Milestone 2 HESI Questions And
Answers
Arclientrcallsrthernurseratrtherclinicrandrreportsrexperiencingrarsensationrasrthoughrtheraffec
tedrlegrisrfallingrasleepreverrsincertherveinrligationrandrstrippingrprocedurerwasrperformed.r
Thernurserwouldrmakerwhichrresponsertortherclient?
1.r"Applyrwarmrpacksrtortherleg."
2.r"Keeprtherlegrelevatedrasrmuchrasrpossible."
3.r"Yourrprimaryrhealthrcarerproviderrneedsrtorbercontactedrtorreportrthisrproblem."
4.r"Thisrnormallyroccursrafterrsurgeryrandrwillrsubsiderwhenrtheredemargoesrdown."r-
rCORRECTrrANSWER-
"Yourrprimaryrhealthrcarerproviderrneedsrtorbercontactedrtorreportrthisrproblem."
Arsensationrofrpinsrandrneedlesrorrfeelingrasrthoughrthersurgicalrlimbrisrfallingrasleeprmayri
ndicatertemporaryrorrpermanentrnerverdamagerafterrsurgery.rThersaphenousrveinrandrther
saphenousrnerverrunrclosertogether,randrdamagertorthernerverwillrproducerparesthesias.rT
herremainingroptionsrarerinaccuraterresponses.rAnralternativertorsurgeryrisrendovenousrab
lationrofrthersaphenousrvein.rAblationrinvolvesrtherinsertionrofrarcatheterrthatremitsrenergy.r
Thisrcausesrcollapserandrsclerosisrofrthervein.rPotentialrcomplicationsrincluderbruising,rtig
htnessralongrthervein,rrecanalizationr(reopeningrofrthervein),randrparesthesia.rEndovenou
srablationralsormayrberdonerinrcombinationrwithrsaphenofemoralrligationrorrphlebectomy.rT
ransilluminatedrpowderedrphlebectomyrinvolvesrtheruserofrarpowderedrresectorrtordestroyr
thervaricesrandrthenrremovesrtherpiecesrviaraspiration.
Arclientrhadrarcolectomyr2rdaysrearlierrtorremoverarbowelrtumorrandrhadrarnewrcolostomyrc
reated.rTherclientrisrbeginningrtorpassrmalodorousrflatusrfromrtherstoma.rWhatrisrthercorrec
trinterpretationrbyrthernurse?
1.rThisrisrarnormal,rexpectedrevent.
2.rTherclientrisrexperiencingrearlyrsignsrofrischemicrbowel.
3.rTherclientrwouldrnotrhaverthernasogastricrtuberremoved.
4.rThisrindicatesrinadequaterpreoperativerbowelrpreparation.r-rCORRECTrrANSWER-
Thisrisrarnormal,rexpectedrevent.
,Asrperistalsisrreturnsrfollowingrcreationrofrarcolostomy,rtherclientrbeginsrtorpassrmalodorou
srflatus.rThisrindicatesrreturningrbowelrfunctionrandrisranrexpectedrevent.rWithinr72rhoursro
frsurgery,rtherclientrwouldrbeginrpassingrstoolrviarthercolostomy.rOptionsr2,r3,randr4rarerinc
orrectrinterpretations.
Arclientrhasrbeenrprescribedrclozapine.rThernurserreviewsrtherresultrofrwhichrlaboratoryrstu
dyrtordetectrarseriousradversereffectrassociatedrwithrthisrmedication?
1.rPlateletrcount
2.rLiverrfunction
3.rBloodrglucoserlevel
4.rWhiterbloodrcellrcountr-rCORRECTrrANSWER-Plateletrcount
Clozapinerisranrantipsychoticrmedication.rTherclientrtakingrclozapinermayrexperienceragra
nulocytosisrasranradversereffect,rwhichrisrmonitoredrbyrobtainingrweeklyrwhiterbloodrcellrco
unts.rTreatmentrisrwithheldrifrtherlevelrdropsrbelowr3000rmm3r(3r×r109/L).rAgranulocytosisr
couldrberfatalrifrundetectedrandruntreated.rTherotherroptionsrarerincorrect.
