HESI Milestone 2 Exam Questions and Answers
Latest Update | HESI Milestone 2
Comprehensive Study Guide, Test Bank,
Practice Questions with Verified Answers and
Detailed Rationales for Nursing Students
Preparing for HESI Milestone 2 Assessment
and NCLEX Readiness
Question 1: A nurse is preparing to administer a subcutaneous injection of insulin to a patient with
diabetes. Which angle should the nurse use for the needle insertion if the patient has adequate
subcutaneous tissue?
A. 15 degrees
B. 30 degrees
C. 45 to 90 degrees
D. 180 degrees
CORRECT ANSWER: C. 45 to 90 degrees
RATIONALE: For subcutaneous injections, if the patient has adequate subcutaneous tissue, a 45 to 90-
degree angle is appropriate to ensure the medication is delivered into the subcutaneous layer rather
than the muscle.
Question 2: A patient is admitted with a diagnosis of deep vein thrombosis (DVT). Which assessment
finding should the nurse prioritize reporting to the healthcare provider?
A. Mild swelling in the affected leg
B. Warmth and redness over the calf
C. Sudden onset of shortness of breath
D. Pain upon dorsiflexion of the foot
CORRECT ANSWER: C. Sudden onset of shortness of breath
RATIONALE: Sudden shortness of breath may indicate a pulmonary embolism, a life-threatening
complication of DVT, requiring immediate intervention.
Question 3: When performing a sterile dressing change, which action by the nurse indicates a break in
sterile technique?
A. Holding sterile items above waist level
B. Opening the sterile package away from the body
C. Reaching over the sterile field to grab an item
D. Pouring sterile solution from a height of 6 inches
CORRECT ANSWER: C. Reaching over the sterile field to grab an item
,RATIONALE: Reaching over a sterile field contaminates it because particles from the arms or clothing
can fall onto the sterile surface.
Question 4: A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which
oxygen delivery method is most appropriate to maintain an SpO2 of 88-92%?
A. Non-rebreather mask at 15 L/min
B. Nasal cannula at 1-2 L/min
C. Simple face mask at 6 L/min
D. Venturi mask set at 24%
CORRECT ANSWER: B. Nasal cannula at 1-2 L/min
RATIONALE: Patients with COPD often rely on a hypoxic drive; low-flow oxygen via nasal cannula (1-2
L/min) is typically used to maintain target saturation without suppressing the respiratory drive.
Question 5: A patient is prescribed digoxin 0.25 mg orally. The nurse notes the patient's apical pulse is
58 beats per minute. What is the priority nursing action?
A. Administer the medication as prescribed
B. Hold the medication and notify the provider
C. Administer half the dose
D. Check the blood pressure before administering
CORRECT ANSWER: B. Hold the medication and notify the provider
RATIONALE: Digoxin should be withheld if the apical pulse is less than 60 beats per minute in an adult
due to the risk of severe bradycardia and toxicity.
Question 6: Which finding in a patient with heart failure indicates effective treatment with diuretics?
A. Increased jugular vein distention
B. Decreased daily weight
C. Elevated blood pressure
D. Increased crackles in lung bases
CORRECT ANSWER: B. Decreased daily weight
RATIONALE: Diuretics promote fluid loss; a decrease in daily weight is a reliable indicator of reduced
fluid volume and effective treatment in heart failure.
Question 7: A nurse is teaching a patient about warfarin therapy. Which statement by the patient
indicates a need for further teaching?
A. "I will use a soft-bristled toothbrush."
B. "I will avoid foods high in vitamin K."
C. "I will take ibuprofen for headaches."
D. "I will report any unusual bleeding."
CORRECT ANSWER: C. "I will take ibuprofen for headaches."
,RATIONALE: Ibuprofen and other NSAIDs increase the risk of bleeding when taken with warfarin;
acetaminophen is generally preferred for pain relief.
Question 8: A patient with a nasogastric (NG) tube connected to suction complains of nausea. What is
the first action the nurse should take?
A. Increase the suction pressure
B. Irrigate the tube with normal saline
C. Check the tube placement and patency
D. Administer an antiemetic medication
CORRECT ANSWER: C. Check the tube placement and patency
RATIONALE: Nausea may indicate the tube is clogged or displaced; assessing placement and patency is
the priority before intervening further.
Question 9: Which assessment finding is most indicative of hypokalemia in a patient taking
furosemide?
A. Hyperactive bowel sounds
B. Muscle weakness and cramps
C. Elevated blood pressure
D. Decreased urine output
CORRECT ANSWER: B. Muscle weakness and cramps
RATIONALE: Hypokalemia (low potassium) commonly presents with muscle weakness, cramps, and
potential cardiac dysrhythmias due to impaired muscle function.
