assessing the patient’s readiness to learn and determining the best approach to maximize comprehension provide the basis for preoperative patient education. This is of particular importance in patients who are developmentally delayed and those who are cognitively impaired, where the approach to patient education and consent will include the legal guardian.
NSG123.02.02 Malignant hyperthermia (MH)
Malignant hyperthermia is a rare inherited muscle disorder that is chemically induced by anesthetic agents. This disorder can be triggered by myopathies, emotional stress, heatstroke, neuroleptic malignant syndrome, strenuous exercise exertion, and trauma.
MH occurs because of a genetic autosomal dominant disorder involving a mutation on the ryanodine receptor that causes an atypical increase in release of calcium in muscle cells
RF: bulky muscles, a history of muscle cramps or muscle weakness and unexplained temperature elevation, and an unexplained death of a family member during surgery that was accompanied by a febrile response
NSG123.02.03 Post op pain
Culture remains the gold standard for laboratory confirmation of TB disease,
and growing bacteria are required to perform drug-susceptibility testing and
genotyping
Active TB detection:
-chest xray
sputum smear microscopy
NSG123.02.03 Perforated bowel first sign
Severe abdominal pain, an elevated white blood cell count (due to infection), fever, nausea, noticeable blood loss, and hemodynamic instability (septic shock)
NSG123.04.06 NGT with decreased peristalsis
NSG123.05.01 Cholelithiasis N&V
After laparoscopic cholecystectomy, the nurse assesses the patient for anorexia, vomiting, pain, abdominal distension, and temperature elevation. These may indicate infection or disruption of the GI tract and should be reported to the surgeon promptly.
The nurse should note and report right upper quadrant abdominal pain, nausea and vomiting, bile drainage around any drainage tube, clay-colored stools, and a change in vital signs.
Hesi hint: Decompression of the stomach via NG tube
NSG123.05.
NSG123.05.
Diverticulitis WBC
(NSG123.05.04)The WBC is frequently elevated; however, a normal WBC count does not rule out diverticulitis. Up to 40% of patients with diverticulitis have a normal WBC count.
(NSG123.05.04)The white blood cell count is elevated (> 11,000/mm3) and may demonstrate a relative increase in the bands (i., immature neutrophils), consistent with bacterial infection.
NSG123.06.03 Anemia labs
Initial evaluation includes hemoglobin, hematocrit, reticulocyte count, and RBC indices, including mean corpuscular volume (MCV), and red cell distribution width (RDW). Other studies may include iron studies (serum iron level, total iron-binding capacity [TIBC], percent saturation, and ferritin), serum vitamin B12, folate levels, haptoglobin, and erythropoietin levels (Elder, Winland-Brown, & Porter, 2019; Nair, 2018). The remaining complete blood count (CBC) values are also useful in determining if the anemia is an isolated condition or associated with another hematologic condition such as leukemia (i., malignancy of the WBCs) or myelodysplastic syndrome (MDS). Bone marrow aspiration may be performed to asses for cellular abnormalities. Additional studies such as colonoscopy or upper endoscopy may be performed to determine if underlying conditions causing the anemia are present
NSG123.12.02 Plaquenil teach
is used to prevent or treat malaria caused by mosquito bites.. It can also treat lupus and arthritis
Swallow the tablet whole. Do not crush, break, or chew it. Take this medicine with meals or milk to lessen stomach upset, unless otherwise directed by your doctor. Keep using this medicine for the full treatment time, even if you feel better after the first few doses.
It can induce retinal toxicity
NSG123.06.03 Blood administration - overload
A febrile nonhemolytic reaction is caused by antibodies to donor leukocytes that remain in the unit of blood or blood component; it is the most common type of transfusion reaction (Stubbs, 2018). It occurs more frequently in patients who have had previous transfusions (exposure to multiple antigens from previous blood products) and in Rh-negative women who have borne Rh-positive children (exposure to an Rh-positive fetus raises antibody levels in the untreated mother).
The signs and symptoms of a febrile nonhemolytic transfusion reaction are chills (minimal to severe) followed by fever (more than 1°C elevation
The following sections describe the most common or potentially severe transfusion-related complications:
● Febrile nonhemolytic reaction ● Acute Hemolytic Reaction ● Allergic Reaction ● Transfusion-Associated Circulatory Overload (TACO) ● Bacterial Contamination ● Transfusion-Related Acute Lung Injury (TRALI) ● Delayed hemolytic reactions
If too much blood is infused too quickly, hypervolemia can occur
NSG123.13.03 ABG head injury
Respiratory acidosis causes hypercapnia (excess CO2) which causes vasodilation of cerebral arteries, increasing intracranial pressure
NSG222.12.02 Celiac disease - diet
The child must adhere to a strict gluten-free diet for his or her entire life.
