Hesi Milestone Exam Latest Updates
2023/2024
Exam Questions and Explained Answers
The client can best determine fluid status at home by weighing himself or herself
on a daily basis. Increases of 2 to 3 lb (0.9 to 1.4 kg) in a short period are reported
to the primary health care provider (PHCP). The client needs to sleep with the head
of the bed elevated. During recumbent sleep, fluid (which has seeped into the
interstitium with the assistance of the effects of gravity) is rapidly reabsorbed into
the systemic circulation. Sleeping with the head of the bed flat is therefore avoided.
The client does not modify medication dosages without consulting the PHCP.
The nurse is caring for a client with acute pancreatitis and is monitoring the client
for paralytic ileus. Which piece of assessment data would alert the nurse to this
occurrence?
1. Inability to pass flatus
2. Loss of anal sphincter control
3. Severe, constant pain with rapid onset
4. Firm, nontender mass palpable at the lower right costal margin - CORRECT
ANSWER - Inability to pass flatus
An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the
most common form of nonmechanical obstruction. Inability to pass flatus is a
clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of
paralytic ileus. Pain is associated with paralytic ileus, but the pain usually
manifests as a more constant generalized discomfort. Option 4 is the description of
the physical finding of liver enlargement. The liver may be enlarged in cases of
cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged
liver is not a sign of paralytic ileus or intestinal obstruction.
The nurse is caring for a client with a resolved intestinal obstruction who has a
nasogastric tube in place. The primary health care provider has now prescribed that
the nasogastric tube be removed. What is the priority nursing assessment prior to
removing the tube?
1. Checking for normal serum electrolyte levels
2. Checking for normal pH of the gastric aspirate
3. Checking for proper nasogastric tube placement
4. Checking for the presence of bowel sounds in all four quadrants - CORRECT
ANSWER - Checking for the presence of bowel sounds in all four quadrants
,Distention, vomiting, and abdominal pain are a few of the symptoms associated
with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid
from the stomach, relieving distention and vomiting. Bowel sounds return to
normal as the obstruction is resolved and normal bowel function is restored.
Discontinuing the nasogastric tube before normal bowel function may result in a
return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum
electrolyte levels, pH of the gastric aspirate, and tube placement are important
assessments for the client with a nasogastric tube in place but would not assist in
determining the readiness for removing the nasogastric tube.
The nurse is caring for a client who is on strict bed rest and creates a plan of care
with goals related to the prevention of deep vein thrombosis and pulmonary
emboli. Which nursing action is most helpful in preventing these disorders from
developing?
1. Restricting fluids
2. Placing a pillow under the knees
3. Encouraging active range-of-motion exercises
4. Applying a heating pad to the lower extremities - CORRECT ANSWER -
Encouraging active range-of-motion exercises
Clients at greatest risk for deep vein thrombosis and pulmonary emboli are
immobilized clients. Basic preventive measures include early ambulation, leg
elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf
compression. Keeping the client well hydrated is essential because dehydration
predisposes to clotting. A pillow under the knees may cause venous stasis. Heat
would not be applied without a primary health care provider's prescription.
The nurse is caring for a teenage client admitted to the hospital with a suspected
diagnosis of acute appendicitis. Which laboratory result should the nurse expect to
note if the client does have appendicitis?
1. Leukopenia with a shift to the left
2. Leukocytosis with a shift to the left
3. Leukopenia with a shift to the right
4. Leukocytosis with a shift to the right - CORRECT ANSWER - Leukocytosis
with a shift to the left
Laboratory findings do not establish the diagnosis of appendicitis, but there is often
an elevation of the white blood cell count (leukocytosis) with a shift to the left (an
, increased number of immature white blood cells). Options 1, 3, and 4 are incorrect
because they are not associated findings in acute appendicitis.
A home care nurse is visiting a client to provide follow-up evaluation and care of a
leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the
ulcer is pale and deep and that the surrounding tissue is cool to the touch. The
nurse would document that these findings identify which type of ulcer?
1. A stage 1 ulcer
2. A vascular ulcer
3. An arterial ulcer
4. A venous stasis ulcer - CORRECT ANSWER - An arterial ulcer
Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with
trophic changes such as dry skin and loss of hair. Arterial ulcers are caused by
tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1
ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer
(vascular) has a dark red base and is surrounded by brown skin with local edema.
This type of ulcer is caused by the accumulation of waste products of metabolism
that are not cleared, as a result of venous congestion.
A client calls the nurse at the clinic and reports experiencing a sensation as though
the affected leg is falling asleep ever since the vein ligation and stripping
procedure was performed. The nurse would make which response to the client?
1. "Apply warm packs to the leg."
2. "Keep the leg elevated as much as possible."
3. "Your primary health care provider needs to be contacted to report this
problem."
4. "This normally occurs after surgery and will subside when the edema goes
down." - CORRECT ANSWER - "Your primary health care provider needs to
be contacted to report this problem."
A sensation of pins and needles or feeling as though the surgical limb is falling
asleep may indicate temporary or permanent nerve damage after surgery. The
saphenous vein and the saphenous nerve run close together, and damage to the
nerve will produce paresthesias. The remaining options are inaccurate responses.