Question 10: A nurse is caring for a patient with a chest tube. The water seal chamber shows
continuous bubbling. What does this indicate?
A. Normal function of the system
B. An air leak in the system
C. The lung has fully re-expanded
D. Excessive suction pressure
CORRECT ANSWER: B. An air leak in the system
RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak, either from the
patient's pleural space or a connection in the tubing.
Question 11: When administering blood products, what is the priority nursing action immediately
before starting the transfusion?
A. Prime the tubing with normal saline
B. Verify the patient's identity and blood type with another nurse
C. Obtain baseline vital signs
D. Ensure the patient has signed the consent form
CORRECT ANSWER: B. Verify the patient's identity and blood type with another nurse
, RATIONALE: Verifying patient identity and blood compatibility with a second nurse is the critical safety
step to prevent fatal hemolytic transfusion reactions.
Question 12: A patient with type 1 diabetes presents with confusion, fruity breath odor, and deep
rapid respirations. What condition should the nurse suspect?
A. Hypoglycemia
B. Diabetic ketoacidosis (DKA)
C. Hyperosmolar hyperglycemic state (HHS)
D. Somogyi phenomenon
CORRECT ANSWER: B. Diabetic ketoacidosis (DKA)
RATIONALE: Fruity breath, confusion, and Kussmaul respirations (deep, rapid) are classic signs of DKA
caused by acidosis from ketone production.
Question 13: Which intervention is most effective in preventing pressure injuries in an immobile
patient?
A. Massaging bony prominences
B. Using a donut-shaped cushion
C. Repositioning every 2 hours
D. Keeping the linens tight and wrinkle-free only
CORRECT ANSWER: C. Repositioning every 2 hours
RATIONALE: Frequent repositioning relieves pressure on bony prominences, which is the primary
mechanism for preventing pressure injury development.
Question 14: A nurse is assessing a patient with suspected pneumonia. Which lung sound is most
expected?
A. Wheezes
B. Stridor
C. Crackles
D. Pleural friction rub
CORRECT ANSWER: C. Crackles
RATIONALE: Crackles (rales) are discontinuous sounds caused by fluid in the alveoli, commonly
associated with pneumonia.
Question 15: What is the primary purpose of administering low-molecular-weight heparin (LMWH)
post-operatively?
A. To treat existing clots
B. To prevent deep vein thrombosis
C. To reduce inflammation
D. To control blood pressure
CORRECT ANSWER: B. To prevent deep vein thrombosis
Latest Update | HESI Milestone 2
Comprehensive Study Guide, Test Bank,
Practice Questions with Verified Answers and
Detailed Rationales for Nursing Students
Preparing for HESI Milestone 2 Assessment
and NCLEX Readiness
Question 1: A nurse is preparing to administer a subcutaneous injection of insulin to a patient with
diabetes. Which angle should the nurse use for the needle insertion if the patient has adequate
subcutaneous tissue?
A. 15 degrees
B. 30 degrees
C. 45 to 90 degrees
D. 180 degrees
CORRECT ANSWER: C. 45 to 90 degrees
RATIONALE: For subcutaneous injections, if the patient has adequate subcutaneous tissue, a 45 to 90-
degree angle is appropriate to ensure the medication is delivered into the subcutaneous layer rather
than the muscle.
Question 2: A patient is admitted with a diagnosis of deep vein thrombosis (DVT). Which assessment
finding should the nurse prioritize reporting to the healthcare provider?
A. Mild swelling in the affected leg
B. Warmth and redness over the calf
C. Sudden onset of shortness of breath
D. Pain upon dorsiflexion of the foot
CORRECT ANSWER: C. Sudden onset of shortness of breath
RATIONALE: Sudden shortness of breath may indicate a pulmonary embolism, a life-threatening
complication of DVT, requiring immediate intervention.
Question 3: When performing a sterile dressing change, which action by the nurse indicates a break in
sterile technique?
A. Holding sterile items above waist level
B. Opening the sterile package away from the body
C. Reaching over the sterile field to grab an item
D. Pouring sterile solution from a height of 6 inches
CORRECT ANSWER: C. Reaching over the sterile field to grab an item
,RATIONALE: Reaching over a sterile field contaminates it because particles from the arms or clothing
can fall onto the sterile surface.
Question 4: A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which
oxygen delivery method is most appropriate to maintain an SpO2 of 88-92%?
A. Non-rebreather mask at 15 L/min
B. Nasal cannula at 1-2 L/min
C. Simple face mask at 6 L/min
D. Venturi mask set at 24%
CORRECT ANSWER: B. Nasal cannula at 1-2 L/min
RATIONALE: Patients with COPD often rely on a hypoxic drive; low-flow oxygen via nasal cannula (1-2
L/min) is typically used to maintain target saturation without suppressing the respiratory drive.
