HESI MILESTONE 2 PRACTICE
QUESTION with 113 complete detailed
solutions.
HESI MILESTONE 2 PRACTICE
QUESTION with 113 complete detailed
solutions.
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 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 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 Answer: Urine Osmolarity
A client has a history of GERD. Why should the nurse monitor the client for clinical manifestation of
heart disease? - ANSWER Esophageal pain may imitate the symptoms of a heart attack
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? - ANSWER Maintaining
normoglycemia
The nurse is caring for a client before, during and immediately after surgery. Which type of care is
provided to the client? - ANSWER 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? - ANSWER Performing postural drainage
,HESI MILESTONE 2 PRACTICE
QUESTION with 113 complete detailed
solutions.
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? -
ANSWER 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? - ANSWER "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? - ANSWER Peristaltic waves that transverse the
epigastrium.
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? - ANSWER "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? - ANSWER 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. - ANSWER 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.
,HESI MILESTONE 2 PRACTICE
QUESTION with 113 complete detailed
solutions.
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. - ANSWER 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. -
ANSWER 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. - ANSWER B
, HESI MILESTONE 2 PRACTICE
QUESTION with 113 complete detailed
solutions.
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. - ANSWER 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. - ANSWER A
Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi
ancestry.
The client is taking digoxin for congestive heart failure. The nurse would be correct in withholding a dose
of digoxin based on which assessment?
A. serum digoxin level is 1.5.
B. blood pressure is 104/68.
C. serum potassium level is 3.
D. apical pulse is 68/min. - ANSWER C
QUESTION with 113 complete detailed
solutions.
HESI MILESTONE 2 PRACTICE
QUESTION with 113 complete detailed
solutions.
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 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 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 Answer: Urine Osmolarity
A client has a history of GERD. Why should the nurse monitor the client for clinical manifestation of
heart disease? - ANSWER Esophageal pain may imitate the symptoms of a heart attack
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? - ANSWER Maintaining
normoglycemia
The nurse is caring for a client before, during and immediately after surgery. Which type of care is
provided to the client? - ANSWER 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? - ANSWER Performing postural drainage
,HESI MILESTONE 2 PRACTICE
QUESTION with 113 complete detailed
solutions.
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? -
ANSWER 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? - ANSWER "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? - ANSWER Peristaltic waves that transverse the
epigastrium.
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? - ANSWER "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? - ANSWER 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. - ANSWER 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.
,HESI MILESTONE 2 PRACTICE
QUESTION with 113 complete detailed
solutions.
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. - ANSWER 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. -
ANSWER 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. - ANSWER B
, HESI MILESTONE 2 PRACTICE
QUESTION with 113 complete detailed
solutions.
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. - ANSWER 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. - ANSWER A
Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi
ancestry.
The client is taking digoxin for congestive heart failure. The nurse would be correct in withholding a dose
of digoxin based on which assessment?
A. serum digoxin level is 1.5.
B. blood pressure is 104/68.
C. serum potassium level is 3.
D. apical pulse is 68/min. - ANSWER C
