HESI MILESTONE EXAM 1 PRACTICE BANK | 200
Q&AS WITH VERIFIED ANSWERS &
EXPLANATIONS (PROVEN PASS)
Question 1
A nurse is preparing to perform a physical assessment on an adult client's
abdomen. Which sequence of physical assessment techniques should the nurse
follow?
A) Inspection, Palpation, Percussion, Auscultation
, B) Inspection, Auscultation, Percussion, Palpation
C) Auscultation, Inspection, Percussion, Palpation
D) Palpation, Percussion, Auscultation, Inspection
VERIFIED ANSWER: B
EXPLANATION: Auscultation is performed second during an abdominal
assessment because palpation and percussion can stimulate bowel motility,
artificially altering the frequency and character of bowel sounds. Inspection
must always be performed first to visually check for distension, scars, or
pulsations before touching the patient.
Question 2
A client diagnosed with hypertension is prescribed lisinopril. Which life-
threatening adverse effect must the nurse teach the client to monitor for and
report immediately?
A) A persistent, dry, nonproductive cough
B) Severe swelling of the face, lips, tongue, or pharynx
C) Transient dizziness when standing up quickly
D) Mild, generalized muscle weakness
VERIFIED ANSWER: B
EXPLANATION: Swelling of the face, tongue, or airway tissues indicates
angioedema, which is a rare but life-threatening adverse effect of
Angiotensin-Converting Enzyme (ACE) inhibitors. This condition requires
immediate emergency medical intervention to secure the airway. A dry cough
is a common, non-emergent side effect.
, Question 3
A nurse is evaluating an adult client for orthostatic hypotension. Which change
in vital signs upon standing constitutes a positive assessment finding?
A) A decrease in systolic blood pressure of 10 mmHg
B) An increase in diastolic blood pressure of 15 mmHg
C) A decrease in systolic blood pressure of 25 mmHg
D) A decrease in heart rate of 15 beats per minute
VERIFIED ANSWER: C
EXPLANATION: Orthostatic hypotension is clinically defined as a drop in
systolic blood pressure of 20 mmHg or more, or a drop in diastolic blood
pressure of 10 mmHg or more within three minutes of standing up from a
supine or sitting position.
Question 4
A nurse is assessing a client who complains of severe, sharp abdominal pain of
unknown origin. Which action should the nurse completely avoid?
A) Auscultating the abdomen for presence of bowel sounds
B) Administering a prescribed PRN stimulant laxative
C) Measuring the client's current tympanic temperature
D) Assessing the pain using a standard numeric scale
VERIFIED ANSWER: B
EXPLANATION: Stimulant laxatives are strictly contraindicated in
individuals experiencing undiagnosed abdominal pain. If the underlying
cause is an acute bowel obstruction or appendicitis, increasing peristalsis can
cause structural perforation or rupture, leading to life-threatening peritonitis.
Q&AS WITH VERIFIED ANSWERS &
EXPLANATIONS (PROVEN PASS)
Question 1
A nurse is preparing to perform a physical assessment on an adult client's
abdomen. Which sequence of physical assessment techniques should the nurse
follow?
A) Inspection, Palpation, Percussion, Auscultation
, B) Inspection, Auscultation, Percussion, Palpation
C) Auscultation, Inspection, Percussion, Palpation
D) Palpation, Percussion, Auscultation, Inspection
VERIFIED ANSWER: B
EXPLANATION: Auscultation is performed second during an abdominal
assessment because palpation and percussion can stimulate bowel motility,
artificially altering the frequency and character of bowel sounds. Inspection
must always be performed first to visually check for distension, scars, or
pulsations before touching the patient.
Question 2
A client diagnosed with hypertension is prescribed lisinopril. Which life-
threatening adverse effect must the nurse teach the client to monitor for and
report immediately?
A) A persistent, dry, nonproductive cough
B) Severe swelling of the face, lips, tongue, or pharynx
C) Transient dizziness when standing up quickly
D) Mild, generalized muscle weakness
VERIFIED ANSWER: B
EXPLANATION: Swelling of the face, tongue, or airway tissues indicates
angioedema, which is a rare but life-threatening adverse effect of
Angiotensin-Converting Enzyme (ACE) inhibitors. This condition requires
immediate emergency medical intervention to secure the airway. A dry cough
is a common, non-emergent side effect.
, Question 3
A nurse is evaluating an adult client for orthostatic hypotension. Which change
in vital signs upon standing constitutes a positive assessment finding?
A) A decrease in systolic blood pressure of 10 mmHg
B) An increase in diastolic blood pressure of 15 mmHg
C) A decrease in systolic blood pressure of 25 mmHg
D) A decrease in heart rate of 15 beats per minute
VERIFIED ANSWER: C
EXPLANATION: Orthostatic hypotension is clinically defined as a drop in
systolic blood pressure of 20 mmHg or more, or a drop in diastolic blood
pressure of 10 mmHg or more within three minutes of standing up from a
supine or sitting position.
Question 4
A nurse is assessing a client who complains of severe, sharp abdominal pain of
unknown origin. Which action should the nurse completely avoid?
A) Auscultating the abdomen for presence of bowel sounds
B) Administering a prescribed PRN stimulant laxative
C) Measuring the client's current tympanic temperature
D) Assessing the pain using a standard numeric scale
VERIFIED ANSWER: B
EXPLANATION: Stimulant laxatives are strictly contraindicated in
individuals experiencing undiagnosed abdominal pain. If the underlying
cause is an acute bowel obstruction or appendicitis, increasing peristalsis can
cause structural perforation or rupture, leading to life-threatening peritonitis.