Arclientrhasrexperiencedranrepisoderofrpulmonaryredema.rThernurserdeterminesrthatrthercl
ient'srrespiratoryrstatusrisrimprovingrafterrthisrepisoderifrwhichrbreathrsoundsrarernoted?
1.rRonchi
2.rWheezes
3.rCracklesrinrtherbases
4.rCracklesrthroughoutrtherlungrfieldsr-rCORRECTrrANSWER-Cracklesrinrtherbase
Pulmonaryredemarisrcharacterizedrbyrextremerbreathlessness,rdyspnea,rairrhunger,randrt
herproductionrofrfrothy,rpink-
tingedrsputum.rAsrtherclient'srconditionrimproves,rtheramountrofrfluidrinrtheralveolirdecreas
es,rwhichrmayrberdetectedrbyrcracklesrinrtherbases.r(Clearrlungrsoundsrindicaterfullrresoluti
onrofrtherepisode.)rRhonchirandrwheezesrarernotrassociatedrwithrpulmonaryredema.rAusc
ultationrofrtherlungsrrevealsrcracklesrthroughoutrtherlungrfields.
Arclientrreceivedr20runitsrofrHumulinrNrinsulinrsubcutaneouslyratr08:00.rAtrwhatrtimerwouldr
thernurserplanrtorassessrtherclientrforrarhypoglycemicrreaction?
1.r10:00
2.r11:00
3.r17:00
4.r24:00r-rCORRECTrrANSWER-17:00
HumulinrNrisranrintermediate-
actingrinsulin.rTheronsetrofractionrisr60rtor120rminutes,ritrpeaksrinr6rtor14rhours,randrtherdur
ationrofractionrisr16rtor24rhours.rHypoglycemicrreactionsrmostrlikelyroccurrduringrpeakrtime.
, Arclientrrecoveringrfromrpulmonaryredemarisrpreparingrforrdischarge.rWhatrwouldrthernurs
erplanrtorteachrtherclientrtordortormanagerorrpreventrrecurrentrsymptomsrafterrdischarge?
1.rWeighrselfronrardailyrbasis.
2.rSleeprwithrtherheadrofrtherbedrflat.
3.rTakerardoublerdoserofrtherdiureticrifrperipheralredemarisrnoted.
4.rWithholdrprescribedrdigoxinrifrslightrrespiratoryrdistressroccurs.r-rCORRECTrrANSWER-
Weighrselfronrardailyrbasis.
Therclientrcanrbestrdeterminerfluidrstatusratrhomerbyrweighingrhimselfrorrherselfronrardailyr
basis.rIncreasesrofr2rtor3rlbr(0.9rtor1.4rkg)rinrarshortrperiodrarerreportedrtortherprimaryrhealth
rcarerproviderr(PHCP).rTherclientrneedsrtorsleeprwithrtherheadrofrtherbedrelevated.rDuringrr
ecumbentrsleep,rfluidr(whichrhasrseepedrintortherinterstitiumrwithrtherassistancerofrthereffe
ctsrofrgravity)risrrapidlyrreabsorbedrintorthersystemicrcirculation.rSleepingrwithrtherheadrofrt
herbedrflatrisrthereforeravoided.rTherclientrdoesrnotrmodifyrmedicationrdosagesrwithoutrcon
sultingrtherPHCP.
Arclientrwithrcoronaryrarteryrdiseaserisrscheduledrtorhaverardiagnosticrexerciserstressrtest.r
Whichrinstructionrwouldrthernurserplanrtorprovidertortherclientraboutrthisrprocedure?
1.rEatrbreakfastrjustrbeforertherprocedure.
2.rWearrfirm,rrigidrshoes,rsuchrasrworkrboots.
3.rWearrlooserclothingrwithrarshirtrthatrbuttonsrinrfront.