Question 5: A patient is prescribed digoxin 0.25 mg orally. The nurse notes the patient's apical pulse is
58 beats per minute. What is the priority nursing action?
A. Administer the medication as prescribed
B. Hold the medication and notify the provider
C. Administer half the dose
D. Check the blood pressure before administering
CORRECT ANSWER: B. Hold the medication and notify the provider
RATIONALE: Digoxin should be withheld if the apical pulse is less than 60 beats per minute in an adult
due to the risk of severe bradycardia and toxicity.
Question 6: Which finding in a patient with heart failure indicates effective treatment with diuretics?
A. Increased jugular vein distention
B. Decreased daily weight
C. Elevated blood pressure
D. Increased crackles in lung bases
CORRECT ANSWER: B. Decreased daily weight
RATIONALE: Diuretics promote fluid loss; a decrease in daily weight is a reliable indicator of reduced
fluid volume and effective treatment in heart failure.
Question 7: A nurse is teaching a patient about warfarin therapy. Which statement by the patient
indicates a need for further teaching?
A. "I will use a soft-bristled toothbrush."
B. "I will avoid foods high in vitamin K."
C. "I will take ibuprofen for headaches."
D. "I will report any unusual bleeding."
CORRECT ANSWER: C. "I will take ibuprofen for headaches."
,RATIONALE: Ibuprofen and other NSAIDs increase the risk of bleeding when taken with warfarin;
acetaminophen is generally preferred for pain relief.
Question 8: A patient with a nasogastric (NG) tube connected to suction complains of nausea. What is
the first action the nurse should take?
A. Increase the suction pressure
B. Irrigate the tube with normal saline
C. Check the tube placement and patency
D. Administer an antiemetic medication
CORRECT ANSWER: C. Check the tube placement and patency
RATIONALE: Nausea may indicate the tube is clogged or displaced; assessing placement and patency is
the priority before intervening further.
Question 9: Which assessment finding is most indicative of hypokalemia in a patient taking
furosemide?
A. Hyperactive bowel sounds
B. Muscle weakness and cramps
C. Elevated blood pressure
D. Decreased urine output
CORRECT ANSWER: B. Muscle weakness and cramps
RATIONALE: Hypokalemia (low potassium) commonly presents with muscle weakness, cramps, and
potential cardiac dysrhythmias due to impaired muscle function.
Question 10: A nurse is caring for a patient with a chest tube. The water seal chamber shows
continuous bubbling. What does this indicate?
A. Normal function of the system
B. An air leak in the system
C. The lung has fully re-expanded
D. Excessive suction pressure
CORRECT ANSWER: B. An air leak in the system
RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak, either from the
patient's pleural space or a connection in the tubing.
Question 11: When administering blood products, what is the priority nursing action immediately
before starting the transfusion?
A. Prime the tubing with normal saline
B. Verify the patient's identity and blood type with another nurse
C. Obtain baseline vital signs
D. Ensure the patient has signed the consent form
CORRECT ANSWER: B. Verify the patient's identity and blood type with another nurse
, RATIONALE: Verifying patient identity and blood compatibility with a second nurse is the critical safety
step to prevent fatal hemolytic transfusion reactions.
Question 12: A patient with type 1 diabetes presents with confusion, fruity breath odor, and deep
rapid respirations. What condition should the nurse suspect?
A. Hypoglycemia
B. Diabetic ketoacidosis (DKA)
C. Hyperosmolar hyperglycemic state (HHS)
D. Somogyi phenomenon
CORRECT ANSWER: B. Diabetic ketoacidosis (DKA)
RATIONALE: Fruity breath, confusion, and Kussmaul respirations (deep, rapid) are classic signs of DKA
caused by acidosis from ketone production.
Question 13: Which intervention is most effective in preventing pressure injuries in an immobile
patient?
A. Massaging bony prominences
B. Using a donut-shaped cushion
C. Repositioning every 2 hours
D. Keeping the linens tight and wrinkle-free only
CORRECT ANSWER: C. Repositioning every 2 hours
RATIONALE: Frequent repositioning relieves pressure on bony prominences, which is the primary
mechanism for preventing pressure injury development.
Question 14: A nurse is assessing a patient with suspected pneumonia. Which lung sound is most
expected?
A. Wheezes
B. Stridor
C. Crackles
D. Pleural friction rub
CORRECT ANSWER: C. Crackles
RATIONALE: Crackles (rales) are discontinuous sounds caused by fluid in the alveoli, commonly
associated with pneumonia.
Question 15: What is the primary purpose of administering low-molecular-weight heparin (LMWH)
post-operatively?
A. To treat existing clots
B. To prevent deep vein thrombosis
C. To reduce inflammation
D. To control blood pressure
CORRECT ANSWER: B. To prevent deep vein thrombosis
