HESI MILESTONE EXAM QUESTIONS AND CORRECT
ANSWERS
LATEST UPDATED
Abnormal lung sounds: Rhonchi - low- heard mainly in expiration when pt is breathing
out (made up of one sound- whistle or whine and high pitch, musical instrument sound
MULTIPLE sounds- mainly heard in expiration CONDITION: PNEUMONIA
abnormal lung sounds: stridor - airway obstruction, high pitch whispering or gas
(CROUP, EMERGENCY, EPIGLOTTIS)
Abnormal lung sounds: Crackles - coarse(low pitch, wet sound) fine
(high pitch, doesnt clear w/cough, crackling of fire sound)
CONDITION:RESPIRATORY EDEMA/OBSTRUCTIVE DISEASE
Normal Lung Sounds - Normal: bronchial (heard anteriorly) over larynx and trachea
(INSPIRIATION slightly shorter than expiration),
Bronchiovesicular (heard anteriorly and posteriorly)INSPIRATION AND EXPIRATION
EQUAL ,
Vesicular (heard both) lower lungs, low pitch, INSPIRATION GREATER THAN
EXPIRATION)
Abnormal lung sounds: Pleural Friction Rub - Pleural friction rub (low pitch, harsh
grating sound)
Assessment of the Respiratory System - tachypnea- rapid breathing bradypnea-
slow breathing
Normally, respirations are quiet and nonlabored, and occur at a rate of 12 to 20 times
each minute in healthy adults. Note any flaring of the nostrils, muscular retractions,
Heart Function System - Abnormal size or location of the PMI or the presence of
vibrations can indicate heart failure, myocardial infarction, disease of the heart valves,
or other cardiac diseases.
, Abdominal Assessment - Inspect, auscultate, percussion, and palpate. Nurse assess
lumps, masses or tenderness
Musculoskeletal System - Pronation & Supination - prone- plank (face downward),
supine- on the back,
Disorder: osteoporosis- break down of bone (weight bearing activity is encouraged)
Secondary osteoporosis- steroids' aka bones porous and bone prone to fractures
Compression fracture- changing position slowly, tenderness of palpitation of spine, in
pain
Neuro Assessment- Cranial Nerves - Olfactory (smell),Cranial Nerve 2: optic, cranial
nerve 3: oculomotor, cranial nerve 4: Trochlear, cranial nerve 5: Trigeminal nerve,
Cranial nerve 6: abducens cranial nerve 7: facial nerve cranial nerve 8: acoustic, cranial
nerve 9: Glossopharyngeal cranial nerve 10: vagus cranial nerve 11: accessory cranial
nerve 12: hypoglossal
Full Description - (Cranial Nerve 1: Olfactory (smell),Cranial Nerve 2: confrontational
field (cover up eye in fields in all fields) and visual acuity (Snellen Chart) reading at 20
feet from the chart . Cranial Nerve III: oculomotor- nystagmus- moving penlight in 6
cardinal fields of gaze, Cranial nerve IV: Trochlear: assess pupil constriction (normal: 35
mm), PERRLA and Cranial nerve VI: Abducens , Cranial nerve 5: Trigeminal nerve-
mastification (feel temporal and masseter muscle)open and close mouth against
resistance, cranial nerve 7: facial nerve (open and close eyes, frown, smile, Cranial
nerve 8: occlude ears and whisper word and pt repeat, Cranial nerve 9:
Glossopharyngeal-test gag reflex, vagus nerve- pt able to speak and swallow, cranial
nerve 11- accessory- shrug shoulders w/ease, Hypoglossal: pt moves tongue from side
to side
Confusion Causes - underlying infections, dehydration, electrolyte imbalances
Preventive Screening and Symptom Assessment - Tools & Uses - Braden pressure
ulcer scale (Sensory perception, moisture, activity, mobility, nutrition, friction and shear),
fall risk assessment
Heart Sounds - Technique & Representation of Sounds - S1- louder than S2 S1-"lub",
S2- "dub"= Systole
S3- "dub", S4- "lub" = diastole
Murmur - Murmur- blowing or swooshing sound due to cardio or circulatory disturbance.
