COMPREHENSIVE NURSING MILESTONE
ASSESSMENT PREPARATION WITH UPDATED
CLINICAL CONCEPTS, CRITICAL THINKING, AND
NCLEX-STYLE REVIEW || REAL HESI MILESTONE 2–
STYLE QUESTIONS WITH VERIFIED DETAILED
ACCURATE ANSWERS LATEST EDITION || ELITE A+
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The answer is after the question.
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.
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
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 produce neurologic deficits within an hour,
and the client's current elevated blood pressure requires
antihypertensive medication.
A client has been hospitalized with a femur fracture and is being treated
with traction. Which action by the nurse is the priority when caring for
this client?
A. Assess neurovascular status.
B. Change the client's position.
C. Inspect the traction equipment.
D. Review pain medication orders.
A
The use of traction for long bone fractures reduces the potential for
damage to the surrounding tissues. Reports of increased pain may
indicate circulatory compromise or tissue damage (compartment
syndrome). Assessing the client's neurovascular status is the nurse's
highest priority.
A middle-aged male client with diabetes continues to eat an abundance
of foods that are high in sugar and fat. According to the Health Belief
Model, which event is most likely to increase the client's willingness to
become compliant with the prescribed diet?
A. He visits his diabetic brother who just had surgery to amputate an
infected foot.
B. He is provided with the most current information about the dangers
of untreated diabetes.
C. He comments on the community service announcements about
preventing complications associated with diabetes.
D. His wife expresses a sincere willingness to prepare meals that are
within his prescribed diet.
A
, The loss of a limb due to diabetes by a family member should be the
strongest event or "cue to action" and is most likely to increase the
client's perceived seriousness of the disease.
A client who has heart failure is admitted with a serum potassium level
of 2.9 mEq/L (2.9 mmol/L). Which action is most important for the
nurse to implement?
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