HESI MILESTONE 2 RETAKE EXAM NEWEST 2025 ACTUAL
EXAM COMPLETE 180+ QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
Question 1
A nurse is preparing to administer digoxin to an adult client. The client's
apical pulse is 52 beats/minute. What is the nurse's priority action?
A) Administer the digoxin as prescribed.
B) Hold the digoxin and notify the healthcare provider.
C) Administer half the prescribed dose.
D) Document the apical pulse and administer the medication.
E) Recheck the apical pulse in 30 minutes.
Correct Answer: B) Hold the digoxin and notify the healthcare
provider
Rationale: Digoxin can cause bradycardia. The nurse should hold the
medication and notify the healthcare provider if the apical pulse is
below 60 beats/minute in an adult, as administering it could further
dangerously lower the heart rate.
Question 2
A client with a history of heart failure is prescribed a loop diuretic. Which of
the following laboratory values should the nurse monitor closely for potential
adverse effects of this medication?
A) Sodium
B) Potassium
C) Calcium
D) Magnesium
E) Phosphate
Correct Answer: B) Potassium
Rationale: Loop diuretics, such as furosemide, are known to cause
significant potassium loss (hypokalemia) due to their mechanism of
action in the renal tubules.
,Question 3
A nurse is caring for a client with a nasogastric (NG) tube connected to low
intermittent suction. What is the primary reason for connecting the NG tube
to suction?
A) To administer enteral feedings.
B) To decompress the stomach and remove secretions/gas.
C) To provide oxygen therapy.
D) To instill medications directly into the small intestine.
E) To measure gastric pH for ulcer assessment.
Correct Answer: B) To decompress the stomach and remove
secretions/gas
Rationale: The primary purpose of an NG tube connected to suction
is to decompress the stomach, removing gastric secretions and gas
to relieve distension, nausea, and vomiting.
Question 4
The nurse is assessing a client who complains of sudden, sharp, radiating
chest pain, shortness of breath, and palpitations. The client's blood pressure
is 90/60 mmHg, heart rate is 120 bpm, and oxygen saturation is 88% on
room air. What is the nurse's priority action?
A) Administer an analgesic for pain.
B) Obtain a 12-lead electrocardiogram (ECG).
C) Apply oxygen and elevate the head of the bed.
D) Document the findings in the client's chart.
E) Prepare for cardioversion.
Correct Answer: C) Apply oxygen and elevate the head of the bed
Rationale: The client is exhibiting signs of hypoxemia and
hemodynamic instability. Applying oxygen and elevating the head of
the bed will immediately address the oxygenation and breathing
difficulties, which are critical priorities.
,Question 5
A client with chronic kidney disease is advised to follow a low-sodium, low-
potassium, and low-phosphate diet. Which food choice by the client indicates
a need for further teaching?
A) Fresh apples and grapes.
B) Roasted chicken with green beans.
C) A banana and a glass of milk.
D) White rice and unsalted crackers.
E) Plain grilled fish.
Correct Answer: C) A banana and a glass of milk
Rationale: Bananas are high in potassium, and milk is high in
phosphate, making these choices unsuitable for a client on a
restricted renal diet.
Question 6
The nurse is preparing to administer an intramuscular (IM) injection to an
adult client. Which site is generally considered the safest for IM injections
due to the absence of major nerves and blood vessels?
A) Deltoid
B) Dorsogluteal
C) Ventrogluteal
D) Rectus femoris
E) Vastus lateralis
Correct Answer: C) Ventrogluteal
Rationale: The ventrogluteal site is generally preferred for IM
injections in adults because it is deep and free of major nerves and
blood vessels, minimizing the risk of injury.
Question 7
A client is admitted with a diagnosis of dehydration. The nurse anticipates an
order for which type of intravenous (IV) fluid to rapidly expand the
extracellular fluid volume?
, A) 0.45% Sodium Chloride (half-normal saline).
B) 5% Dextrose in Water (D5W).
C) Lactated Ringer's.
D) 10% Dextrose in Water (D10W).
E) 3% Sodium Chloride.
Correct Answer: C) Lactated Ringer's
Rationale: Lactated Ringer's is an isotonic solution that is commonly
used for fluid replacement, especially in cases of dehydration or
hypovolemia, as it expands the extracellular fluid volume without
causing fluid shifts into the cells.
Question 8
A client undergoing chemotherapy reports severe nausea and vomiting.
Which intervention should the nurse prioritize to manage this adverse effect?
A) Offer large meals twice a day.
B) Administer antiemetic medication before meals and chemotherapy.
C) Encourage consumption of fatty and spicy foods.
D) Provide carbonated beverages with meals.
E) Limit fluid intake to prevent vomiting.
Correct Answer: B) Administer antiemetic medication before meals
and chemotherapy
Rationale: Prophylactic administration of antiemetics before
chemotherapy and meals is most effective in preventing and
controlling chemotherapy-induced nausea and vomiting.
Question 9
The nurse is caring for a client who is receiving continuous enteral feedings
via a gastrostomy tube. The nurse notes the client is experiencing diarrhea.
What is the nurse's initial action?
A) Administer an antidiarrheal medication.
B) Increase the feeding rate.
