HESI MILESTONE 2 ACTUAL EXAM 2023/2024 RATED A+
1. 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: Apple Juice
2. 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: "Excessive
aldosterone and cortisone cause retention of sodium and loss of potassium."
3. 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
4. A client has a history of GERD. Why should the nurse monitor the client
for clinical manifestation of heart disease?: Esophageal pain may imitate the
symptoms of a heart attack
5. 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?: Maintaining normoglycemia
6. The nurse is caring for a client before, during and immediately after
surgery. Which type of care is provided to the client?: Care that supports
homeostatic regulation
7. A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory in-
fection. The nurse determines that the adolescent is cyanotic, has a bar-
rel-shaped chest, and is in the 10th percentile for both height and weight.
What is the priority nursing intervention?: Performing postural drainage
8. 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?: Developing a sequenc
of goals with the child and parents.
9. The nurse concludes that a client with glaucoma needs education when
the client makes which statement?: "It is dangerous for me to use sedatives."
Sedatives have no effect on intraocular pressure
10. 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 like-
ly indicated pyloric stenosis?: Peristaltic waves that transverse the epigastrium
, HESI MILESTONE 2 PRACTICE QUESTION
11. The registered nurse is teaching a student nurse the points to be include
while educating a client on cortisol replacement therapy about self-manage-
ment. Which statement provided by the student nurse indicates the need for
further teaching?: "I will advise the client to take the medication before meals."
12. 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?: Urine osmolarity
13. 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.: 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.
14. 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.: 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.
15. 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 infecte
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 prevent-
, HESI MILESTONE 2 PRACTICE QUESTION
ing complications associated with diabetes.
D. His wife expresses a sincere willingness to prepare meals that are within
his prescribed diet.: A
The loss of a limb due to diabetes by a family member should be the strongest eve
or "cue to action" and is most likely to increase the client's perceived seriousness
of the disease.
16. 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.: B
Hypokalemia (normal 3.5 to 5 mEq/L [3.5 to 5 mmol/L]) causes changes in myoca
dial 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.
17. 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 med-
ication.
D. Joint pain is worse during the day and involves unilateral joints.: 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.
18. 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.: A
Ulcerative colitis is 4 to 5 times more common among individuals of Jewish
European or Ashkenazi ancestry.
1. 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: Apple Juice
2. 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: "Excessive
aldosterone and cortisone cause retention of sodium and loss of potassium."
3. 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
4. A client has a history of GERD. Why should the nurse monitor the client
for clinical manifestation of heart disease?: Esophageal pain may imitate the
symptoms of a heart attack
5. 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?: Maintaining normoglycemia
6. The nurse is caring for a client before, during and immediately after
surgery. Which type of care is provided to the client?: Care that supports
homeostatic regulation
7. A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory in-
fection. The nurse determines that the adolescent is cyanotic, has a bar-
rel-shaped chest, and is in the 10th percentile for both height and weight.
What is the priority nursing intervention?: Performing postural drainage
8. 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?: Developing a sequenc
of goals with the child and parents.
9. The nurse concludes that a client with glaucoma needs education when
the client makes which statement?: "It is dangerous for me to use sedatives."
Sedatives have no effect on intraocular pressure
10. 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 like-
ly indicated pyloric stenosis?: Peristaltic waves that transverse the epigastrium
, HESI MILESTONE 2 PRACTICE QUESTION
11. The registered nurse is teaching a student nurse the points to be include
while educating a client on cortisol replacement therapy about self-manage-
ment. Which statement provided by the student nurse indicates the need for
further teaching?: "I will advise the client to take the medication before meals."
12. 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?: Urine osmolarity
13. 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.: 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.
14. 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.: 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.
15. 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 infecte
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 prevent-
, HESI MILESTONE 2 PRACTICE QUESTION
ing complications associated with diabetes.
D. His wife expresses a sincere willingness to prepare meals that are within
his prescribed diet.: A
The loss of a limb due to diabetes by a family member should be the strongest eve
or "cue to action" and is most likely to increase the client's perceived seriousness
of the disease.
16. 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.: B
Hypokalemia (normal 3.5 to 5 mEq/L [3.5 to 5 mmol/L]) causes changes in myoca
dial 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.
17. 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 med-
ication.
D. Joint pain is worse during the day and involves unilateral joints.: 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.
18. 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.: A
Ulcerative colitis is 4 to 5 times more common among individuals of Jewish
European or Ashkenazi ancestry.
