HESI Milestone 2 Exam V5 2025 with 150
Questions and Verified Answers 100% Correct
QUESTION
The nurse is developing the plan of care for a client with pneumonia and includes the nursing
diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which
intervention is most important for the nurse to include in the client's plan of care?
Answer:
Increase fluid intake to 3,000 ml/daily
QUESTION
Pneumonia Treatment/Prevention
Answer:
oxygen therapy, hydration, bed rest, positioning to facilitate breathing, deep breathing, humidified
air, chest physiotherapy, suctioning prn,
QUESTION
A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen with a Venturi
mask at a rate of 3 L/min. Prior to initiating oxygen therapy, the patient appeared anxious with
gray skin, a respiratory rate of 24 breaths/min, and an oxygen saturation of 87%. After 15
minutes of oxygen therapy, the nurse observes the patient resting with closed eyes, pink
coloration, a respiratory rate of 12 breaths/min, and an oxygen saturation of 95%. Which action
by the nurse is correct?
Answer:
Decrease the oxygen to 2 L/min to improve respiratory rate
QUESTION
,What are the nutritional needs of this client throughout recovery?
,Answer:
Acute phase: NPO, IV fluids
• Recovery phase: no fiber or foods that irritate the bowel
• Maintenance phase: high-fiber diet with bulk-forming laxatives
QUESTION
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing
intervention has the highest priority
Answer:
Place the client on NPO status.
QUESTION
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The
client refuses breakfast and reports nausea. Which of the following actions should the nurse take
first?
Answer:
Check the client's vital signs.
QUESTION
The healthcare provider prescribes digitalis (Digoxin) for a client diagnosed with congestive heart
failure. Which intervention should the nurse implement prior to administering the digoxin?
Answer:
Assess the serum potassium level
QUESTION
, A 77-year-old female client is admitted to the hospital. She is confused and has had no appetite
for several days. She has been nauseated and vomited several times prior to admission. She is
currently complaining of a headache. Her pulse rate is 43 beats/min. The nurse is most concerned
about the client's history related to what medication?
Questions and Verified Answers 100% Correct
QUESTION
The nurse is developing the plan of care for a client with pneumonia and includes the nursing
diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which
intervention is most important for the nurse to include in the client's plan of care?
Answer:
Increase fluid intake to 3,000 ml/daily
QUESTION
Pneumonia Treatment/Prevention
Answer:
oxygen therapy, hydration, bed rest, positioning to facilitate breathing, deep breathing, humidified
air, chest physiotherapy, suctioning prn,
QUESTION
A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen with a Venturi
mask at a rate of 3 L/min. Prior to initiating oxygen therapy, the patient appeared anxious with
gray skin, a respiratory rate of 24 breaths/min, and an oxygen saturation of 87%. After 15
minutes of oxygen therapy, the nurse observes the patient resting with closed eyes, pink
coloration, a respiratory rate of 12 breaths/min, and an oxygen saturation of 95%. Which action
by the nurse is correct?
Answer:
Decrease the oxygen to 2 L/min to improve respiratory rate
QUESTION
,What are the nutritional needs of this client throughout recovery?
,Answer:
Acute phase: NPO, IV fluids
• Recovery phase: no fiber or foods that irritate the bowel
• Maintenance phase: high-fiber diet with bulk-forming laxatives
QUESTION
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing
intervention has the highest priority
Answer:
Place the client on NPO status.
QUESTION
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The
client refuses breakfast and reports nausea. Which of the following actions should the nurse take
first?
Answer:
Check the client's vital signs.
QUESTION
The healthcare provider prescribes digitalis (Digoxin) for a client diagnosed with congestive heart
failure. Which intervention should the nurse implement prior to administering the digoxin?
Answer:
Assess the serum potassium level
QUESTION
, A 77-year-old female client is admitted to the hospital. She is confused and has had no appetite
for several days. She has been nauseated and vomited several times prior to admission. She is
currently complaining of a headache. Her pulse rate is 43 beats/min. The nurse is most concerned
about the client's history related to what medication?
