HESI MILESTONE EXAM 1 PRACTICE GUIDE
UPDATED 2026 TESTED SOLUTIONS
⫸ Enema Patient Preparation Answer: -Explain the purpose
-A reclining position for enema administration
-Specifically left side-lying with the upper thigh pulled toward the
abdomen if possible, or the knee-chest position
-If the patient has a respiratory disorder or is having difficulty breathing,
elevate the head of the bed slightly.
-Avoid Fowler's position because the solution will remain in the rectum
and expulsion will occur rapidly, resulting in minimal cleansing.
-Some patients think the solution should be expelled as soon as possible.
Reinforce the need to retain the solution to achieve the desired results.
⫸ Residual Urine Answer: urine that remains in the bladder after
voiding
⫸ Ambulation Tolerance Answer: The ability to the act, action, or an
instance of moving about or walking
⫸ Wheelchair Transfer CVA Answer: Bedside to Wheelchair
1) Support pt.'s weakest side
2) Turn pt. to a decubitus position
3) Place one arm under neck & other over the legs
,4) "Swoop" pt. into sitting position
5) Straddle pt.'s legs
6) Put hands on pt.'s hips
7) Lift & pivot into the wheelchair
⫸ Wheelchair Safety Answer: -Check wheel locks;
-Check for flat or loose tires; Check wheel spokes;
-Be sure casters point forward for balance and stability;
- Be sure person's feet are on footplates before pushing or repositioning
(feet cannot touch or drag on floor);
-Push chair forward when transporting person, going backward ONLY
through a doorway;
-Lock both wheels before you transfer person to or from the wheelchair;
- Follow care plan for keeping wheels locked when not mving
wheelchair (locking would keep person from moving or getting out of
chair is so desired);
-DO NOT let person stand on footplates;
-DO NOT let footplates fall back onto person's legs;
-Make sure person has needed safety belt, pouch, tray, lapboard or
cushions;
-Remove armrests (if able) when transferring person to bed, toilet,
commode, tub, or car;
-Swing front rigging out of way to transfer to & from wheelchair (some
detach);
- Clean wheelchair according to agency policy;
,-Ask nurse or PT to show you how to propel wheelchair up steps, ramps,
and over curbs; ---Follow measure to prevent equipment accidents
⫸ Droplet precautions Answer: -Use a private room, if available. Door
may remain open.
-Wear PPE upon entry into the room for all interactions that may involve
contact with the patient and potentially contaminated areas in the
patient's environment.
-Transport patient out of room only when necessary and place a surgical
mask on the patient if possible.
-Keep visitors three ft from the infected person.
⫸ Droplet Precautions Answer: -Flu
-Meningitis
-Mumps
-Pneumonia
⫸ Restraints Answer: -are devices that limit the patient's movement and
are used to prevent the client from injury
-RN is to protect and promote the patient's rights while in them
-Need MD order and frequent monitoring by RN
-Every 15 minutes (q15m) for the first hour, then every 30 minutes
(q30m) to ensure proper circulation.
-Removed every 2 hours (q2h) for range of motion, toileting, and offer
of fluids.
, -Written order by provider based on exam before applied, no PRN
orders, minimum q4 hour assessment for adults, MD assessment face-to-
face q 24 hours, Reportable if death during use w/I 24 hours
⫸ Side Rails Restraints Answer: -not considered a restraint if the patient
requests that it be raised to be able to get in and out of bed.
-They have to be able to demonstrate that they can raise and lower the
side rail by themselves
-Usually in the hospital setting 4 side rails is considered a restraint
-can pose serious risks for a confused or agitated patient. Entanglement
or injury, asphyxiation and can be fatal.
