HESI MILESTONE EXAM 3 Questions and
Answers (2024/2025)(Verified Answers)
A male client with stomach cancer returns to the unit following a total gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour
after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart
rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding
to the surgeon. Which action should the nurse implement first?
a. Measure and document the client's urinary output.
b. Request the client's reserved unit if packed red blood cells.
c. Prepare the placement of a central venous catheter.
d. Increase the infusion rate of Lactated Ringer's solution.
d. Increase the infusion rate of Lactated Ringer's solution.
An adult male who fell 20 feet from the roof of this home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the
intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the - 10 cm
H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is
measured in the collection chamber. Which intervention should the nurse implement?
a. Add sterile water to the suction control chamber.
b. Give blood from the collection chamber as auto-transfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wall suction to eliminate fluctuation in water seal.
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg,
heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting
shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which
action should the nurse take first?
a. Elevate the foot of the bed.
b. Restrict the client's fluid.
c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis.
A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based
on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all
that apply)
a. Headache and tremors
b. Irregular heart rate
c. Skin hyperpigmentation
d. Postural hypotension
e. Pallor and diaphoresis
a. Headache and tremors
b. Irregular heart rate
e. Pallor and diaphoresis
.An older client is admitted with fluid volume deficit and dehydration. Which assessment finding
is the best indicator of hydration that the nurse should report to the healthcare provider?
a. Urine specific gravity is 1.040b.
b. Systolic blood pressure decreases 10 points when standing.
c. The client denies being thirsty.
d. Skin tenting occurs when the client's forearm is pinched.
.d. Skin tenting occurs when the client's forearm is pinched
,After an inservice about electronic health record (EHR) security and safeguarding client information,
the nurse observes a colleague going home with printed copies of client information in a uniform
pocket. Which action should the nurse take?
a. File a detailed incident report with the specific hiring facility.
b. Warn the colleague that their actions are unprofessional.
c. Comment anonymously about the action of a staff discussion board.
d. Communicate the colleague's actions to the unit charge nurse.
a. File a detailed incident report with the specific hiring facility.
The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease
implemented in a rural health clinic. Which outcome indicate the program is effective?
a. At-risk clients received an increased number of routine health screenings.
b. Clients reported having new confidence in making healthy food choices.
c. Clients who incurred disease complications promptly received rehabilitation.
d. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
c. Clients who incurred disease complications promptly received rehabilitation.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at
2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased
shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement
first?
a. Determine if the client is experiencing any anxiety.
b. Auscultate the client's bilateral lung sounds and oxygen saturation.
c. Notify the healthcare provider about the client's distress.
d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate
investigation by the nurse?
a. "When I get out of bed quickly, I feel a little dizzy."
b. "The dressing over my incision feels like it is too tight."
c. "I'm most comfortable when the head of the bed is raised."
d. "This IV infusion makes me urinate more often than usual."
a. "When I get out of bed quickly, I feel a little dizzy."
An older adult male who is in his early 70's is admitted to the emergency department because of a
COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for
endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to
stop the procedure and provide the nurse a copy of the client's living will. Which actionshould the
nurse take?
a. Facilitate a family meeting with the palliative care team.
b. Notify the healthcare provider of the client's wishes.
c. Place a certified copy of the living will in the client's record.
d. Alert the nursing staff of the client's don't resuscitate status.
b. Notify the healthcare provider of the client's wishes.
An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose
prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client
is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the
bedside commode. How should the nurse respond?
a. Determine the client's level of mobility and need for assistance.
, b. Instruct the UAP that all clients deserve equal care.
c. Advise the client to maintain bedrest so that safety can be ensured.
d. Assign another UAP to care for the client.
c. Advise the client to maintain bedrest so that safety can be ensured.
A nurse determines that more than 25% of the students at a middle school are overweight. The nurse
presents the information at the parent-teacher meeting. What action is most important for the nurse
to include in the meeting?
a. Provide information on ways to increase activity for the family.
b. Have several teachers talk about health risks associated with obesity.
c. Distribute a shopping list of suggested healthy snack items.
d. Determine the parents' degree of concern about their children's weight.
c. Distribute a shopping list of suggested healthy snack items.
After several months of chronic fatigue, morning stiffness, and join pain, a young adult is diagnosed
with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education
should the nurse provide the client with regard to taking prednisone?
a. Take prednisone doses before meals on an empty stomach.
b. Wear sunglasses when exposed to bright sunlight.
c. If sequential doses are missed, notify the healthcare provider.
d. Schedule a monthly laboratory visit for a complete blood count.
c. If sequential doses are missed, notify the healthcare provider.
The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's
immediate attention?
a. A 16-year-old client diagnosed with major depression who refuses to participate in group.
b. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.
c. An 18-year-old client with antisocial behavior who is being yelled at by other clients.
d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby..
c. An 18-year-old client with antisocial behavior who is being yelled at by other clients.
The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?
a. Positive Epstein-Barr, and malaise.
b. Ear pain and fever.
c. Elevated WBC and sedimentation rate.
d. Increased BUN and serum creatinine.
b. Ear pain and fever.
A client arrives for an annual physical exam and complains of having calf pain. The client's health
history reveals peripheral atrial disease. Which question should the nurse ask the client about
expected finding related to chronic arterial symptoms?
a. Were your legs ever suddenly swollen, red, warm, and painful?
b. Does the calf pain occur when walking short distances?
c. Did you receive treatment for weeping ulcers on lower legs?
d. Have you experienced ankle edema and varicose veins?
b. Does the calf pain occur when walking short distances?
The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which
client report is most important for them to explore further prior to the start of the procedure?
a. Drank a glass of water in the past 2 hours.
b. Reports left chest wall pain prior to admission.