An alternative to surgery is endovenous ablation of the saphenous vein. Ablation
involves the insertion of a catheter that emits energy. This causes collapse and
sclerosis of the vein. Potential complications include bruising, tightness along the
2023/2024
Exam Questions and Explained Answers
The client can best determine fluid status at home by weighing himself or herself
on a daily basis. Increases of 2 to 3 lb (0.9 to 1.4 kg) in a short period are reported
to the primary health care provider (PHCP). The client needs to sleep with the head
of the bed elevated. During recumbent sleep, fluid (which has seeped into the
interstitium with the assistance of the effects of gravity) is rapidly reabsorbed into
the systemic circulation. Sleeping with the head of the bed flat is therefore avoided.
The client does not modify medication dosages without consulting the PHCP.
The nurse is caring for a client with acute pancreatitis and is monitoring the client
for paralytic ileus. Which piece of assessment data would alert the nurse to this
occurrence?
1. Inability to pass flatus
2. Loss of anal sphincter control
3. Severe, constant pain with rapid onset
4. Firm, nontender mass palpable at the lower right costal margin - CORRECT
ANSWER - Inability to pass flatus
An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the
most common form of nonmechanical obstruction. Inability to pass flatus is a
clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of
paralytic ileus. Pain is associated with paralytic ileus, but the pain usually
manifests as a more constant generalized discomfort. Option 4 is the description of
the physical finding of liver enlargement. The liver may be enlarged in cases of
cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged
liver is not a sign of paralytic ileus or intestinal obstruction.
The nurse is caring for a client with a resolved intestinal obstruction who has a
nasogastric tube in place. The primary health care provider has now prescribed that
the nasogastric tube be removed. What is the priority nursing assessment prior to
removing the tube?
1. Checking for normal serum electrolyte levels
2. Checking for normal pH of the gastric aspirate
3. Checking for proper nasogastric tube placement
4. Checking for the presence of bowel sounds in all four quadrants - CORRECT
ANSWER - Checking for the presence of bowel sounds in all four quadrants
,Distention, vomiting, and abdominal pain are a few of the symptoms associated
with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid
from the stomach, relieving distention and vomiting. Bowel sounds return to
normal as the obstruction is resolved and normal bowel function is restored.
Discontinuing the nasogastric tube before normal bowel function may result in a
return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum
electrolyte levels, pH of the gastric aspirate, and tube placement are important
assessments for the client with a nasogastric tube in place but would not assist in
determining the readiness for removing the nasogastric tube.
The nurse is caring for a client who is on strict bed rest and creates a plan of care
with goals related to the prevention of deep vein thrombosis and pulmonary
emboli. Which nursing action is most helpful in preventing these disorders from
developing?
1. Restricting fluids
2. Placing a pillow under the knees
3. Encouraging active range-of-motion exercises
4. Applying a heating pad to the lower extremities - CORRECT ANSWER -
Encouraging active range-of-motion exercises
Clients at greatest risk for deep vein thrombosis and pulmonary emboli are
immobilized clients. Basic preventive measures include early ambulation, leg
elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf
compression. Keeping the client well hydrated is essential because dehydration
predisposes to clotting. A pillow under the knees may cause venous stasis. Heat
would not be applied without a primary health care provider's prescription.
The nurse is caring for a teenage client admitted to the hospital with a suspected
diagnosis of acute appendicitis. Which laboratory result should the nurse expect to
note if the client does have appendicitis?
1. Leukopenia with a shift to the left
2. Leukocytosis with a shift to the left
3. Leukopenia with a shift to the right
4. Leukocytosis with a shift to the right - CORRECT ANSWER - Leukocytosis
with a shift to the left
Laboratory findings do not establish the diagnosis of appendicitis, but there is often
an elevation of the white blood cell count (leukocytosis) with a shift to the left (an
, increased number of immature white blood cells). Options 1, 3, and 4 are incorrect
because they are not associated findings in acute appendicitis.
A home care nurse is visiting a client to provide follow-up evaluation and care of a
leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the
ulcer is pale and deep and that the surrounding tissue is cool to the touch. The
nurse would document that these findings identify which type of ulcer?
1. A stage 1 ulcer
2. A vascular ulcer
3. An arterial ulcer
4. A venous stasis ulcer - CORRECT ANSWER - An arterial ulcer
Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with
trophic changes such as dry skin and loss of hair. Arterial ulcers are caused by
tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1
ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer
(vascular) has a dark red base and is surrounded by brown skin with local edema.
This type of ulcer is caused by the accumulation of waste products of metabolism
that are not cleared, as a result of venous congestion.
A client calls the nurse at the clinic and reports experiencing a sensation as though
the affected leg is falling asleep ever since the vein ligation and stripping
procedure was performed. The nurse would make which response to the client?
1. "Apply warm packs to the leg."
2. "Keep the leg elevated as much as possible."
3. "Your primary health care provider needs to be contacted to report this
problem."
4. "This normally occurs after surgery and will subside when the edema goes
down." - CORRECT ANSWER - "Your primary health care provider needs to
be contacted to report this problem."
A sensation of pins and needles or feeling as though the surgical limb is falling
asleep may indicate temporary or permanent nerve damage after surgery. The
saphenous vein and the saphenous nerve run close together, and damage to the
nerve will produce paresthesias. The remaining options are inaccurate responses.
An alternative to surgery is endovenous ablation of the saphenous vein. Ablation
involves the insertion of a catheter that emits energy. This causes collapse and
sclerosis of the vein. Potential complications include bruising, tightness along the