C) Check the osmolarity of the feeding formula.
EXAM COMPLETE 180+ QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
Question 1
A nurse is preparing to administer digoxin to an adult client. The client's
apical pulse is 52 beats/minute. What is the nurse's priority action?
A) Administer the digoxin as prescribed.
B) Hold the digoxin and notify the healthcare provider.
C) Administer half the prescribed dose.
D) Document the apical pulse and administer the medication.
E) Recheck the apical pulse in 30 minutes.
Correct Answer: B) Hold the digoxin and notify the healthcare
provider
Rationale: Digoxin can cause bradycardia. The nurse should hold the
medication and notify the healthcare provider if the apical pulse is
below 60 beats/minute in an adult, as administering it could further
dangerously lower the heart rate.
Question 2
A client with a history of heart failure is prescribed a loop diuretic. Which of
the following laboratory values should the nurse monitor closely for potential
adverse effects of this medication?
A) Sodium
B) Potassium
C) Calcium
D) Magnesium
E) Phosphate
Correct Answer: B) Potassium
Rationale: Loop diuretics, such as furosemide, are known to cause
significant potassium loss (hypokalemia) due to their mechanism of
action in the renal tubules.
,Question 3
A nurse is caring for a client with a nasogastric (NG) tube connected to low
intermittent suction. What is the primary reason for connecting the NG tube
to suction?
A) To administer enteral feedings.
B) To decompress the stomach and remove secretions/gas.
C) To provide oxygen therapy.
D) To instill medications directly into the small intestine.
E) To measure gastric pH for ulcer assessment.
Correct Answer: B) To decompress the stomach and remove
secretions/gas
Rationale: The primary purpose of an NG tube connected to suction
is to decompress the stomach, removing gastric secretions and gas
to relieve distension, nausea, and vomiting.
Question 4
The nurse is assessing a client who complains of sudden, sharp, radiating
chest pain, shortness of breath, and palpitations. The client's blood pressure
is 90/60 mmHg, heart rate is 120 bpm, and oxygen saturation is 88% on
room air. What is the nurse's priority action?
A) Administer an analgesic for pain.
B) Obtain a 12-lead electrocardiogram (ECG).
C) Apply oxygen and elevate the head of the bed.
D) Document the findings in the client's chart.
E) Prepare for cardioversion.
Correct Answer: C) Apply oxygen and elevate the head of the bed
Rationale: The client is exhibiting signs of hypoxemia and
hemodynamic instability. Applying oxygen and elevating the head of
the bed will immediately address the oxygenation and breathing
difficulties, which are critical priorities.
,Question 5
A client with chronic kidney disease is advised to follow a low-sodium, low-
potassium, and low-phosphate diet. Which food choice by the client indicates
a need for further teaching?
A) Fresh apples and grapes.
B) Roasted chicken with green beans.
C) A banana and a glass of milk.
D) White rice and unsalted crackers.
E) Plain grilled fish.
Correct Answer: C) A banana and a glass of milk
Rationale: Bananas are high in potassium, and milk is high in
phosphate, making these choices unsuitable for a client on a
restricted renal diet.
Question 6
The nurse is preparing to administer an intramuscular (IM) injection to an
adult client. Which site is generally considered the safest for IM injections
due to the absence of major nerves and blood vessels?
A) Deltoid
B) Dorsogluteal
C) Ventrogluteal
D) Rectus femoris
E) Vastus lateralis
Correct Answer: C) Ventrogluteal
Rationale: The ventrogluteal site is generally preferred for IM
injections in adults because it is deep and free of major nerves and
blood vessels, minimizing the risk of injury.
Question 7
A client is admitted with a diagnosis of dehydration. The nurse anticipates an
order for which type of intravenous (IV) fluid to rapidly expand the
extracellular fluid volume?
, A) 0.45% Sodium Chloride (half-normal saline).
B) 5% Dextrose in Water (D5W).
C) Lactated Ringer's.
D) 10% Dextrose in Water (D10W).
E) 3% Sodium Chloride.
Correct Answer: C) Lactated Ringer's
Rationale: Lactated Ringer's is an isotonic solution that is commonly
used for fluid replacement, especially in cases of dehydration or
hypovolemia, as it expands the extracellular fluid volume without
causing fluid shifts into the cells.
Question 8
A client undergoing chemotherapy reports severe nausea and vomiting.
Which intervention should the nurse prioritize to manage this adverse effect?
A) Offer large meals twice a day.
B) Administer antiemetic medication before meals and chemotherapy.
C) Encourage consumption of fatty and spicy foods.
D) Provide carbonated beverages with meals.
E) Limit fluid intake to prevent vomiting.
Correct Answer: B) Administer antiemetic medication before meals
and chemotherapy
Rationale: Prophylactic administration of antiemetics before
chemotherapy and meals is most effective in preventing and
controlling chemotherapy-induced nausea and vomiting.
Question 9
The nurse is caring for a client who is receiving continuous enteral feedings
via a gastrostomy tube. The nurse notes the client is experiencing diarrhea.
What is the nurse's initial action?
A) Administer an antidiarrheal medication.
B) Increase the feeding rate.
C) Check the osmolarity of the feeding formula.