NSG222.06.04 Prolapsed cord delivery
The examiner places a sterile gloved hand into the vagina and holds the presenting part off the umbilical cord until delivery. Changing the woman’s position to a modified Sims, Trendelenburg, or knee–chest position also helps relieve cord pressure.
If the mother’s cervix is not fully dilated, prepare the woman for an emergency cesarean birth to save the fetus’s life if that is the intervention planned for by her health care provider.
NSG222.02.03 Gestational diabetes lab
NSG222.06.03 GBS positive
Group B streptococcus (GBS) is a naturally occurring bacterium found in approximately 50% of healthy adults. Women who test positive for GBS bacteria are considered carriers. Carrier status is transient and does not indicate illness. Approximately 50% of pregnant women carry GBS in the rectum or vagina, thus introducing the risk of colonization of the fetus during birth.
Although GBS is rarely serious in adults, it can be life threatening to newborns. GBS is the most common cause of sepsis and meningitis in newborns and is a frequent cause of newborn pneumonia
NSG222.06.04 Placenta abruption actions
Definition: Refers to premature separation of a normally implanted placenta from the maternal myometrium.
Management of placental abruption depends on the gestational age, the extent of the hemorrhage, and maternal–fetal oxygenation perfusion or reserve status.
Typically, once the diagnosis is established, the focus is on maintaining the cardiovascular status of the mother and developing a plan to deliver the fetus quickly. A cesarean birth may take place quickly if the fetus is still alive with only a partial abruption. A vaginal birth may take place if there is fetal demise secondary to a complete abruption.
NSG222.03.
Variable deceleration actions
Reposition to left or right lateral, knee-chest, or hands and knees.
(HESI)Nursing actions for variable decelerations
Change maternal position.
Stimulate fetus if indicated.
Discontinue oxytocin (Pitocin) if infusing.
Administer oxygen (O2) at 10 L by tight facemask.
Perform a vaginal examination to check for cord prolapse.
Report findings to physician and document.
NSG222.06.05 Hemorrhage postpartum care
Massage the uterus if uterine atony is noted. Massage the boggy uterus to stimulate contractions and expression of any accumulated blood clots while supporting the lower uterine segment.
Administer a uterotonic drug if repeated fundal massage and expression of clots fail. Oxytocin (Pitocin); misoprostol (Cytotec); dinoprostone (Prostin E2); methylergonovine maleate (Methergine); and a derivative of prostaglandin (PGF2α), carboprost (Hemabate), are drugs used to manage postpartum hemorrhage.
NSG222.03.03 Post epidural headache
NSG222.13.01 Sickle cell dehydration
Sickling may be triggered by any stress or traumatic event, such as infection, fever, dehydration, physical exertion, excessive cold exposure, or hypoxia.
Dehydration can trigger sickling Other signs are elevated HR, pain, hyperthermia
Promote hydration, give IV fluids
NSG222.13.03 Hypoglycemia - milk
A hypoglycemic patient needs to be treated with sugar (i., milk, juice), followed by some form of protein intake
(google) Milk contains vitamin D and carbohydrates, so Norton suggests drinking one cup of fat-free milk when your glucose levels start to drop. Milk is particularly ideal, as it contains both a simple sugar, lactose, and proteins.
NSG222.11.01 Meningitis assess
NSG222.12.02 Biliary atresia
definition: is an absence of some or all of the major biliary ducts, resulting in obstruction of bile flow. The ensuing obstruction to bile flow causes cholestasis resulting in jaundice and eventual progressive fibrosis with end-stage cirrhosis of the liver.
Assess: persistent jaundice, enlarged liver, chalky white stools
Management: vitamins ADEK, antibiotics, diuretics for ascites
NSG222.14.02 Seizure PEDI
There are three categories of seizures—focal (previously known as partial), generalized and unknown seizures (i., epileptic spasms). In focal seizures only one hemisphere of the brain is involved, while general seizures involve the entire brain. Focal seizures are seen in 60% of those with epilepsy and are described based on impairment of consciousness, localization, and progression of the seizure (National Institute of Neurological Disorders and Stroke, 2018). Generalized seizures include absence seizures, tonic, clonic, tonic–clonic seizures, myoclonic seizures, and atonic seizures. Unknown is used for epileptic spasms, tonic–clonic, and behavior arrest where it is unclear whether the mode of onset is generalized or focal (Fisher et al., 2017). Focal to bilateral tonic–clonic seizures replaces the term secondarily generalized seizures to describe seizures that start on one side of the brain and spread to both sides (Fisher et al., 2017).