Ex. anemia, pregnancy
Adults - aortic stenosis, mitral insufficiency
ANSWERS
LATEST UPDATED
Abnormal lung sounds: Rhonchi - low- heard mainly in expiration when pt is breathing
out (made up of one sound- whistle or whine and high pitch, musical instrument sound
MULTIPLE sounds- mainly heard in expiration CONDITION: PNEUMONIA
abnormal lung sounds: stridor - airway obstruction, high pitch whispering or gas
(CROUP, EMERGENCY, EPIGLOTTIS)
Abnormal lung sounds: Crackles - coarse(low pitch, wet sound) fine
(high pitch, doesnt clear w/cough, crackling of fire sound)
CONDITION:RESPIRATORY EDEMA/OBSTRUCTIVE DISEASE
Normal Lung Sounds - Normal: bronchial (heard anteriorly) over larynx and trachea
(INSPIRIATION slightly shorter than expiration),
Bronchiovesicular (heard anteriorly and posteriorly)INSPIRATION AND EXPIRATION
EQUAL ,
Vesicular (heard both) lower lungs, low pitch, INSPIRATION GREATER THAN
EXPIRATION)
Abnormal lung sounds: Pleural Friction Rub - Pleural friction rub (low pitch, harsh
grating sound)
Assessment of the Respiratory System - tachypnea- rapid breathing bradypnea-
slow breathing
Normally, respirations are quiet and nonlabored, and occur at a rate of 12 to 20 times
each minute in healthy adults. Note any flaring of the nostrils, muscular retractions,
Heart Function System - Abnormal size or location of the PMI or the presence of
vibrations can indicate heart failure, myocardial infarction, disease of the heart valves,
or other cardiac diseases.
, Abdominal Assessment - Inspect, auscultate, percussion, and palpate. Nurse assess
lumps, masses or tenderness
Musculoskeletal System - Pronation & Supination - prone- plank (face downward),
supine- on the back,
Disorder: osteoporosis- break down of bone (weight bearing activity is encouraged)
Secondary osteoporosis- steroids' aka bones porous and bone prone to fractures
Compression fracture- changing position slowly, tenderness of palpitation of spine, in
pain
Neuro Assessment- Cranial Nerves - Olfactory (smell),Cranial Nerve 2: optic, cranial
nerve 3: oculomotor, cranial nerve 4: Trochlear, cranial nerve 5: Trigeminal nerve,
Cranial nerve 6: abducens cranial nerve 7: facial nerve cranial nerve 8: acoustic, cranial
nerve 9: Glossopharyngeal cranial nerve 10: vagus cranial nerve 11: accessory cranial
nerve 12: hypoglossal
Full Description - (Cranial Nerve 1: Olfactory (smell),Cranial Nerve 2: confrontational
field (cover up eye in fields in all fields) and visual acuity (Snellen Chart) reading at 20
feet from the chart . Cranial Nerve III: oculomotor- nystagmus- moving penlight in 6
cardinal fields of gaze, Cranial nerve IV: Trochlear: assess pupil constriction (normal: 35
mm), PERRLA and Cranial nerve VI: Abducens , Cranial nerve 5: Trigeminal nerve-
mastification (feel temporal and masseter muscle)open and close mouth against
resistance, cranial nerve 7: facial nerve (open and close eyes, frown, smile, Cranial
nerve 8: occlude ears and whisper word and pt repeat, Cranial nerve 9:
Glossopharyngeal-test gag reflex, vagus nerve- pt able to speak and swallow, cranial
nerve 11- accessory- shrug shoulders w/ease, Hypoglossal: pt moves tongue from side
to side
Confusion Causes - underlying infections, dehydration, electrolyte imbalances
Preventive Screening and Symptom Assessment - Tools & Uses - Braden pressure
ulcer scale (Sensory perception, moisture, activity, mobility, nutrition, friction and shear),
fall risk assessment
Heart Sounds - Technique & Representation of Sounds - S1- louder than S2 S1-"lub",
S2- "dub"= Systole
S3- "dub", S4- "lub" = diastole
Murmur - Murmur- blowing or swooshing sound due to cardio or circulatory disturbance.
Ex. anemia, pregnancy
Adults - aortic stenosis, mitral insufficiency
