HESI MILESTONE 2 VERIFIED
SOLUTION WITH CORRECT
ANSWERS
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
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."
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
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
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
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
,A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse
determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile
for both height and weight. What is the priority nursing intervention?
Performing postural drainage
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 sequence of goals with the child and parents.
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
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 likely indicated pyloric stenosis?
Peristaltic waves that transverse the epigastrium.
The registered nurse is teaching a student nurse the points to be included while educating a client
on cortisol replacement therapy about self-management. Which statement provided by the
student nurse indicates the need for further teaching?
"I will advise the client to take the medication before meals."
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
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.
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.
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 infected 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 preventing 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 event or "cue to
action" and is most likely to increase the client's perceived seriousness of the disease.
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 myocardial
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.
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 medication.
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.
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.
The client is taking digoxin for congestive heart failure. The nurse would be correct in
withholding a dose of digoxin based on which assessment?
SOLUTION WITH CORRECT
ANSWERS
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
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."
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
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
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
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
,A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse
determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile
for both height and weight. What is the priority nursing intervention?
Performing postural drainage
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 sequence of goals with the child and parents.
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
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 likely indicated pyloric stenosis?
Peristaltic waves that transverse the epigastrium.
The registered nurse is teaching a student nurse the points to be included while educating a client
on cortisol replacement therapy about self-management. Which statement provided by the
student nurse indicates the need for further teaching?
"I will advise the client to take the medication before meals."
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
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.
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.
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 infected 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 preventing 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 event or "cue to
action" and is most likely to increase the client's perceived seriousness of the disease.
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 myocardial
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.
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 medication.
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.
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.
The client is taking digoxin for congestive heart failure. The nurse would be correct in
withholding a dose of digoxin based on which assessment?