● Time of onset and length of seizure activity ● Alterations in behavior such as a cry or changes in facial expression, motor abilities, or sensory alterations before the seizure that may indicate an aura ● Precipitating factors such as fever, anxiety, just waking, or eating ● Description of movements and any progression ● Description of respiratory effort and any apnea noted ● Changes in color (pallor or cyanosis) noted ● Position of mouth, any injury to mouth or tongue, inability to swallow, or excessive salivation ● Loss of bladder or bowel control ● State of consciousness during seizure and postictal (after seizure) state—during the seizure, the nurse may ask the child to remember a word; after the seizure, assess if child is able to recall it, to help accurately establish current mental state ● Assess orientation to person, place, and time; motor abilities; speech; behavior; alterations in sensation postictally ● Duration of postictal state
SEIZURE PRECAUTIONS
● Padding of side rails and other hard objects ● Side rails raised on bed at all times when child is in bed ● Oxygen and suction at bedside ● Supervision, especially during bathing, ambulation, or other potentially hazardous activities ● Use of a protective helmet during activity may be appropriate. ● Child should wear a medical alert bracelet.
NSG222.13.01 Wilm’s tumor preop
Wilms tumor is the most common renal tumor, the second most common abdominal solid tumor in children, and most commonly occurs between the ages of 2 and 5 years.
Postoperative care of the child with Wilms tumor resection is similar to that of children undergoing other abdominal surgery. Assessment of remaining kidney function is critical.
realize it take note Avoid palpating the abdomen after the initial assessment preoperatively. Wilms tumor is highly vascular and soft, so excessive handling of the tumor may result in tumor seeding and metastasis.
(hesi) Provide postoperative care.
Monitor for increased blood pressure.
Monitor kidney function: I&O, urine specific gravity.
Provide care for abdominal surgery client.
a. Maintain nasogastric tube.
b. Check for bowel sounds.
- Support child and family during chemotherapy or radiation therapy
NSG222.08.06 VSD fluid overload
The high pulmonary blood flow can also lead to volume overload in the left side of the heart, resulting in enlargement (dilatation) of the left atrium and left ventricle. Over time, this enlargement can lead to congestive heart failure or the occurrence of arrhythmias (irregularities of the heart's rhythm).
Can VSD cause fluid in lungs?
Babies with large VSDs will have excess fluid in their lungs, causing rapid and labored breathing and a fast heartbeat. They may have difficulty feeding because of tiring, and thus gain weight slowly. They can also be prone to respiratory infections.
NSG222.12.01 HF pediatric
Heart failure occurs most often in children with CHD and is the most common reason for admission to the hospital for children with CHD.
Assess: VS, fatigue, weight gain, heart/resp function, apical pulse for 1 min
● Prior placenta previa ● Infertility treatment ● Multiple gestations ● Previous induced surgical abortion ● Smoking ● Previous myomectomy to remove fibroids ● Short interval between pregnancies ● Hypertension or diabetes (Blackburn, 2018)
Assess the client for uterine contractions, which may or may not occur with the bleeding. Palpate the uterus; typically, it is soft and nontender upon examination. Auscultate the fetal heart rate; it is commonly within normal parameters. Fetal distress is usually absent but may occur when cord problems arise, such as umbilical cord prolapse or cord compression, or when the client has experienced blood loss to the extent that maternal shock or placental abruption has occurred
NSG221.14.
NSG221.14.
Self-harm - adolescent
Adolescent suicide, substance use, self-harm ideation and actions, and moderate-to-severe symptoms of depression are correlated with bullying.
Highest risk at ~2 weeks after starting antidepressant medication
A form of PTSD
NSG221.13.02 Alzheimer hallucinations
Hallucinations are a frequent problem. Visual hallucinations are most common and generally unpleasant. Clients are likely to believe the hallucination is reality.
Avoid direct confrontation. Instead, address environmental triggers
NSG221.09.02 Therapeutic milieu
Function within the limits of the therapeutic milieu; for example, follow no-smoking rules, participate in group activities within 2 to 3 days.
NSG221.05.01 Aggression source
The nurse should assess the client’s behavior to determine which phase of the aggression cycle he or she is in so that appropriate interventions can be implemented. The nurse should be aware of factors that influence aggression in the psychiatric environment or unit milieu.
NSG221.06.01 Addiction and relapse
The client will express feelings openly and directly.
The client will practice nonchemical alternatives to deal with stress or difficult situations
Codependence is a maladaptive coping pattern on the part of family members or others resulting from a prolonged relationship with the person who uses substances. Characteristics of codependence are poor relationship skills, excessive anxiety and worry, compulsive behaviors, and resistance to change.
NSG221.06.01 .Heroin hystory
Milestone Exam 2 Version B (Blueprint) Final
Course: Medical-Surgical Nursing II (NSG 223)
University: Herzing University
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