⫸ Saline Flush Answer: prefilled syringe with 10 mL 0.9% sodium
chloride (NS)
⫸ Braden Scale Answer: -Sensory perception, moisture, activity,
mobility, nutrition, friction and shear
-The higher the number the greater the risk
⫸ Fats Answer: 9 cals per gram
⫸ Alchohol Answer: 7 cals per gram
⫸ Protein Answer: 4 cals per gram
UPDATED 2026 TESTED SOLUTIONS
⫸ Enema Patient Preparation Answer: -Explain the purpose
-A reclining position for enema administration
-Specifically left side-lying with the upper thigh pulled toward the
abdomen if possible, or the knee-chest position
-If the patient has a respiratory disorder or is having difficulty breathing,
elevate the head of the bed slightly.
-Avoid Fowler's position because the solution will remain in the rectum
and expulsion will occur rapidly, resulting in minimal cleansing.
-Some patients think the solution should be expelled as soon as possible.
Reinforce the need to retain the solution to achieve the desired results.
⫸ Residual Urine Answer: urine that remains in the bladder after
voiding
⫸ Ambulation Tolerance Answer: The ability to the act, action, or an
instance of moving about or walking
⫸ Wheelchair Transfer CVA Answer: Bedside to Wheelchair
1) Support pt.'s weakest side
2) Turn pt. to a decubitus position
3) Place one arm under neck & other over the legs
,4) "Swoop" pt. into sitting position
5) Straddle pt.'s legs
6) Put hands on pt.'s hips
7) Lift & pivot into the wheelchair
⫸ Wheelchair Safety Answer: -Check wheel locks;
-Check for flat or loose tires; Check wheel spokes;
-Be sure casters point forward for balance and stability;
- Be sure person's feet are on footplates before pushing or repositioning
(feet cannot touch or drag on floor);
-Push chair forward when transporting person, going backward ONLY
through a doorway;
-Lock both wheels before you transfer person to or from the wheelchair;
- Follow care plan for keeping wheels locked when not mving
wheelchair (locking would keep person from moving or getting out of
chair is so desired);
-DO NOT let person stand on footplates;
-DO NOT let footplates fall back onto person's legs;
-Make sure person has needed safety belt, pouch, tray, lapboard or
cushions;
-Remove armrests (if able) when transferring person to bed, toilet,
commode, tub, or car;
-Swing front rigging out of way to transfer to & from wheelchair (some
detach);
- Clean wheelchair according to agency policy;
,-Ask nurse or PT to show you how to propel wheelchair up steps, ramps,
and over curbs; ---Follow measure to prevent equipment accidents
⫸ Droplet precautions Answer: -Use a private room, if available. Door
may remain open.
-Wear PPE upon entry into the room for all interactions that may involve
contact with the patient and potentially contaminated areas in the
patient's environment.
-Transport patient out of room only when necessary and place a surgical
mask on the patient if possible.
-Keep visitors three ft from the infected person.
⫸ Droplet Precautions Answer: -Flu
-Meningitis
-Mumps
-Pneumonia
⫸ Restraints Answer: -are devices that limit the patient's movement and
are used to prevent the client from injury
-RN is to protect and promote the patient's rights while in them
-Need MD order and frequent monitoring by RN
-Every 15 minutes (q15m) for the first hour, then every 30 minutes
(q30m) to ensure proper circulation.
-Removed every 2 hours (q2h) for range of motion, toileting, and offer
of fluids.
, -Written order by provider based on exam before applied, no PRN
orders, minimum q4 hour assessment for adults, MD assessment face-to-
face q 24 hours, Reportable if death during use w/I 24 hours
⫸ Side Rails Restraints Answer: -not considered a restraint if the patient
requests that it be raised to be able to get in and out of bed.
-They have to be able to demonstrate that they can raise and lower the
side rail by themselves
-Usually in the hospital setting 4 side rails is considered a restraint
-can pose serious risks for a confused or agitated patient. Entanglement
or injury, asphyxiation and can be fatal.
⫸ Saline Flush Answer: prefilled syringe with 10 mL 0.9% sodium
chloride (NS)
⫸ Braden Scale Answer: -Sensory perception, moisture, activity,
mobility, nutrition, friction and shear
-The higher the number the greater the risk
⫸ Fats Answer: 9 cals per gram
⫸ Alchohol Answer: 7 cals per gram
⫸ Protein Answer: 4 cals per gram