Answers (2024/2025)(Verified Answers)
A male client with stomach cancer returns to the unit following a total gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour
after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart
rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding
to the surgeon. Which action should the nurse implement first?
a. Measure and document the client's urinary output.
b. Request the client's reserved unit if packed red blood cells.
c. Prepare the placement of a central venous catheter.
d. Increase the infusion rate of Lactated Ringer's solution.
d. Increase the infusion rate of Lactated Ringer's solution.
An adult male who fell 20 feet from the roof of this home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the
intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the - 10 cm
H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is
measured in the collection chamber. Which intervention should the nurse implement?
a. Add sterile water to the suction control chamber.
b. Give blood from the collection chamber as auto-transfusion
c. Manipulate blood in tubing to drain into chamber.
d. Increase wall suction to eliminate fluctuation in water seal.
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg,
heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting
shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which
action should the nurse take first?
a. Elevate the foot of the bed.
b. Restrict the client's fluid.
c. Begin supplemental oxygen.
d. Prepare the client for hemodialysis.
A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based
on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all
that apply)
a. Headache and tremors
b. Irregular heart rate
c. Skin hyperpigmentation
d. Postural hypotension
e. Pallor and diaphoresis
a. Headache and tremors
b. Irregular heart rate
e. Pallor and diaphoresis
.An older client is admitted with fluid volume deficit and dehydration. Which assessment finding
is the best indicator of hydration that the nurse should report to the healthcare provider?
a. Urine specific gravity is 1.040b.
b. Systolic blood pressure decreases 10 points when standing.
c. The client denies being thirsty.
d. Skin tenting occurs when the client's forearm is pinched.
.d. Skin tenting occurs when the client's forearm is pinched
,After an inservice about electronic health record (EHR) security and safeguarding client information,
the nurse observes a colleague going home with printed copies of client information in a uniform
pocket. Which action should the nurse take?
a. File a detailed incident report with the specific hiring facility.
b. Warn the colleague that their actions are unprofessional.
c. Comment anonymously about the action of a staff discussion board.
d. Communicate the colleague's actions to the unit charge nurse.
a. File a detailed incident report with the specific hiring facility.
The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease
implemented in a rural health clinic. Which outcome indicate the program is effective?
a. At-risk clients received an increased number of routine health screenings.
b. Clients reported having new confidence in making healthy food choices.
c. Clients who incurred disease complications promptly received rehabilitation.
d. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
c. Clients who incurred disease complications promptly received rehabilitation.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at
2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased
shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement
first?
a. Determine if the client is experiencing any anxiety.
b. Auscultate the client's bilateral lung sounds and oxygen saturation.
c. Notify the healthcare provider about the client's distress.
d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate
investigation by the nurse?
a. "When I get out of bed quickly, I feel a little dizzy."
b. "The dressing over my incision feels like it is too tight."
c. "I'm most comfortable when the head of the bed is raised."
d. "This IV infusion makes me urinate more often than usual."
a. "When I get out of bed quickly, I feel a little dizzy."
An older adult male who is in his early 70's is admitted to the emergency department because of a
COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for
endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to
stop the procedure and provide the nurse a copy of the client's living will. Which actionshould the
nurse take?
a. Facilitate a family meeting with the palliative care team.
b. Notify the healthcare provider of the client's wishes.
c. Place a certified copy of the living will in the client's record.
d. Alert the nursing staff of the client's don't resuscitate status.
b. Notify the healthcare provider of the client's wishes.
An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose
prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client
is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the
bedside commode. How should the nurse respond?
a. Determine the client's level of mobility and need for assistance.
, b. Instruct the UAP that all clients deserve equal care.
c. Advise the client to maintain bedrest so that safety can be ensured.
d. Assign another UAP to care for the client.
c. Advise the client to maintain bedrest so that safety can be ensured.
A nurse determines that more than 25% of the students at a middle school are overweight. The nurse
presents the information at the parent-teacher meeting. What action is most important for the nurse
to include in the meeting?
a. Provide information on ways to increase activity for the family.
b. Have several teachers talk about health risks associated with obesity.
c. Distribute a shopping list of suggested healthy snack items.
d. Determine the parents' degree of concern about their children's weight.
c. Distribute a shopping list of suggested healthy snack items.
After several months of chronic fatigue, morning stiffness, and join pain, a young adult is diagnosed
with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education
should the nurse provide the client with regard to taking prednisone?
a. Take prednisone doses before meals on an empty stomach.
b. Wear sunglasses when exposed to bright sunlight.
c. If sequential doses are missed, notify the healthcare provider.
d. Schedule a monthly laboratory visit for a complete blood count.
c. If sequential doses are missed, notify the healthcare provider.
The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's
immediate attention?
a. A 16-year-old client diagnosed with major depression who refuses to participate in group.
b. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.
c. An 18-year-old client with antisocial behavior who is being yelled at by other clients.
d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby..
c. An 18-year-old client with antisocial behavior who is being yelled at by other clients.
The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?
a. Positive Epstein-Barr, and malaise.
b. Ear pain and fever.
c. Elevated WBC and sedimentation rate.
d. Increased BUN and serum creatinine.
b. Ear pain and fever.
A client arrives for an annual physical exam and complains of having calf pain. The client's health
history reveals peripheral atrial disease. Which question should the nurse ask the client about
expected finding related to chronic arterial symptoms?
a. Were your legs ever suddenly swollen, red, warm, and painful?
b. Does the calf pain occur when walking short distances?
c. Did you receive treatment for weeping ulcers on lower legs?
d. Have you experienced ankle edema and varicose veins?
b. Does the calf pain occur when walking short distances?
The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which
client report is most important for them to explore further prior to the start of the procedure?
a. Drank a glass of water in the past 2 hours.
b. Reports left chest wall pain prior to admission.