4.rAvoidrcigarettesrforr30rminutesrbeforertherprocedure.r-rCORRECTrrANSWER-
Wearrlooserclothingrwithrarshirtrthatrbuttonsrinrfront.
Therclientrneedsrtorwearrloose,rcomfortablerclothingrforrtherprocedure.rElectrocardiogramr(
ECG)rleadrplacementrisrenhancedrifrtherclientrwearsrarshirtrthatrbuttonsrinrtherfront.rTherclie
ntrneedsrtorreceivernothingrbyrmouthrafterrbedtimerorrforrarminimumrofr2rhoursrbeforertherte
st.rTherclientrwouldrwearrrubber-
soled,rsupportivershoes,rsuchrasrathleticrtrainingrshoes.rTherclientrneedsrtoravoidrsmoking,
ralcohol,randrcaffeineronrtherdayrofrthertest.rInadequaterorrincorrectrpreparationrcanrinterfer
erwithrthertest,rwithrtherpotentialrforrarfalse-positiverresult.
Arclientrwithrheartrfailurerhasrbeenrexperiencingrdifficultyrwithrcompletionrofrdailyractivities,r
asrevidencedrbyrexertionalrfatiguerandrincreasedrbloodrpressure.rWhichrobservationrbyrth
ernurserbestrindicatesrclientrprogressrinrmeetingrgoalsrforrthisrproblem?
1.rAmbulatesr10rfeetr(3rmeters)rfartherreachrday
2.rVerbalizesrtherbenefitsrofrincreasingractivity
3.rChoosesrarhealthyrdietrthatrmeetsrcaloricrneeds
4.rSleepsrwithoutrawakeningrthroughoutrthernightr-rCORRECTrrANSWER-
Choosesrarhealthyrdietrthatrmeetsrcaloricrneeds
Eachrofrtheroptionsrindicatesrarpositiveroutcomeronrtherpartrofrtherclient.rBothroptionr2randrt
hercorrectronerrelatertortherclientrproblemrofrdifficultyrwithrcompletionrofrdailyractivities.rHo
Answers
Arclientrcallsrthernurseratrtherclinicrandrreportsrexperiencingrarsensationrasrthoughrtheraffec
tedrlegrisrfallingrasleepreverrsincertherveinrligationrandrstrippingrprocedurerwasrperformed.r
Thernurserwouldrmakerwhichrresponsertortherclient?
1.r"Applyrwarmrpacksrtortherleg."
2.r"Keeprtherlegrelevatedrasrmuchrasrpossible."
3.r"Yourrprimaryrhealthrcarerproviderrneedsrtorbercontactedrtorreportrthisrproblem."
4.r"Thisrnormallyroccursrafterrsurgeryrandrwillrsubsiderwhenrtheredemargoesrdown."r-
rCORRECTrrANSWER-
"Yourrprimaryrhealthrcarerproviderrneedsrtorbercontactedrtorreportrthisrproblem."
Arsensationrofrpinsrandrneedlesrorrfeelingrasrthoughrthersurgicalrlimbrisrfallingrasleeprmayri
ndicatertemporaryrorrpermanentrnerverdamagerafterrsurgery.rThersaphenousrveinrandrther
saphenousrnerverrunrclosertogether,randrdamagertorthernerverwillrproducerparesthesias.rT
herremainingroptionsrarerinaccuraterresponses.rAnralternativertorsurgeryrisrendovenousrab
lationrofrthersaphenousrvein.rAblationrinvolvesrtherinsertionrofrarcatheterrthatremitsrenergy.r
Thisrcausesrcollapserandrsclerosisrofrthervein.rPotentialrcomplicationsrincluderbruising,rtig
htnessralongrthervein,rrecanalizationr(reopeningrofrthervein),randrparesthesia.rEndovenou
srablationralsormayrberdonerinrcombinationrwithrsaphenofemoralrligationrorrphlebectomy.rT
ransilluminatedrpowderedrphlebectomyrinvolvesrtheruserofrarpowderedrresectorrtordestroyr
thervaricesrandrthenrremovesrtherpiecesrviaraspiration.
