HESI MILESTONE 2 PRACTICE EXAM WITH
ANSWERS AND RATIONALES TESTED AND
APPROCED
A client calls the nurse at the clinic and reports experiencing a sensation as though the
affected leg is falling asleep ever since the vein ligation and stripping procedure was
performed. The nurse would make which response to the client?
1. "Apply warm packs to the leg."
2. "Keep the leg elevated as much as possible."
3. "Your primary health care provider needs to be contacted to report this problem."
4. "This normally occurs after surgery and will subside when the edema goes down." --
ANSWER--"Your primary health care provider needs to be contacted to report this problem."
A sensation of pins and needles or feeling as though the surgical limb is falling asleep may
indicate temporary or permanent nerve damage after surgery. The saphenous vein and the
saphenous nerve run close together, and damage to the nerve will produce paresthesias. The
remaining options are inaccurate responses. An alternative to surgery is endovenous ablation
of the saphenous vein. Ablation involves the insertion of a catheter that emits energy. This
causes collapse and sclerosis of the vein. Potential complications include bruising, tightness
along the vein, recanalization (reopening of the vein), and paresthesia. Endovenous ablation
also may be done in combination with saphenofemoral ligation or phlebectomy.
Transilluminated powdered phlebectomy involves the use of a powdered resector to destroy
the varices and then removes the pieces via aspiration.
Page 1 of 94
,The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure.
Which assessment component would elicit specific information regarding the client's
leftsided heart function?
1. Listening to lung sounds
2. Palpating for organomegaly
3. Assessing for jugular vein distention
4. Assessing for peripheral and sacral edema -- ANSWER--Listening to lung sounds.
The client with heart failure may present with different symptoms, depending on whether the
right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein
distention, and organomegaly all are manifestations of problems with right-sided heart
function. Lung sounds constitute an accurate indicator of left-sided heart function.
The registered nurse (RN) is educating a new RN about the use of oxygen for clients with
angina pectoris. Which statement by the new nurse indicates that the teaching has been
effective?
1. "Oxygen has a calming effect."
2. "Oxygen will prevent the development of any thrombus."
3. "The pain of angina pectoris occurs because of a decreased oxygen supply to heart
cells."
4. "Oxygen dilates the blood vessels so that they can supply more nutrients to the heart
muscle." -- ANSWER--"The pain of angina pectoris occurs because of a decreased oxygen
supply to heart cells."
Page 2 of 94
,The pain associated with angina results from ischemia of myocardial cells. The pain often is
precipitated by activity that places more oxygen demand on heart muscle. Supplemental
oxygen will help meet the added demands on the heart muscle. Oxygen does not dilate blood
vessels or prevent thrombus formation and does not directly calm the client.
The nurse has provided dietary instructions to a client with coronary artery disease. Which
statement by the client indicates an understanding of the dietary instructions?
1. "I'll need to become a strict vegetarian."
2. "I should use polyunsaturated oils in my diet."
3. "I need to substitute eggs and whole milk for meat."
4. "I should eliminate all cholesterol and fat from my diet." -- ANSWER--"I should use
polyunsaturated oils in my diet."
The client with coronary artery disease needs to avoid foods high in saturated fat and
cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in
low-density lipoproteins. The use of polyunsaturated oils is recommended to control
hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It
is not necessary to become a strict vegetarian.
The home care nurse has taught a client with heart failure and a problem of inadequate
cardiac output about helpful lifestyle adaptations to promote health. Which statement by the
client best demonstrates an understanding of the information provided?
1. "I will try to exercise vigorously to strengthen my heart muscle."
2. "I will eat enough daily fiber to prevent straining during bowel movement."
3. "I will drink 3000 to 3500 mL of fluid daily to promote good kidney function."
Page 3 of 94
, 4. "Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood
vessels." -- ANSWER--"I will eat enough daily fiber to prevent straining during bowel
movement."
Standard home care instructions for a client with this problem include, among others, lifestyle
changes such as avoiding alcohol intake, avoiding activities that increase the demands on the
heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid
and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will
increase the cardiac workload.
A client recovering from pulmonary edema is preparing for discharge. What would the nurse
plan to teach the client to do to manage or prevent recurrent symptoms after discharge?
1. Weigh self on a daily basis.
2. Sleep with the head of the bed flat.
3. Take a double dose of the diuretic if peripheral edema is noted.
4. Withhold prescribed digoxin if slight respiratory distress occurs. -- ANSWER--Weigh
self on a daily basis.
The client can best determine fluid status at home by weighing himself or herself on a daily
basis. Increases of 2 to 3 lb (0.9 to 1.4 kg) in a short period are reported to the primary health
care provider (PHCP). The client needs to sleep with the head of the bed elevated. During
recumbent sleep, fluid (which has seeped into the interstitium with the assistance of the
effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head
of the bed flat is therefore avoided. The client does not modify medication dosages without
consulting the PHCP.
The nurse is caring for a client with acute pancreatitis and is monitoring the client for
paralytic ileus. Which piece of assessment data would alert the nurse to this occurrence?
