HESI MILESTONE 2 EXAM (2026/ 2027) |
QUESTIONS AND VERIFIED ANSWERS|
100% CORRECT
The nurse is planning care for a client with deep vein thrombosis of the right
leg. Which interventions would the nurse anticipate the physician to most
likely prescribe? Select all that apply.
1. Strict bed rest
2. Elevation of the right leg
3. Administration of acetaminophen
4. Application of moist heat to the right leg
5. Monitoring for signs of pulmonary embolism......ANSWER.......Elevation of
right leg, Administration of acetaminophen, Application of moist heat to the
right leg, Monitoring for signs of pulmonary embolism
Standard management for the client with DVT includes maintaining the
activity level as prescribed by the physician; limb elevation; relief of
discomfort with warm, moist heat; and analgesics as needed. Strict bed rest
is not likely to be prescribed; recent research is showing that ambulation
does not cause pulmonary embolism and does not cause the existing DVT to
worsen. Additionally, bed rest can cause complications such as skin integrity
problems, weakness due to immobility, and respiratory problems.
,The nurse is teaching a pregnant client with diabetes about nutrition and
insulin needs during pregnancy. The nurse would provide the client with
which information?
1. Glucose crosses the placenta.
2. Insulin crosses the placenta.
3. Increased caloric intake is needed.
4. Decreased caloric intake is required.......ANSWER.......Glucose crosses the
placenta.
Glucose crosses the placenta, but insulin does not. High fetal demands for
glucose, combined with the insulin resistance caused by hormonal changes
in the last half of pregnancy can result in elevation of maternal blood glucose
levels. This increases the pregnant client's demand for insulin and is referred
to as the diabetogenic effect of pregnancy. Caloric requirements are not
affected by diabetes.
A client had a colectomy 2 days earlier to remove a bowel tumor and had a
new colostomy created. The client is beginning to pass malodorous flatus
from the stoma. What is the correct interpretation by the nurse?
1. This is a normal, expected event.
2. The client is experiencing early signs of ischemic bowel.
3. The client would not have the nasogastric tube removed.
4. This indicates inadequate preoperative bowel
preparation.......ANSWER.......This is a normal, expected event.
, As peristalsis returns following creation of a colostomy, the client begins to
pass malodorous flatus. This indicates returning bowel function and is an
expected event. Within 72 hours of surgery, the client would begin passing
stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations.
The home health nurse visits a client with a diagnosis of type 1 diabetes
mellitus. The client relates a history of vomiting and diarrhea and tells the
nurse that no food has been consumed for the last 24 hours. Which
additional statement by the client indicates a need for further teaching?
1. "I need to stop my insulin."
2. "I need to increase my fluid intake."
3. "I need to monitor my blood glucose every 3 to 4 hours."
4. "I need to call the primary health care provider (PHCP) because of these
symptoms."......ANSWER......."I need to stop my insulin."
When a client with diabetes mellitus is unable to eat normally because of
illness, the client still needs to take the prescribed insulin or oral medication.
The client would consume additional fluids and needs to notify the PHCP.
The client needs to monitor the blood glucose level every 3 to 4 hours. The
client would also monitor the urine for ketones during illness.
The nurse is preparing to care for a newborn receiving phototherapy. Which
interventions would be included in the plan of care? Select all that apply.
1. Avoid stimulation.
QUESTIONS AND VERIFIED ANSWERS|
100% CORRECT
The nurse is planning care for a client with deep vein thrombosis of the right
leg. Which interventions would the nurse anticipate the physician to most
likely prescribe? Select all that apply.
1. Strict bed rest
2. Elevation of the right leg
3. Administration of acetaminophen
4. Application of moist heat to the right leg
5. Monitoring for signs of pulmonary embolism......ANSWER.......Elevation of
right leg, Administration of acetaminophen, Application of moist heat to the
right leg, Monitoring for signs of pulmonary embolism
Standard management for the client with DVT includes maintaining the
activity level as prescribed by the physician; limb elevation; relief of
discomfort with warm, moist heat; and analgesics as needed. Strict bed rest
is not likely to be prescribed; recent research is showing that ambulation
does not cause pulmonary embolism and does not cause the existing DVT to
worsen. Additionally, bed rest can cause complications such as skin integrity
problems, weakness due to immobility, and respiratory problems.
,The nurse is teaching a pregnant client with diabetes about nutrition and
insulin needs during pregnancy. The nurse would provide the client with
which information?
1. Glucose crosses the placenta.
2. Insulin crosses the placenta.
3. Increased caloric intake is needed.
4. Decreased caloric intake is required.......ANSWER.......Glucose crosses the
placenta.
Glucose crosses the placenta, but insulin does not. High fetal demands for
glucose, combined with the insulin resistance caused by hormonal changes
in the last half of pregnancy can result in elevation of maternal blood glucose
levels. This increases the pregnant client's demand for insulin and is referred
to as the diabetogenic effect of pregnancy. Caloric requirements are not
affected by diabetes.
A client had a colectomy 2 days earlier to remove a bowel tumor and had a
new colostomy created. The client is beginning to pass malodorous flatus
from the stoma. What is the correct interpretation by the nurse?
1. This is a normal, expected event.
2. The client is experiencing early signs of ischemic bowel.
3. The client would not have the nasogastric tube removed.
4. This indicates inadequate preoperative bowel
preparation.......ANSWER.......This is a normal, expected event.
, As peristalsis returns following creation of a colostomy, the client begins to
pass malodorous flatus. This indicates returning bowel function and is an
expected event. Within 72 hours of surgery, the client would begin passing
stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations.
The home health nurse visits a client with a diagnosis of type 1 diabetes
mellitus. The client relates a history of vomiting and diarrhea and tells the
nurse that no food has been consumed for the last 24 hours. Which
additional statement by the client indicates a need for further teaching?
1. "I need to stop my insulin."
2. "I need to increase my fluid intake."
3. "I need to monitor my blood glucose every 3 to 4 hours."
4. "I need to call the primary health care provider (PHCP) because of these
symptoms."......ANSWER......."I need to stop my insulin."
When a client with diabetes mellitus is unable to eat normally because of
illness, the client still needs to take the prescribed insulin or oral medication.
The client would consume additional fluids and needs to notify the PHCP.
The client needs to monitor the blood glucose level every 3 to 4 hours. The
client would also monitor the urine for ketones during illness.
The nurse is preparing to care for a newborn receiving phototherapy. Which
interventions would be included in the plan of care? Select all that apply.
1. Avoid stimulation.