Arclientrhadrarcolectomyr2rdaysrearlierrtorremoverarbowelrtumorrandrhadrarnewrcolostomyrc
reated.rTherclientrisrbeginningrtorpassrmalodorousrflatusrfromrtherstoma.rWhatrisrthercorrec
trinterpretationrbyrthernurse?
1.rThisrisrarnormal,rexpectedrevent.
2.rTherclientrisrexperiencingrearlyrsignsrofrischemicrbowel.
3.rTherclientrwouldrnotrhaverthernasogastricrtuberremoved.
4.rThisrindicatesrinadequaterpreoperativerbowelrpreparation.r-rCORRECTrrANSWER-
Thisrisrarnormal,rexpectedrevent.
,Asrperistalsisrreturnsrfollowingrcreationrofrarcolostomy,rtherclientrbeginsrtorpassrmalodorou
srflatus.rThisrindicatesrreturningrbowelrfunctionrandrisranrexpectedrevent.rWithinr72rhoursro
frsurgery,rtherclientrwouldrbeginrpassingrstoolrviarthercolostomy.rOptionsr2,r3,randr4rarerinc
orrectrinterpretations.
Arclientrhasrbeenrprescribedrclozapine.rThernurserreviewsrtherresultrofrwhichrlaboratoryrstu
dyrtordetectrarseriousradversereffectrassociatedrwithrthisrmedication?
1.rPlateletrcount
2.rLiverrfunction
3.rBloodrglucoserlevel
4.rWhiterbloodrcellrcountr-rCORRECTrrANSWER-Plateletrcount
Clozapinerisranrantipsychoticrmedication.rTherclientrtakingrclozapinermayrexperienceragra
nulocytosisrasranradversereffect,rwhichrisrmonitoredrbyrobtainingrweeklyrwhiterbloodrcellrco
unts.rTreatmentrisrwithheldrifrtherlevelrdropsrbelowr3000rmm3r(3r×r109/L).rAgranulocytosisr
couldrberfatalrifrundetectedrandruntreated.rTherotherroptionsrarerincorrect.
Arclientrhasrexperiencedranrepisoderofrpulmonaryredema.rThernurserdeterminesrthatrthercl
ient'srrespiratoryrstatusrisrimprovingrafterrthisrepisoderifrwhichrbreathrsoundsrarernoted?
1.rRonchi
2.rWheezes
3.rCracklesrinrtherbases
4.rCracklesrthroughoutrtherlungrfieldsr-rCORRECTrrANSWER-Cracklesrinrtherbase
Pulmonaryredemarisrcharacterizedrbyrextremerbreathlessness,rdyspnea,rairrhunger,randrt
herproductionrofrfrothy,rpink-
tingedrsputum.rAsrtherclient'srconditionrimproves,rtheramountrofrfluidrinrtheralveolirdecreas
es,rwhichrmayrberdetectedrbyrcracklesrinrtherbases.r(Clearrlungrsoundsrindicaterfullrresoluti
onrofrtherepisode.)rRhonchirandrwheezesrarernotrassociatedrwithrpulmonaryredema.rAusc
ultationrofrtherlungsrrevealsrcracklesrthroughoutrtherlungrfields.
Arclientrreceivedr20runitsrofrHumulinrNrinsulinrsubcutaneouslyratr08:00.rAtrwhatrtimerwouldr
thernurserplanrtorassessrtherclientrforrarhypoglycemicrreaction?
1.r10:00
2.r11:00
3.r17:00
4.r24:00r-rCORRECTrrANSWER-17:00
HumulinrNrisranrintermediate-
actingrinsulin.rTheronsetrofractionrisr60rtor120rminutes,ritrpeaksrinr6rtor14rhours,randrtherdur
ationrofractionrisr16rtor24rhours.rHypoglycemicrreactionsrmostrlikelyroccurrduringrpeakrtime.