Page 4 of 94
ANSWERS AND RATIONALES TESTED AND
APPROCED
A client calls the nurse at the clinic and reports experiencing a sensation as though the
affected leg is falling asleep ever since the vein ligation and stripping procedure was
performed. The nurse would make which response to the client?
1. "Apply warm packs to the leg."
2. "Keep the leg elevated as much as possible."
3. "Your primary health care provider needs to be contacted to report this problem."
4. "This normally occurs after surgery and will subside when the edema goes down." --
ANSWER--"Your primary health care provider needs to be contacted to report this problem."
A sensation of pins and needles or feeling as though the surgical limb is falling asleep may
indicate temporary or permanent nerve damage after surgery. The saphenous vein and the
saphenous nerve run close together, and damage to the nerve will produce paresthesias. The
remaining options are inaccurate responses. An alternative to surgery is endovenous ablation
of the saphenous vein. Ablation involves the insertion of a catheter that emits energy. This
causes collapse and sclerosis of the vein. Potential complications include bruising, tightness
along the vein, recanalization (reopening of the vein), and paresthesia. Endovenous ablation
also may be done in combination with saphenofemoral ligation or phlebectomy.
Transilluminated powdered phlebectomy involves the use of a powdered resector to destroy
the varices and then removes the pieces via aspiration.
Page 1 of 94
,The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure.
Which assessment component would elicit specific information regarding the client's
leftsided heart function?
1. Listening to lung sounds
2. Palpating for organomegaly
3. Assessing for jugular vein distention
4. Assessing for peripheral and sacral edema -- ANSWER--Listening to lung sounds.
The client with heart failure may present with different symptoms, depending on whether the
right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein
distention, and organomegaly all are manifestations of problems with right-sided heart
function. Lung sounds constitute an accurate indicator of left-sided heart function.
The registered nurse (RN) is educating a new RN about the use of oxygen for clients with
angina pectoris. Which statement by the new nurse indicates that the teaching has been
effective?
1. "Oxygen has a calming effect."
2. "Oxygen will prevent the development of any thrombus."
3. "The pain of angina pectoris occurs because of a decreased oxygen supply to heart
cells."
4. "Oxygen dilates the blood vessels so that they can supply more nutrients to the heart
muscle." -- ANSWER--"The pain of angina pectoris occurs because of a decreased oxygen
supply to heart cells."
Page 2 of 94
,The pain associated with angina results from ischemia of myocardial cells. The pain often is
precipitated by activity that places more oxygen demand on heart muscle. Supplemental
oxygen will help meet the added demands on the heart muscle. Oxygen does not dilate blood
vessels or prevent thrombus formation and does not directly calm the client.
The nurse has provided dietary instructions to a client with coronary artery disease. Which
statement by the client indicates an understanding of the dietary instructions?
1. "I'll need to become a strict vegetarian."
2. "I should use polyunsaturated oils in my diet."
3. "I need to substitute eggs and whole milk for meat."
4. "I should eliminate all cholesterol and fat from my diet." -- ANSWER--"I should use
polyunsaturated oils in my diet."
The client with coronary artery disease needs to avoid foods high in saturated fat and
cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in
low-density lipoproteins. The use of polyunsaturated oils is recommended to control
hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It
is not necessary to become a strict vegetarian.
The home care nurse has taught a client with heart failure and a problem of inadequate
cardiac output about helpful lifestyle adaptations to promote health. Which statement by the
client best demonstrates an understanding of the information provided?
1. "I will try to exercise vigorously to strengthen my heart muscle."
2. "I will eat enough daily fiber to prevent straining during bowel movement."
3. "I will drink 3000 to 3500 mL of fluid daily to promote good kidney function."
Page 3 of 94
, 4. "Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood
vessels." -- ANSWER--"I will eat enough daily fiber to prevent straining during bowel
movement."
Standard home care instructions for a client with this problem include, among others, lifestyle
changes such as avoiding alcohol intake, avoiding activities that increase the demands on the
heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid
and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will
increase the cardiac workload.
A client recovering from pulmonary edema is preparing for discharge. What would the nurse
plan to teach the client to do to manage or prevent recurrent symptoms after discharge?
1. Weigh self on a daily basis.
2. Sleep with the head of the bed flat.
3. Take a double dose of the diuretic if peripheral edema is noted.
4. Withhold prescribed digoxin if slight respiratory distress occurs. -- ANSWER--Weigh
self on a daily basis.
The client can best determine fluid status at home by weighing himself or herself on a daily
basis. Increases of 2 to 3 lb (0.9 to 1.4 kg) in a short period are reported to the primary health
care provider (PHCP). The client needs to sleep with the head of the bed elevated. During
recumbent sleep, fluid (which has seeped into the interstitium with the assistance of the
effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head
of the bed flat is therefore avoided. The client does not modify medication dosages without
consulting the PHCP.
The nurse is caring for a client with acute pancreatitis and is monitoring the client for
paralytic ileus. Which piece of assessment data would alert the nurse to this occurrence?
Page 4 of 94
