HESI MILESTONE 2 RETAKE EXAM
NEWEST 2026 VERSION | ALL
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALE | RATED
A+ | NEW !!
1. A nurse is caring for a patient who has just undergone abdominal
surgery and reports sudden shortness of breath and chest pain.
What is the priority nursing action?
A. Administer the prescribed analgesic
B. Encourage deep breathing exercises
C. Notify the rapid response team immediately
D. Position the patient in a supine position
Rationale: The sudden onset of chest pain and shortness of
breath post-surgery may indicate a pulmonary embolism, which
is a life-threatening emergency. Immediate activation of the
rapid response team is the priority.
2. A patient with heart failure presents with dyspnea, edema, and
weight gain of 3 pounds in 24 hours. Which intervention should
the nurse implement first?
A. Restrict fluid intake to 1500 mL/day
B. Assess lung sounds and oxygen saturation
C. Administer prescribed diuretics
D. Encourage ambulation
Rationale: Assessing lung sounds and oxygen saturation allows
the nurse to evaluate the severity of fluid overload and potential
pulmonary congestion, guiding immediate interventions.
3. A nurse is preparing to administer morphine to a postoperative
patient. The patient’s respiratory rate is 8 breaths per minute. What
is the most appropriate action?
A. Administer the morphine as prescribed
, B. Call the provider to request a lower dose
C. Withhold the morphine and notify the provider
D. Encourage the patient to take deep breaths before administering
Rationale: Morphine can further depress respiration.
Withholding the medication and notifying the provider ensures
patient safety.
4. A nurse is teaching a patient newly diagnosed with type 2 diabetes
about diet management. Which statement by the patient indicates
understanding?
A. “I can eat as many fruits as I want since they are healthy.”
B. “I should monitor carbohydrate intake at each meal.”
C. “I should completely avoid all carbohydrates.”
D. “I only need to take insulin if I eat sugar.”
Rationale: Monitoring carbohydrate intake is essential for
glycemic control in type 2 diabetes; total avoidance is
unnecessary, and fruit must be consumed in moderation.
5. During a home visit, a nurse notices that a patient’s caregiver is
verbally abusive toward the patient. What is the nurse’s best initial
action?
A. Call law enforcement immediately
B. Confront the caregiver about their behavior
C. Document the observations and report to the appropriate
protective services
D. Remove the patient from the home immediately
Rationale: Nurses are mandated reporters. Documenting and
reporting ensures patient safety while following legal procedures.
6. A patient receiving IV vancomycin reports flushing and itching
during the infusion. What is the nurse’s priority action?
A. Administer an antihistamine and continue infusion
B. Stop the infusion and notify the provider
C. Slow the infusion rate and observe for changes
D. Document the reaction and continue monitoring
Rationale: The patient may be experiencing “Red Man
Syndrome,” which requires stopping the infusion to prevent
further adverse reactions.
,7. A patient with chronic kidney disease is prescribed a low-
potassium diet. Which food choice by the patient indicates correct
understanding?
A. Bananas
B. Oranges
C. Apples
D. Spinach
Rationale: Apples are low in potassium and appropriate for a
low-potassium diet. Bananas, oranges, and spinach are high in
potassium.
8. A nurse observes a new graduate performing hand hygiene
incorrectly before a sterile procedure. What is the best response?
A. Allow them to continue to avoid embarrassment
B. Report the incident to the manager
C. Stop the procedure and provide immediate corrective
teaching
D. Document the observation in the patient’s chart
Rationale: Patient safety is paramount. Immediate corrective
action prevents potential infection.
9. A patient with COPD is experiencing increased dyspnea and use of
accessory muscles. Which action should the nurse implement first?
A. Administer the prescribed bronchodilator
B. Assess oxygen saturation and vital signs
C. Encourage coughing and deep breathing
D. Notify the provider immediately
Rationale: Assessment of oxygenation and vital signs is the first
step to determine the severity of respiratory distress before
interventions.
10. A nurse is caring for a patient with a nasogastric tube and
observes a sudden decrease in output and abdominal distention.
What is the priority action?
A. Reposition the patient
B. Check for tube kinking or obstruction
C. Administer antiemetic as prescribed
D. Notify the provider after documenting
, Rationale: Tube obstruction can cause abdominal distention and
complications; checking for blockage is the immediate action.
11. A patient with hypoglycemia is confused and diaphoretic.
Which action should the nurse take first?
A. Call the provider for orders
B. Administer glucagon subcutaneously
C. Provide a fast-acting carbohydrate orally if the patient can
swallow
D. Check blood glucose in 30 minutes
Rationale: Rapid correction of hypoglycemia with oral
carbohydrates is the first priority if the patient is alert enough to
swallow safely.
12. A nurse is reviewing lab results and notes a potassium level
of 6.2 mEq/L. The patient has peaked T waves on ECG. What is
the most urgent action?
A. Administer prescribed potassium supplements
B. Encourage oral potassium intake
C. Notify the provider immediately and prepare for
interventions to lower potassium
D. Continue routine monitoring
Rationale: Hyperkalemia with ECG changes is life-threatening
and requires immediate intervention.
13. A patient recovering from a stroke has left-sided weakness.
Which action is most important when assisting with ambulation?
A. Walk beside the patient on the right side
B. Encourage the patient to lead with the affected leg
C. Use a gait belt and support the patient’s weak side
D. Allow the patient to ambulate independently
Rationale: Using a gait belt and supporting the weak side
ensures safety and prevents falls.
14. A nurse is teaching a patient with asthma about peak flow
monitoring. Which statement indicates correct understanding?
A. “I only need to check my peak flow when I feel short of
breath.”