, Arclientrrecoveringrfromrpulmonaryredemarisrpreparingrforrdischarge.rWhatrwouldrthernurs
erplanrtorteachrtherclientrtordortormanagerorrpreventrrecurrentrsymptomsrafterrdischarge?
1.rWeighrselfronrardailyrbasis.
2.rSleeprwithrtherheadrofrtherbedrflat.
3.rTakerardoublerdoserofrtherdiureticrifrperipheralredemarisrnoted.
4.rWithholdrprescribedrdigoxinrifrslightrrespiratoryrdistressroccurs.r-rCORRECTrrANSWER-
Weighrselfronrardailyrbasis.
Therclientrcanrbestrdeterminerfluidrstatusratrhomerbyrweighingrhimselfrorrherselfronrardailyr
basis.rIncreasesrofr2rtor3rlbr(0.9rtor1.4rkg)rinrarshortrperiodrarerreportedrtortherprimaryrhealth
rcarerproviderr(PHCP).rTherclientrneedsrtorsleeprwithrtherheadrofrtherbedrelevated.rDuringrr
ecumbentrsleep,rfluidr(whichrhasrseepedrintortherinterstitiumrwithrtherassistancerofrthereffe
ctsrofrgravity)risrrapidlyrreabsorbedrintorthersystemicrcirculation.rSleepingrwithrtherheadrofrt
herbedrflatrisrthereforeravoided.rTherclientrdoesrnotrmodifyrmedicationrdosagesrwithoutrcon
sultingrtherPHCP.
Arclientrwithrcoronaryrarteryrdiseaserisrscheduledrtorhaverardiagnosticrexerciserstressrtest.r
Whichrinstructionrwouldrthernurserplanrtorprovidertortherclientraboutrthisrprocedure?
1.rEatrbreakfastrjustrbeforertherprocedure.
2.rWearrfirm,rrigidrshoes,rsuchrasrworkrboots.
3.rWearrlooserclothingrwithrarshirtrthatrbuttonsrinrfront.
4.rAvoidrcigarettesrforr30rminutesrbeforertherprocedure.r-rCORRECTrrANSWER-
Wearrlooserclothingrwithrarshirtrthatrbuttonsrinrfront.
Therclientrneedsrtorwearrloose,rcomfortablerclothingrforrtherprocedure.rElectrocardiogramr(
ECG)rleadrplacementrisrenhancedrifrtherclientrwearsrarshirtrthatrbuttonsrinrtherfront.rTherclie
ntrneedsrtorreceivernothingrbyrmouthrafterrbedtimerorrforrarminimumrofr2rhoursrbeforertherte
st.rTherclientrwouldrwearrrubber-
soled,rsupportivershoes,rsuchrasrathleticrtrainingrshoes.rTherclientrneedsrtoravoidrsmoking,
ralcohol,randrcaffeineronrtherdayrofrthertest.rInadequaterorrincorrectrpreparationrcanrinterfer
erwithrthertest,rwithrtherpotentialrforrarfalse-positiverresult.
Arclientrwithrheartrfailurerhasrbeenrexperiencingrdifficultyrwithrcompletionrofrdailyractivities,r
asrevidencedrbyrexertionalrfatiguerandrincreasedrbloodrpressure.rWhichrobservationrbyrth
ernurserbestrindicatesrclientrprogressrinrmeetingrgoalsrforrthisrproblem?
1.rAmbulatesr10rfeetr(3rmeters)rfartherreachrday
2.rVerbalizesrtherbenefitsrofrincreasingractivity
3.rChoosesrarhealthyrdietrthatrmeetsrcaloricrneeds
4.rSleepsrwithoutrawakeningrthroughoutrthernightr-rCORRECTrrANSWER-
Choosesrarhealthyrdietrthatrmeetsrcaloricrneeds
Eachrofrtheroptionsrindicatesrarpositiveroutcomeronrtherpartrofrtherclient.rBothroptionr2randrt
hercorrectronerrelatertortherclientrproblemrofrdifficultyrwithrcompletionrofrdailyractivities.rHo
