HESI MILESTONE 2 RETAKE LATEST
2025-2026 ACTUAL EXAM 130
QUESTIONS AND CORRECT
DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
Levels of Health Promotion - ANSWER-primary, secondary, tertiary
Application Examples of Levels of Promotion - ANSWER-primary- weight loss,
diet, smoking cessation
Secondary- papsmears, mammograms, testicular exams
Tertiary- medication therapy, surgical treatment, physical therapy, teaching foot
care education to diabetic care
Primary - ANSWER-promotes health and preventing development of disease
process or injury
Secondary - ANSWER-screening for early detection of disease
Tertiary - ANSWER-begins after illness is diagnosed and treatment. Aims to
prevent long-term consequences of chronic illnesses or disabilities
Nursing Assessments - ANSWER-Comprehensive- (Head to Toe) = Can be done
inpatient and through primary care (Physical assessment- annual exam)
Focused- Health and physical hx of specific problem.- ex. Sick visit
Emergency- crisis, life threatening. ex. airway, breathing, injury, disability,
exposure, med reconciliation
Phases of Interview process - ANSWER-Pre-interaction, beginning, working
(open and close ended questions), closing
Data sources - ANSWER-Primary- individual patient
Secondary- chart info, family members
Purposes of Documentation - ANSWER-verbal communication, SBAR, written
document
, Lifespan Nutritional Considerations - Nutrition: Pregnant Women - ANSWER-
need additional 300-500 cal/day (whole foods
Lifespan Nutritional Considerations - Nutrition: infants/children - ANSWER-
infants/children: whole milk for ages 2-5 fat intake-brain development
Lifespan Nutritional Considerations - Nutrition: Older - ANSWER-BMR declines,
Vitamin D supplements, Problems: decreased thirst, increase risk for
osteoarthritis, osteoporosis, dementia, obesity, social isolation
General Survey - ANSWER-mental note of overall health (hygiene/appearance).
Assessing pain: documentation, OLDCARTS/OPQRST. Aggravating and
alleviating factors, pain goal and funtional goal
Assessing Pain - Documentation - ANSWER-Acute vs. Chronic-Location
Priority - ANSWER-Priority pain: stones (kidney, gallbladder, calcium and/or
struvite), myocardial infarcation (HA), burns and sickle cell
Heart Rate Elevated - ANSWER-above 100 beats per minute
Blood Pressure- Normal - ANSWER-above systolic- 120-129, diastolic- less than
80,
Blood Pressure- elevated - ANSWER-Hypertension: Stage 1: 130-139 or 80-89,
Stage Hypertension 2: more than 140, or greater than or equal to 90
When should BP be taken? - ANSWER-after patient rests for 5 minutues or 30
minutes after caffeine, smoking
Assessment of the Head and Neck - ANSWER-Inspect, palpate, auscultate
Infection - ANSWER-If nodes are palpable, warm, tender = infection
Assessment of the Ear - Techniques - ANSWER-Adults: up and back
Children: down and back
Assessment of the Ear - Techniques Part 2 - ANSWER-observe behavioral
responses to speech, inspect ear formation (size, shape & any malformation to
the auricle, condition)
Perform whisper test & Rinne test. Pt plug one ear at a time
Perform weber test (evaluate unilateral hearing loss
2025-2026 ACTUAL EXAM 130
QUESTIONS AND CORRECT
DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
Levels of Health Promotion - ANSWER-primary, secondary, tertiary
Application Examples of Levels of Promotion - ANSWER-primary- weight loss,
diet, smoking cessation
Secondary- papsmears, mammograms, testicular exams
Tertiary- medication therapy, surgical treatment, physical therapy, teaching foot
care education to diabetic care
Primary - ANSWER-promotes health and preventing development of disease
process or injury
Secondary - ANSWER-screening for early detection of disease
Tertiary - ANSWER-begins after illness is diagnosed and treatment. Aims to
prevent long-term consequences of chronic illnesses or disabilities
Nursing Assessments - ANSWER-Comprehensive- (Head to Toe) = Can be done
inpatient and through primary care (Physical assessment- annual exam)
Focused- Health and physical hx of specific problem.- ex. Sick visit
Emergency- crisis, life threatening. ex. airway, breathing, injury, disability,
exposure, med reconciliation
Phases of Interview process - ANSWER-Pre-interaction, beginning, working
(open and close ended questions), closing
Data sources - ANSWER-Primary- individual patient
Secondary- chart info, family members
Purposes of Documentation - ANSWER-verbal communication, SBAR, written
document
, Lifespan Nutritional Considerations - Nutrition: Pregnant Women - ANSWER-
need additional 300-500 cal/day (whole foods
Lifespan Nutritional Considerations - Nutrition: infants/children - ANSWER-
infants/children: whole milk for ages 2-5 fat intake-brain development
Lifespan Nutritional Considerations - Nutrition: Older - ANSWER-BMR declines,
Vitamin D supplements, Problems: decreased thirst, increase risk for
osteoarthritis, osteoporosis, dementia, obesity, social isolation
General Survey - ANSWER-mental note of overall health (hygiene/appearance).
Assessing pain: documentation, OLDCARTS/OPQRST. Aggravating and
alleviating factors, pain goal and funtional goal
Assessing Pain - Documentation - ANSWER-Acute vs. Chronic-Location
Priority - ANSWER-Priority pain: stones (kidney, gallbladder, calcium and/or
struvite), myocardial infarcation (HA), burns and sickle cell
Heart Rate Elevated - ANSWER-above 100 beats per minute
Blood Pressure- Normal - ANSWER-above systolic- 120-129, diastolic- less than
80,
Blood Pressure- elevated - ANSWER-Hypertension: Stage 1: 130-139 or 80-89,
Stage Hypertension 2: more than 140, or greater than or equal to 90
When should BP be taken? - ANSWER-after patient rests for 5 minutues or 30
minutes after caffeine, smoking
Assessment of the Head and Neck - ANSWER-Inspect, palpate, auscultate
Infection - ANSWER-If nodes are palpable, warm, tender = infection
Assessment of the Ear - Techniques - ANSWER-Adults: up and back
Children: down and back
Assessment of the Ear - Techniques Part 2 - ANSWER-observe behavioral
responses to speech, inspect ear formation (size, shape & any malformation to
the auricle, condition)
Perform whisper test & Rinne test. Pt plug one ear at a time
Perform weber test (evaluate unilateral hearing loss