B. “I should measure my peak flow daily and record the
NEWEST 2026 VERSION | ALL
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALE | RATED
A+ | NEW !!
1. A nurse is caring for a patient who has just undergone abdominal
surgery and reports sudden shortness of breath and chest pain.
What is the priority nursing action?
A. Administer the prescribed analgesic
B. Encourage deep breathing exercises
C. Notify the rapid response team immediately
D. Position the patient in a supine position
Rationale: The sudden onset of chest pain and shortness of
breath post-surgery may indicate a pulmonary embolism, which
is a life-threatening emergency. Immediate activation of the
rapid response team is the priority.
2. A patient with heart failure presents with dyspnea, edema, and
weight gain of 3 pounds in 24 hours. Which intervention should
the nurse implement first?
A. Restrict fluid intake to 1500 mL/day
B. Assess lung sounds and oxygen saturation
C. Administer prescribed diuretics
D. Encourage ambulation
Rationale: Assessing lung sounds and oxygen saturation allows
the nurse to evaluate the severity of fluid overload and potential
pulmonary congestion, guiding immediate interventions.
3. A nurse is preparing to administer morphine to a postoperative
patient. The patient’s respiratory rate is 8 breaths per minute. What
is the most appropriate action?
A. Administer the morphine as prescribed
, B. Call the provider to request a lower dose
C. Withhold the morphine and notify the provider
D. Encourage the patient to take deep breaths before administering
Rationale: Morphine can further depress respiration.
Withholding the medication and notifying the provider ensures
patient safety.
4. A nurse is teaching a patient newly diagnosed with type 2 diabetes
about diet management. Which statement by the patient indicates
understanding?
A. “I can eat as many fruits as I want since they are healthy.”
B. “I should monitor carbohydrate intake at each meal.”
C. “I should completely avoid all carbohydrates.”
D. “I only need to take insulin if I eat sugar.”
Rationale: Monitoring carbohydrate intake is essential for
glycemic control in type 2 diabetes; total avoidance is
unnecessary, and fruit must be consumed in moderation.
5. During a home visit, a nurse notices that a patient’s caregiver is
verbally abusive toward the patient. What is the nurse’s best initial
action?
A. Call law enforcement immediately
B. Confront the caregiver about their behavior
C. Document the observations and report to the appropriate
protective services
D. Remove the patient from the home immediately
Rationale: Nurses are mandated reporters. Documenting and
reporting ensures patient safety while following legal procedures.
6. A patient receiving IV vancomycin reports flushing and itching
during the infusion. What is the nurse’s priority action?
A. Administer an antihistamine and continue infusion
B. Stop the infusion and notify the provider
C. Slow the infusion rate and observe for changes
D. Document the reaction and continue monitoring
Rationale: The patient may be experiencing “Red Man
Syndrome,” which requires stopping the infusion to prevent
further adverse reactions.
,7. A patient with chronic kidney disease is prescribed a low-
potassium diet. Which food choice by the patient indicates correct
understanding?
A. Bananas
B. Oranges
C. Apples
D. Spinach
Rationale: Apples are low in potassium and appropriate for a
low-potassium diet. Bananas, oranges, and spinach are high in
potassium.
8. A nurse observes a new graduate performing hand hygiene
incorrectly before a sterile procedure. What is the best response?
A. Allow them to continue to avoid embarrassment
B. Report the incident to the manager
C. Stop the procedure and provide immediate corrective
teaching
D. Document the observation in the patient’s chart
Rationale: Patient safety is paramount. Immediate corrective
action prevents potential infection.
9. A patient with COPD is experiencing increased dyspnea and use of
accessory muscles. Which action should the nurse implement first?
A. Administer the prescribed bronchodilator
B. Assess oxygen saturation and vital signs
C. Encourage coughing and deep breathing
D. Notify the provider immediately
Rationale: Assessment of oxygenation and vital signs is the first
step to determine the severity of respiratory distress before
interventions.
10. A nurse is caring for a patient with a nasogastric tube and
observes a sudden decrease in output and abdominal distention.
What is the priority action?
A. Reposition the patient
B. Check for tube kinking or obstruction
C. Administer antiemetic as prescribed
D. Notify the provider after documenting
, Rationale: Tube obstruction can cause abdominal distention and
complications; checking for blockage is the immediate action.
11. A patient with hypoglycemia is confused and diaphoretic.
Which action should the nurse take first?
A. Call the provider for orders
B. Administer glucagon subcutaneously
C. Provide a fast-acting carbohydrate orally if the patient can
swallow
D. Check blood glucose in 30 minutes
Rationale: Rapid correction of hypoglycemia with oral
carbohydrates is the first priority if the patient is alert enough to
swallow safely.
12. A nurse is reviewing lab results and notes a potassium level
of 6.2 mEq/L. The patient has peaked T waves on ECG. What is
the most urgent action?
A. Administer prescribed potassium supplements
B. Encourage oral potassium intake
C. Notify the provider immediately and prepare for
interventions to lower potassium
D. Continue routine monitoring
Rationale: Hyperkalemia with ECG changes is life-threatening
and requires immediate intervention.
13. A patient recovering from a stroke has left-sided weakness.
Which action is most important when assisting with ambulation?
A. Walk beside the patient on the right side
B. Encourage the patient to lead with the affected leg
C. Use a gait belt and support the patient’s weak side
D. Allow the patient to ambulate independently
Rationale: Using a gait belt and supporting the weak side
ensures safety and prevents falls.
14. A nurse is teaching a patient with asthma about peak flow
monitoring. Which statement indicates correct understanding?
A. “I only need to check my peak flow when I feel short of
breath.”
B. “I should measure my peak flow daily and record the
